OIG issues nursing home/hospice fraud alert
The HHS Office of the Inspector General's latest special fraud alert tackles questionable arrangements between nursing homes and hospices. The OIG is particularly watching for hospices that provide illegal kickbacks to nursing homes to influence the referral of patients.
Under the anti-kickback statue, it's illegal to "knowingly and willfully solicit, receive, offer, or pay anything of value to induce referrals of items or services payable by a federal health care program" such as Medicare.
OIG officials claim to have observed recent instances of such illegal arrangements between hospices and nursing homes. The agency notes that, although the hospice benefit makes up only about 1.5% of total Medicare Part A expenditures, the amount of Medicare hospice payments has grown steadily throughout the 90s and now accounts for more than $1 billion in payments per year.
Here are the "red flags" the OIG is looking for under this alert:
s a hospice offering free goods or goods at below fair market value to induce a nursing home to refer patients to the hospice;
s a hospice paying "room and board" payments to the nursing home in amounts in excess of what the nursing home would have received directly from Medicaid, had the patient not been enrolled in hospice;
s a hospice paying amounts to the nursing home for "additional" services that Medicaid considers to be included in its room and board payment to the hospice;
s a hospice paying above fair market value for "additional" non-core services which Medicaid does not consider to be included in its room and board payment to the nursing home;
s a hospice referring its patients to a nursing home to induce the nursing home to refer its patients to the hospice;
s a hospice providing free or below fair market value care to nursing home patients for whom the nursing home is receiving Medicare payment under the skilled nursing facility benefit, with the expectation that after the patient exhausts the skilled nursing facility benefit, the patient will receive hospice services from that hospice;
s a hospice providing staff at its expense to the nursing home to perform duties that otherwise would be performed by the nursing home.
In general, the OIG says, "payments by a hospice to a nursing home for 'room and board' provided to a Medicaid hospice patient should not exceed what the nursing home otherwise would have received if the patient had not been enrolled in hospice. Any additional payment must represent the fair market value of additional services actually provided to that patient that are not included in the Medicaid daily rate.
Providers that violate the anti-kickback statute may be criminally prosecuted by the Department of Justice, excluded from federal health care programs, and/or subject to civil monetary penalties imposed by the OIG. (See related story on new civil monetary penalties, page 1.)
You have reached your article limit for the month. Subscribe now to access this article plus other member-only content.
- Award-winning Medical Content
- Latest Advances & Development in Medicine
- Unbiased Content