OIG Reviews Rhode Island Hospice GIP Claims Under Medicaid

The Office of the Inspector General (OIG) released a report based on a review that was completed of the Rhode Island Executive Office of Health and Human Services Office of Medicaid’s payments for hospice general inpatient services (GIP).  The purpose of the review was to determine whether the state agency made Medicaid payments for hospice GIP services in accordance with federal and state regulations. 

A prior OIG review found Medicaid overpayments to hospice providers that submitted and received reimbursement for claims that did not meet the requirements for GIP and should have been billed as routine home care. All of the unallowable services were provided in a nursing home setting.  The OIG has had GIP care and state Medicaid compliance with federal reimbursement requirements on its Annual Work Plan for several years and has had hospice care in nursing homes on the annual OIG work plan for several years, as well.

There are less than 10 hospice providers in Rhode Island - and the reviewed claims were from a single agency that has a 24-bed inpatient hospice facility where it provides GIP services. It also provides GIP care in contracted hospitals and skilled nursing facilities.  Directed by the OIG, the state Medicaid agency performed a review of 43 of the hospice’s GIP claims from 2007-2010.   The claims were for 25 hospice patients.  The OIG found that 15 of the 43 claims were paid for care that should have been billed at the routine home care level of care. 

The OIG stated this occurred because the state Medicaid agency and the hospice did not have adequate internal controls.  The total amount of the overpayment was $28,321 with $17,114 being the federal share.  The OIG recommended that the state Medicaid agency refund this portion to the federal government.  The OIG also recommended that the state agency strengthen internal controls, such as issuing guidance to hospices that better define the circumstances for billing at the GIP care level and consider performing additional medical reviews of hospice GIP care services performed in the nursing home setting.   

The agency responded to the OIG findings. In general, it agreed that all but one of the claims could be billed at the routine home care level of care.  The OIG is allowing the hospice to work with the state’s medical reviewer on this case and it adjusted the federal government reimbursement amount accordingly.

The report details the reasons the claims did not support a GIP level of care.  In general, it was insufficient documentation in the hospice’s medical records to show increased pain and symptom management that would justify the GIP level of care.  NAHC and its affiliate, the Hospice Association of America (HAA), reminds hospices that the GIP level of care is short term and intended to provide pain and symptom management that cannot be accomplished in another setting.  One would expect that in reviewing documentation for the GIP level of care, there is evidence of interventions implemented for the pain/symptom(s) at a different level of care that did not adequately control the pain/symptom(s) and, therefore, the patient needs the GIP level of care. 

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