Objective

To determine whether Medicaid made improper payments to providers on behalf of dual-eligible individuals receiving hospice care covered by Medicare. This audit covered the period January 1, 2015 through July 31, 2019.

About the Program

Hospice is a coordinated program of home and/or inpatient care that treats terminally ill individuals and their families. Hospice programs provide palliative care, including nursing, physician, and counseling services; home health aides; physical and occupational therapy; medical appliances and supplies; and drugs. When individuals are enrolled in both Medicaid and Medicare (referred to as dual-eligibles), Medicare is the primary payer for Medicare-covered hospice services, while Medicaid is the payer of last resort.

Several entities are responsible for coordinating services on behalf of individuals who are receiving hospice care. In addition to delivering services, hospice providers are responsible for developing a comprehensive plan of care and coordinating care and services needed by patients. Many dual-eligibles in hospice are also enrolled in Medicaid Managed Long-Term Care (MLTC) plans, which serve people who require nursing home or long-term home health care. When a Medicaid recipient is enrolled in a MLTC plan, the plan is required to coordinate care with other providers, including hospice providers, to avoid duplicative or excessive services and payments. When a recipient is enrolled in Medicaid fee-for-service, Local Departments of Social Services (LDSS) and/or Medicaid providers are generally responsible for authorizing appropriate services and coordinating care to avoid inappropriate Medicaid payments.

Key Findings

The audit identified about $50 million in actual and potential Medicaid overpayments, cost-savings opportunities, and questionable payments for services provided to dual-eligibles enrolled in Medicare-covered hospice, as follows:

• $5.5 million in actual and potential overpayments for services that are not allowed in conjunction with hospice (such as Assisted Living) and services that are covered by the Medicare hospice benefit (such as nursing care and drugs);
• $370,506 in actual and potential overpayments for personal care services in excess of 24 hours in a single day;
• $39.8 million in questionable payments for personal care (totaling $35.7 million) and durable medical equipment and supplies (totaling $4.1 million) that may have been eligible to be covered by the Medicare hospice benefit; and
• $4.3 million in unnecessary payments for nursing home room and board under managed care.

Key Recommendations

• Review the $5.9 million in actual and potential overpayments and ensure proper recoveries are made.
• Improve controls to prevent improper payments for services provided to dual-eligibles receiving Medicare-covered hospice care.
• Advise MLTC plans, LDSS, and hospice providers to coordinate care and financial obligations.