It looked at both hospital and non-hospital-based hospice services. The most recent CERT audit report 6 examining hospice claims was released in December 2022. To accomplish this, CMS has adopted the Comprehensive Error Rate Testing (CERT) program to estimate the error rate. Pursuant to the Improper Payments Information Act of 2002, 5 CMS is required to estimate the improper Medicare fee-for-service payments made to health care providers each year. Comprehensive Error Rate Testing (CERT) Audits of Hospice Claims. In this section, we will limit our discussion to hospice audit initiatives focused on traditional Medicare and Medicaid claims. Depending on your participation status, your agency may be subjected to a hospice audit by a variety of program integrity contractors tasked with conducting medical reviews of Medicare and Medicaid hospice claims, State law enforcement agencies focusing on Medicaid claims, and Special Investigative Units (SIUs) responsible for auditing hospice claims submitted to private payors, Medicare Advantage and Medicaid Managed Care plans. Overview of the Administrative Hospice Audit Landscape:Īs many of you have unfortunately learned, there are a number of Federal and State entities currently conducting audits and medical reviews of hospice claims. We will also lay out a few recommendations for avoiding a hospice audit in 2024. In this article, we will outline the current hospice audit landscape and examine recent updates to integrity programs dealing with hospice care. 3 As the industry grows, payor plans have established more stringent screening protocols and implemented intensive auditing programs to help eliminate fraud and abuse. In Fiscal Year (FY) 2023, hospice payments increased by 3.8% (an estimated $825 million over FY 2022). 2 As the Baby Boomer generation continues aging into Medicare and Medicaid coverage, the relevance of hospice care will only increase. Private equity firms have entered the industry-now estimated at 16% of all hospice providers nationwide-and have capitalized on dementia patient long-term care, the proportion of entities from nonprofit to for-profit. In recent years, the hospice industry has exponentially grown, and the number of Federal, State and Special Investigative Unit (SIU) audits and investigations have similarly increased. To be eligible for hospice care, 1 a patient must be certified as terminally ill and have a life expectancy of six months or less. View, print or share information on the new TPE program with this simple one-pager (PDF).įor further details and information about the TPE program, check out this list of TPE Q&As (PDF).(November 20, 2023) : Medicare, Medicaid, and most private insurance plans cover hospice care and related services. These may include 100 percent prepay review, extrapolation, referral to a Recovery Auditor, or other action. However, any problems that fail to improve after 3 rounds of education sessions will be referred to CMS for next steps. The majority that have participated in the TPE process increased the accuracy of their claims. This should not be a concern for most providers. *MACs may conduct additional review if significant changes in provider billing are detected What if my accuracy still doesn't improve? Providers whose claims are compliant with Medicare policy won't be chosen for TPE. items and services that have high national error rates and are a financial risk to Medicare.providers and suppliers who have high claim error rates or unusual billing practices, and.TPE is intended to increase accuracy in very specific areas. Many common errors are simple – such as a missing physician's signature – and are easily corrected. Medicare Administrative Contractors (MACs) work with you, in person, to identify errors and help you correct them. CMS's Targeted Probe and Educate (TPE) program is designed to help providers and suppliers reduce claim denials and appeals through one-on-one help. When Medicare Claims are submitted accurately, everyone benefits.
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