OIG concludes hospice not so bad after all
National report finds hospice working as intended
"Overall, the Medicare hospice program seems to be working as intended," concludes the latest report on hospice prepared by the Office of Inspector General (OIG). Following several years of often contentious debate over OIG investigations of hospices under Operation Restore Trust (ORT) - some of which landed on the front pages of national newspapers, such as The Wall Street Journal - the quietly favorable results of this latest report seem almost anticlimactic.
However, the hospice industry's two national trade associations immediately greeted the results with guarded expressions of satisfaction. "We're happy that it has finally gotten out, and that the conclusion is that hospice is working as Congress intended," Diane H. Jones, MSW, ACSW, executive director of the Hospice Association of America (HAA), tells Hospice Management Advisor.
According to a statement issued by National Hospice Organization (NHO) president Karen A. Davie, "This report should reassure Americans and the medical community that the Medicare Hospice Benefit is largely working as it was designed and that hospice care is being provided by organizations committed to providing compassionate, quality care to terminally ill individuals, their caregivers and families."
However, Davie also notes that OIG's intense scrutiny of hospice had a "chilling effect on appropriate referrals of terminally ill beneficiaries and resulted in gross under-utilization of hospice services." NHO continues to question OIG's attempts to second-guess providers' determinations of patient prognosis and admission decisions based on retrospective chart audits by peer review organization physicians.
OIG's report, Medicare Hospice Beneficiaries: Services and Eligibility, concludes that "hospice agencies seemed to provide appropriate services to beneficiaries and their families . . . [with] documentation that showed beneficiaries and their families received services as indicated by the plans of care." However, it reinforces previous OIG reports highlighting particular program vulnerabilities for hospice patients residing in the nursing home setting - a problem that the hospice trade associations and the Health Care Financing Administration all agree needs fixing. Only 2% of hospice beneficiaries living at home in OIG's sampling were deemed to be ineligible for the service, based on the lack of a documented terminal prognosis, while for those living in nursing homes the proportion deemed ineligible rose to 29%.
A favorable bottom line
How did OIG reach such a favorable conclusion about hospice after so much controversy? Jones points out that previous ORT reports on hospice tended to target large hospices, and only the small minority of their patients who lived longer than 210 days. "So they were looking at nothing but outliers and trying to extrapolate from there," she notes. The new study was national in scope, looked at 36 providers of varying sizes, 13 of which were site-visited, and examined a later period of time, after providers had gotten used to the heightened scrutiny of focused medical review.
"We need to get the word out to the medical community and say, 'Don't be afraid to refer to hospice,'" Jones says. "Overall, it's a very encour aging report, confirming what we've known, that this industry is working." Adds National Hospice Organization vice president Galen Miller, PhD, "NHO is in the process of reaching out to reporters who have covered the OIG's activities to alert them to this good news. We are optimistic that it will result in coverage to more accurately portray hospice providers and the delivery of hospice care."
Another OIG report, issued in late February, details its investigation of Samaritan Care, Inc., of Lansing, IL, whose former owner has been charged with a broad array of health care fraud charges. Joseph Kirschenbaum, a former stockbroker who founded the hospice in 1991 and later sold it to Integrated Healthcare Services of Owings Mill, MD, faces a 98-count federal indictment detailing fraudulent Medicare billing, mail fraud, making false statements, and money laundering. He also faces civil charges under the False Claims Act and a suit in federal court by Integrated, alleging that he lied about the hospice's financial health and patient load at the time of the sale in 1994.
Where did all the millions come from?
Kirschenbaum, who described himself in hospice records as a volunteer administrator and pastoral counselor, now lives in Hollywood, FL. In statements issued to the press by his attorney, he has vigorously disputed the charges. Yet, U.S. Attorney Scott R. Lassar, JD, observed at the time Kirschenbaum was indicted that "this defendant became a multi-millionaire in less than three years by operating a not-for-profit hospice."
Both the criminal and civil cases against Kirschenbaum are currently on hold, pending appeal of an attempt by Kirschenbaum to free up some of the $20 million in personal assets which were frozen by the Justice Department last October, in order to pay his lawyers' fees. There is no clear timetable for how long it will take to dispose of that issue, says Randall Samborn, public information officer for the U.S. Attorney's office in Chicago.
According to a press release issued by Samborn's office, Kirschenbaum is accused of grossly inflating the number of the hospice's patients on Medicare Cap Reports, enrolling ineligible patients onto hospice care, providing minimal services to the patients - all of whom resided in nursing homes - and collecting huge fees from corporations formed by him and employing only him. These companies would then bill the certified hospice for providing ancillary services. He is also charged with fabricating detailed minutes of fictitious board meetings, employing physicians who signed their names on patient certification forms without seeing the patients or reviewing their records, and employing a social worker who spent two hours a month signing psychosocial assessments prepared by nurses.
The new OIG report hints at the magnitude of Kirschenbaum's operation through its review of 224 beneficiaries on service longer than 210 days. OIG auditors determined that the medical records for 213 (or 95%) of these beneficiaries did not support a prognosis that would make them eligible for hospice care. The medical records of five patients did not contain sufficient medical information to make a determination, and only the six remaining medical records supported such a determination. Ninety of these patients were later discharged by the new owners for being ineligible for hospice. These disputed long-stay patients represent approximately two-thirds of all Medicare payments made to the hospice while Kirschenbaum owned it.
Because of the pending charges against Kirschenbaum, OIG's report does not recommend that HCFA attempt to recoup over $10 million in identified overpayments to Samaritan Hospice. However, it underscores the potential revealed by this case to manipulate the aggregate cap on Medicare hospice reimbursement by overstating the number of patients when filing the cap report. OIG says improved controls are needed to prevent such abuses. It also notes that fiscal intermediary Health Care Service Corporation, which has since gotten out of the business of Medicare claims processing, had not performed any medical reviews on Samaritan Hospice prior to OIG's audit.
The two reports, Medicare Hospice Beneficiaries: Services and Eligibility (OEI-04-93-00270), and Audit of Beneficiary Eligibility at Samaritan Care, Inc., Lansing, IL (A-05-96-00024), are available over the Internet at www.dhhs.gov/progorg/oig, or by calling OIG's public affairs department at (202) 619-1343.
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