New Operation Restore Trust audits underscore changing view of hospice
Is hospice becoming the bad guy’ in regulatory eyes?
Widespread press attention to Operation Restore Trust’s (ORT) audits of hospices’ enrollment practices may be tarnishing the hospice reputation as an idealistic, mission-driven class of providers.
Some hospice insiders believe that growing attention to the ORT audits including newly released information on two draft audit reports on hospices in Dallas will undermine the historically benevolent and indulgent view of hospices taken by health care regulators. Others call this climate of scrutiny both expected and necessary growing pains for a $2 billion industry struggling to take its rightful place as a serious health care provider.
ORT focuses on long stay patients
ORT, a federal program under the Office of the Inspector General (OIG) in the U.S. Department of Health and Human Services aimed at rooting out fraud and abuse in Medicare, has yet to report any cases of hospice fraud. Yet government auditors continue to target patients enrolled on the Medicare hospice benefit longer than 210 days and to conclude that some aren’t eligible for the benefit.
"All of a sudden hospice is the bad guy," observes Bernice Wilson, RN, MS, executive director of the Ohio Hospice Organization, in the wake of a widely reprinted Wall Street Journal article in January, "U.S. cracks down on hospices treating patients who aren’t on brink of death." Wilson sees "a new tenor and tone in the regulatory world," and newly emboldened medical reviewers. Hospices have long fought the notion that hospice patients need to be drawing their last breaths, arguing that the program’s ability to promote and manage peaceful deaths requires more time to unfold. However, shrinking lengths of stay nationwide suggest that this extra time may have become a lost luxury.
ORT targets hospice
Hospice is one of the provider groups targeted by OIG through ORT in partnership with the Health Care Financing Administration (HCFA). It is slated to expand nationwide from its initial states of Florida, New York, Illinois, Texas, and California and broaden its attention to other issues, including how nursing home patients are enrolled in hospice, sales and marketing methods, and systemic weaknesses in the hospice benefit. ORT is distinct from focused medical review, routinely performed by Medicare fiscal intermediaries and increasingly applied to hospices across the country. But these two forms of review are widely viewed as twin thrusts in the new regulatory scrutiny of hospices.
The two new draft audit reports on the Dallas hospices, appearing in January on the Internet home page of the OIG, are certain to further inflame anxieties of hospice providers nationwide. (See Hospice Management Advisor, February 1997, pp. 13-16.)
Draft summaries of audit reports on Family Hospice of Dallas and VNA of Texas, also based in Dallas, dated Jan. 16 and 17, respectively, appear to reach similar conclusions as 1996 ORT reports on two Florida hospices. In Florida, auditors concluded that Hospice of the Florida Suncoast in Largo and Hospice of Lake & Sumter in Tavares erred in determining prognosis for certain long-stay hospice patients and recommended that Medicare’s fiscal intermediary recoup millions of dollars in reimbursement for those patients. The hospices have responded that OIG’s conclusion reflects a subjective difference in medical opinion, especially since the auditors have not released explicit criteria for their decisions. HCFA has not publicly responded to this controversy.
The new ORT reports recommend that $973,094 and $1,242,806 be recouped from Family Hospice and VNA, respectively. When contacted by HMA in early February, spokespersons for the two agencies said they were unaware of their presence on OIG’s home page. However, Family Hospice CEO James Reese subsequently obtained his agency’s draft report.
Reese told HMA that his agency served 2,297 patients between January 1993 and September 1995, the period covered by the OIG audit. Only 60 long-stay patients were reviewed by surveyors and only 22 were deemed ineligible for hospice coverage. Of these, at least 10 subsequently died, suggesting that they were, indeed, terminally ill leaving, in Reese’s computation, less than 0.5% still at question. "Being right 99% of the time seems pretty good to me," he says.
Will reimbursements be demanded?
While the new ORT reports appear to follow the pattern of those on the Florida hospices although much smaller amounts are at stake a new wrinkle on this controversy can be found in a Nov. 18, 1996, letter to OIG by Don G. Wells, director of Medicare Part A Medical Review for Palmetto Government Benefits Administrators of Camden, SC, the Texas hospices’ fiscal intermediary. In response to the draft OIG report on Family Hospice, Wells states that, while he agrees with OIR’s conclusions, "We would be reluctant to recover payments. . . . HCFA had instructed us to educate providers rather than deny services for the time period in question."
The fact that Hospice of the Florida Suncoast, deemed by OIG last August to owe $8.9 million in Medicare reimbursement for ineligible patients, so far has not been subject to any recoupment efforts.
However, even if it turns out that hospices audited under ORT are not subjected to recoupment efforts, the scrutiny is becoming a black eye for the industry. "I think we’re in the most challenging time we’ve ever faced in hospice," asserts Patricia Murphy, RN, director of Marin Home Care in San Rafael, CA, and past president of the California State Hospice Association. "The state has stepped up its scrutiny. [Fiscal intermediary] Blue Cross of California has stepped up its efforts. Apple pie and motherhood for hospice; forget it."
"Hospice providers in this state are strong, and by and large in compliance, because our state has always been very closely regulated, says Amber Jones, MEd, president and chief executive officer of the New York State Hospice Association in Albany. "But the definitions of being in compliance have changed. There’s a huge reaction forming to ORT. The larger hospices are better positioned, but the smaller programs are terrified. They assume they’re guilty without even putting up a fight," Jones says. "And I think the drop in length of stay is directly attributable [to ORT]."
Historically, hospice has been exempt from the kind of intense scrutiny other Medicare providers routinely face, says the hospice’s CEO, Mary Labyak, MSSW, LCSW, CEO for the Hospice of the Florida Suncoast. "Now we’ve joined the big leagues. Clearly the government has seen the big growth in hospice and people entering the business of hospice who are not motivated by its mission. I’m not opposed to hospice being held accountable and responsible. I’d be the first to push for better standards for hospice," Labyak says, even though she challenges the methodology used by OIG to audit her agency. She also insists that admitting patients to hospice too late is a larger problem than admitting patients too early, and the second guessing of hospice medical judgments by ORT surveyors could cause patients and physicians to delay admissions even further.
"We want to take our rightful place in health care. Well, let’s look at what’s important and do it," she adds.
"This process has made all of us step up once we got over the shock to think about what’s the next level of practice in hospice care and hospice management."
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