OIG Issues Report on Illinois Medicaid Reimbursement for Hospice Claims

The Office of the Inspector General (OIG) recently released the report Illinois Did Not Always Properly Claim Medicaid Reimbursement for Hospice Claims.   Previous OIG reviews found that states did not always comply with federal and state requirements for hospice claims.  This report is the second released this month from the OIG regarding compliance with Medicaid hospice requirements. 

The objective of the review was to determine whether Illinois properly claimed federal Medicaid reimbursement for hospice claims submitted by hospices in Illinois.  The review included a random sample of 120 hospice claims of $100 or more paid to Illinois hospices between January 1, 2009 and December 31, 2010.  The sample of claims came from 42 Illinois hospices.

The OIG found that the Illinois Medicaid program properly claimed federal Medicaid reimbursement for 81 percent of the claims (97 out of 120).  It is expected that the OIG request a refund of any federal Medicaid dollars paid to a state agency for improper claims; however, the dollar amount paid by the federal government for the 23 improper claims was determined to be immaterial.  Because of this the OIG did not demand a refund. 

There was a variety of reasons that the OIG cited for the improperly claimed funds, including:

• State agency did not ensure patient credits applied to claims were correct or adjusted when necessary (11 claims)
• State agency did not ensure claims were priced correctly or adjusted when necessary (10 claims)
• Hospice did not meet the physician certification requirements (1 claim)
• Hospice allowed a potentially unqualified worker to perform hospice services (1 claim)
• Hospice claimed the incorrect amount and level of service (1 claim) and
• Hospice did not meet election statement requirements (52)
  • Hospices did not ensure election statements contained required language (50 claims), and
  • Hospices did not retain the election statements (2 claims)

Additionally, the OIG identified that the state agency did not have a uniform election statement for use by all hospices.  In the absence of such a form, the hospice used its own form.  Problems with the election statements centered around the waiver and acknowledgement requirements.  Specifically, the OIG found:

• For 50 claims, the hospice election statements did not include a waiver of all rights to Medicaid payments for hospice care provided by a hospice other than the hospice designated by the individual
• For 10 claims, the hospice election statements did not include a waiver of all rights to Medicaid payments for services related to the treatment of the terminal condition or a related condition for which hospice care was elected or services equivalent to hospice care
• For 2 claims, the hospice election statements did not include the individual’s acknowledgement that he or she had been given a full understanding of hospice care as an alternative to traditional covered Medicaid services

The state agency concurred with the findings of the review and corrected some while the review was being conducted.  The OIG recommended that the state agency develop and implement a uniform hospice election statement as well as ensure that hospice claims are processed correctly, and adjusted when necessary, to meet Medicaid reimbursement requirements and monitor hospices to ensure that federal and state requirements are met with regard to physician certification, the use of qualified workers, and election statement content and retention.  The OIG has had state Medicaid compliance with federal reimbursement requirements on its Annual Work Plan for several years.

Back