NHPCO Management Leadership Conference
September 11, 2006
New York, New York

Hospice Risk Areas

The OIG has identified twenty-eight risk areas for hospices. These risk areas are listed below and explained in great detail in the footnotes at the end of the draft Compliance Program Guidelines found here.

1. Uninformed consent to elect the Medicare Hospice Benefit;
2. Admitting patients to hospice care who are not terminally ill;
3. Arrangement with another health care provider who a hospice knows is submitting claims for services already covered by the Medicare Hospice Benefit;
4. Under-utilization;
5. Falsified medical records or plans of care;
6. Untimely and/or forged physician certifications on plans of care;
7. Inadequate or incomplete services rendered by the Interdisciplinary Group (IDG);
8. Insufficient oversight of patients receiving more than six consecutive months of hospice care;
9. Hospice incentives to actual or potential referral sources (e.g., physicians, nursing homes, hospitals, patients, etc.) that may violate the anti-kickback statute or other similar Federal or State statute or regulation, including improper arrangements with nursing homes;
10. Overlap in the services that a nursing home provides, which results in insufficient care provided by a hospice to a nursing home resident;
11. Improper relinquishment of core services and professional management responsibilities to nursing homes, volunteers, and privately-paid professionals;
12. Providing hospice services in a nursing home before a written agreement has been finalized, if required;
13. Billing for a higher level of services than was necessary;
14. Knowingly billing for inadequate or substandard care;
15. Inadequate justification in the medical record when a patient revokes the Medicare Hospice Benefit;
16. Billing for hospice care provided by unqualified or unlicensed clinical personnel;
17. False dating of amendments to medical records;
18. High-pressure marketing of hospice care to ineligible beneficiaries;
19. Improper patient solicitation activities, such as “patient charting;”
20. Inadequate management and oversight of subcontracted services, which results in improper billing;
21. Sales commissions based upon length of stay in hospice;
22. Deficient coordination of volunteers;
23. Improper indication of the location where hospice services were delivered;
24. Failure to comply with applicable requirements for verbal orders for hospice services;
25. Non-response to late hospice referrals by physicians;
26. Knowing misuse of provider certification numbers, which results in improper billing;
27. Failure to adhere to hospice licensing requirements and Medicare conditions of participation; and
28. Knowing failure to return overpayments made by Federal health programs.

If you have any questions or if you would like more information, please contact:

Connie A. Raffa
212.484.3926
raffa.connie@arentfox.com