The HHS Office of Inspector General (OIG) announced on June 15, 2023 that it plans to initiate a new audit of Medicare payments for hospice general inpatient (GIP) services, focused on hospice GIP services furnished to Medicare beneficiaries who were discharged directly to hospice GIP care from an acute hospital stay.
The OIG will select for its audit claims for beneficiaries who had a hospital inpatient stay that reached or exceeded the geometric mean length of stay for the assigned hospital diagnosis-related group (DRG) and expects to issue its audit report in 2025. In the past, OIG’s GIP evaluations and audits focused on the appropriateness of Medicare payments for what the agency deemed were longer GIP stays of five days or more.
Specifically, the OIG’s 2013 GIP review evaluated whether the longer GIP stays from 2011 were reasonable and necessary at the higher level of care. Arising from that OIG study report, the Centers for Medicare & Medicaid Services (CMS) directed its program integrity contractors, including the Supplemental Medical Review Contractor (SMRC), to audit longer GIP stays, and many audit takebacks and Medicare appeals ensued.
Open Questions for New OIG GIP Audit
The OIG’s work plan descriptions of new audits are usually very brief and general. The OIG’s summary description here is consistent with that approach. As such, there remain many questions about this new OIG GIP audit, including the following:
- Why does OIG consider hospice GIP stays for Medicare beneficiaries whose acute inpatient hospital stay meet or exceed the “geometric mean length of stay” for the assigned DRG “high risk”? Is it because OIG believes such patients should have stabilized in that time during the hospital stay and consequently the GIP service was not needed for acute or chronic symptom management that, OIG will contend, can be managed in another setting, such as a patient’s home? OIG also notes in its audit summary that it will assess whether GIP care was not provided, suggesting that OIG will evaluate whether a less acute level of care was furnished.
- Will OIG use its traditional audit approach of selecting 100 Medicare claims, and, if so, will the claims be selected from the population of the 5,000-plus hospices across the United States, or will OIG perform multiple audits and select 100 GIP claims from individual hospice programs?
- Is OIG focused on the use of GIP care as a form of “step-down” for longer acute care hospital patients when those patients cannot be easily placed by the acute care hospital for discharge?
- Will OIG’s audit exclude hospice GIP claims for those arrangements that involve the Medicare value-based insurance design (VBID) hospice model?
- OIG notes that the Medicare payment rate for GIP is the second-highest daily rate that Medicare pays for hospice services, but will OIG consider the costs associated with providing GIP care as part of its audit?
- Will the OIG audit select GIP claims for various GIP sites of service, including hospitals, skilled nursing facilities, and freestanding inpatient hospice units?
Conclusion
As acute care hospitals and health plans increasingly look to post-acute care partners—including home health, hospice, hospital-at-home programs, and long-term care facilities—to manage Medicare patient populations, the appropriate use of hospice GIP services for beneficiaries who have elected the hospice benefit is increasingly important. The Medicare Advantage “carve in” —now pushed back to 2030 or beyond—will also play a role in the management of the GIP care among hospice beneficiaries.
OIG and CMS have for many years questioned why GIP usage rates were so low among the general hospice population, so it is curious why OIG is focused on these particular hospice GIP claims at this time. A safe assumption is that OIG is auditing these “high-risk” GIP claims to determine if hospices are overutilizing that higher level of care for certain acute care inpatients. Moreover, the OIG audit planning process tends to be quite opaque, and as such likely only time will tell how the questions noted above will be answered.