Overview
During our audit period, MassHealth paid an estimated $45,110,697 in claims12 for professional services such as home health aide services, homemaker services, and companion care that were not coordinated by members’ hospice providers. Instead, they were arranged by members, their relatives, or others without the hospice providers’ knowledge. Subsequently, the non-hospice providers billed MassHealth directly for these services. Because the services were not coordinated by the hospice providers, they may have been duplicative of services that the hospices were already providing and that were therefore unallowable.
Based on our review of these services, we estimate that claims totaling $5,952,842,13 of the total $45,110,697 in claims submitted to MassHealth by non-hospice providers, were already included in members’ plans of care and would have been paid for by the hospice providers. Although the services associated with the remaining $39,157,855 in claims were not included in the members’ plans of care, the services were not coordinated by the hospice providers. Without coordinating these services, hospices do not have the opportunity to review the claims to determine whether they should pay them. MassHealth could have used this money to provide additional services to other MassHealth members.
Authoritative Guidance
According to Section 418.56(e) of Title 42 of the Code of Federal Regulations (CFR), hospice providers must effectively direct, coordinate, and supervise all services provided to dual-eligible members who have chosen to receive hospice services:
Standard: Coordination of services. The hospice must . . .
1. Ensure that the [hospice] interdisciplinary group maintains responsibility for directing, coordinating, and supervising the care and services provided. . . .
4. Provide for and ensure the ongoing sharing of information between all disciplines providing care and services in all settings, whether the care and services are provided directly or under arrangement.
5. Provide for an ongoing sharing of information with other non-hospice healthcare providers furnishing services unrelated to the terminal illness and related conditions.
Effective coordination of services would include ensuring proper billing.
According to 130 CMR 437.421(C)(2), hospice providers must provide all the services members need, as documented in their plans of care, and coordinate all in-home support services that are provided by non-hospice providers.
Role of Team. The hospice interdisciplinary team . . . must supervise care and services, including . . .
b. ensuring that the plan of care is coordinated with any services the member may be authorized to receive from . . . a home- and community-based service network.
In addition, according to 130 CMR 437.412(B)(3)(a), MassHealth does not pay for “any MassHealth services that are equivalent to or duplicative of hospice services.”
Reasons for Issue
Hospice providers did not coordinate these services with non-hospice providers to ensure proper service coordination and billing. In addition, the information in MMIS that identifies dual-eligible members who have chosen to receive hospice services may not be accurate (see Finding 1), which would result in some of these claims not being appropriately screened before payment. For the members who were correctly identified in MMIS as having chosen to receive hospice services, the system edits in MMIS appear not to have been effective in detecting and denying all claims for hospice services that may have been duplicative of services that the hospices were already providing that were therefore unallowable.
Recommendations
- MassHealth should ensure that its hospice providers coordinate professional services with non-hospice providers for dual-eligible members to ensure proper service coordination and billing.
- MassHealth should update its system edits in MMIS to detect and deny claims for dual-eligible members in hospice care that might be duplicative of services that should be paid for by hospice providers.
Auditee’s Response
EOHHS and MassHealth responded,
EOHHS disagrees with the conclusion indicated by the auditors’ draft findings that if a member with disabilities enrolled in an HCBS waiver elects to receive hospice services, the member should cease to receive HCBS waiver services such as residential habilitation, companion services, or services that provide in-home respite. For purposes of residential habilitation, this would likely mean requiring the member to be placed in a nursing facility. Similarly, as hospice does not cover in-home respite (only inpatient respite services), this would likely result in unnecessary and inappropriate hospital admissions for members whose caregivers had previously utilized in-home respite through the member’s HCBS waiver prior to the member’s election of hospice. EOHHS disagrees with an outcome in which members with disabilities enrolled in an HCBS waiver must choose between, on the one hand, their continued receipt of HCBS waiver services that help them to remain in the community, and on the other hand, receipt of hospice services for the palliation and management of their terminal illness. . . .
Pursuant to CMS guidance on the scope of the Medicare hospice benefit, Medicare hospice services are meant to supplement rather than replace personal care services provided under Medicaid. Specifically, CMS clarified at page 32905 of Federal Register Vol. 73, No. 109 (2008) (announcing changes to Medicare hospice regulations) that:
Hospice care is meant to supplement the care provided by the patient’s caregiver. If the individual(s) furnishing Medicaid personal care services is functioning as the patient’s caregiver, then the hospice would not be expected to replace the Medicaid personal care providers with its own homemaker services on a round the-clock basis. The Medicare hospice benefit is not meant to be a caregiver benefit and should not be expected to function as such.
As part of the auditors’ basis for their finding that these services should have been paid by the Medicare hospice provider, the auditors cite federal Medicare guidance addressing the scope of the rates for Medicare covered hospice services. Specifically, the auditors cite . . . Federal Register Vol. 83, No. 89 (2018) (announcing Medicare rates for hospice services) and CMS’s statement that the Medicare rates for hospice are:
comprehensive, and we have reiterated since 1983 that “virtually all” care needed by the terminally ill individual would be provided by hospice. We believe that that it would be unusual and exceptional to see services provided outside of hospice for those individuals who are approaching the end of life.
Notably, however, Medicare and Medicaid are separate health programs and Medicare is a much narrower benefit than Medicaid, covering a substantially smaller scope of services. As a result, while the CMS guidance cited by the auditors is that the Medicare hospice rates are intended to cover “virtually all” Medicare services, EOHHS disagrees with the auditors’ overly broad interpretation that this guidance also means the Medicare hospice rates are intended to cover (or could cover) “virtually all” Medicaid services, such as the array of long term services and supports available under MassHealth that are not covered under Medicare, like Adult Foster Care. . . .
EOHHS disagrees with Finding 2. The audit team identified 70 MassHealth claims for non-hospice services totaling $628,298 that fall under Audit Finding 2, in which the auditors assert that the services “were not coordinated by the hospice providers” and “may have been duplicative of services that the hospice agencies were already providing and that were therefore unallowable.” EOHHS‘s review of these claims indicates that all 70 claims were appropriately paid claims for either MassHealth Category 2—1915(c) HCBS waiver services (57 claims) or MassHealth Category 3—state plan services unrelated to hospice (13 claims). Accordingly, EOHHS strongly disagrees with the auditors’ finding that MassHealth paid an estimated $45,110,697, based on extrapolation as detailed in the draft audit report, for services that may have been unallowable due to a lack of coordination, where these claims were for either payable 1915(c) HCBS waiver claims or payable claims for state plan services unrelated to hospice.
With regard to the 57 HCBS waiver claims, as discussed in EOHHS’ introduction, HCBS waiver services provide long term services and supports that enable members with disabilities to remain in the community as an alternative to a facility and are services which are neither covered under Medicare nor included in the scope of the Medicare hospice benefit. MassHealth members enrolled in an HCBS Waiver are not required to disenroll from their waiver upon the election of hospice and may continue to receive HCBS waiver services while on hospice. Additionally, to avoid duplication of services, members enrolled in an HCBS Waiver receive case management and care coordination of their HCBS waiver services, which includes coordination of their HCBS waiver services with other non-waiver services the member may be receiving, such as hospice.
Contrary to the auditors’ assertions that there was an absence of care coordination, EOHHS’s review of Frail Elder Waiver care plans for the members associated with the identified claims for home health aide, homemaker, and companion waiver services indicates that the member’s waiver case manager was aware of the member’s receipt of hospice services and was coordinating these waiver services with the hospice provider’s provision of hospice services. In many instances, the HCBS waiver services were for the purpose of in-home respite, which is not covered under the Medicare hospice services the member was receiving.14 In other instances, these waiver services were for long standing [activity of daily living and instrumental activity of daily living] support in place prior to the member’s election of hospice and which were not related to the member’s terminal illness and thus also not covered under the Medicare hospice services the member was receiving.
HCBS waiver claims in Audit Finding 2 also included claims for residential habilitation services (group home services) provided under MassHealth’s ID/DD Residential Supports waiver. Residential Habilitation is paid at a per diem rate and is provided in group homes that are provider owned-and-operated and include 24/7 staffing and supervision provided by employees of the provider. Where members receiving residential habilitation reside in the provider’s group home, it is unrealistic to envision a scenario in which the provider of Medicare covered hospice services was not coordinating its delivery of care with the member’s residential habilitation services. Additionally, where residential habilitation services are paid at a per diem rate, absent a denial of residential habilitation services in potential violation of the [Americans with Disabilities Act], it is unclear to EOHHS how “MassHealth could have used this money to provide additional services to other MassHealth members” as the auditors assert. . . .15
Audit Finding 2 also included 13 claims for MassHealth state plan services unrelated to hospice, which were primarily claims for AFC services (10 claims). As noted above, AFC services provide 24/7 personal care that is provided by a live-in caregiver and which, like hospice, are paid at a per diem rate. Pursuant to federal Medicaid guidance, Members may continue to receive personal care services, such as AFC, while on hospice.16 Contrary to the auditors’ assertion that the AFC services were not coordinated with hospice, MassHealth AFC bulletin 13 specifies that “if the member elects hospice, the AFC provider must coordinate its delivery of AFC services with the services provided through hospice. . . .” Notably, the auditors have provided no evidence that the AFC’s live-in caregiver failed to coordinate their delivery of care with the Medicare hospice provider and due to the live-in nature of this care, it is difficult to envision a scenario in which the AFC’s caregiver and the Medicare hospice provider were not coordinating the delivery of their care. Finally, where AFC services are paid at a per diem rate, absent a denial of AFC services in potential violation of the ADA, it is unclear to EOHHS how “MassHealth could have used this money to provide additional services to other MassHealth members” as the auditors assert. . . .17
[Regarding Recommendation 1,] as mentioned above, EOHHS’s review of the professional services identified in Finding 2 indicates that the services were coordinated and the claims were appropriately paid by MassHealth. EOHHS will continue to provide education to MassHealth enrolled hospice providers on their obligation to coordinate the delivery of hospice services with other non-hospice services a member may be receiving.
[Regarding Recommendation 2,] as noted above, EOHHS is implementing processes to proactively identify dual-eligible members receiving Medicare covered hospice services who have not simultaneously executed a MassHealth hospice election form. This process may result in additional MMIS system edits.
Auditor’s Reply
Contrary to what EOHHS states in its response, our audit does not conclude that if a member with disabilities who is enrolled in a home and community-based services (HCBS) program with a waiver elects to receive hospice services, the member should stop receiving their HCBS waiver services. Rather, our report concludes that members who have elected the hospice benefit should receive all of their required services. However, our concern is that all of these services are not being properly coordinated with members’ hospice providers and, therefore, may not always be paid for by the appropriate parties. Further, we do not question the provision of the professional services under HCBS waivers included in our sample and do not suggest that members with disabilities enrolled in an HCBS program with a waiver must choose between their continued receipt of HCBS waiver services and the receipt of hospice services for the palliation and management of their terminal illness.
Although EOHHS states that its review of the Frail Elder Waiver care plans for the members in question indicated that these services were coordinated with the members’ hospice providers, it did not provide us with any documentation to substantiate this assertion. Further, during our audit, OSA reviewed the plans of care for each member and conducted interviews with management at each of the 59 hospices we visited. Based on this audit work, we found no evidence that many of the services included in our sample had been coordinated with the hospice providers. In fact, as noted above, for 70 of the 100 claims in our sample population, hospice management for the members stated that they were unaware that these services had been performed.
In its response, EOHHS states that it determined that it would have paid for most of the claims in our sample. We cannot comment on this because, as previously mentioned, we were not provided with the records EOHHS used to make this determination. However, even if EOHHS’s assertion is accurate, our concern is that MassHealth did not ensure that certain claim processing controls, designed to prevent improper payments for hospice services, functioned as intended. As mentioned in Finding 1, for the majority of the claims in our sample, MassHealth was not aware that the members had elected the hospice benefit. Therefore, none of the claims processed for these members during the audit period had been subjected to the system edit (“edit 2018”) that would have detected and prevented improper payments. Even if EOHHS would have paid for the majority of the claims in our sample as they assert, we estimate that during our audit period, MassHealth processed approximately $56,640,242 in non-hospice-provider claims in the four claim types we reviewed that were not subject to these system edits. As we stated previously in this report, CMS identified an improper payment rate of approximately 21% regarding all Medicaid claims. Therefore, we believe there is a higher-than-acceptable risk that some of these paid claims may have been improper.
In their response, EOHHS asserts that the services in our sample were coordinated with hospice providers, including services provided under a 1915(c) waiver for HCBS, which were coordinated by a waiver case manager. However, there was no documentation (e.g., notations in a member’s plan of care) at the hospices we visited that indicated that the hospices were aware of the services and were coordinating them. On the contrary, hospice providers told us they were unaware that the services were being provided. Moreover, after reviewing the claims in question, a number of hospice officials stated that they would have paid for some of them. Federal regulations require hospice providers to coordinate all hospice services, including those provided under Medicaid waivers. This is because hospice personnel who have evaluated members’ physical condition and determined their service needs are in the best position to ensure that the types and levels of services provided are appropriate, necessary, and not duplicative. Further, in terms of billing, the hospice is the only entity that can determine whether the services provided are related to a member’s terminal illness and/or are contained in a member’s plan of care and therefore represent expenses that should be paid for by the hospice, not MassHealth. State regulation 130 CMR 437.422(B) also makes it clear that hospice providers must coordinate all care for members in hospice and must document all the services the members receive in their plans of care:
The plan of care must reflect member and family goals and interventions based on problems identified in the comprehensive assessment. The plan must include all services necessary for the palliation and management of the terminal illness and related conditions, including the coordination of all in-home supports. The plan of care must be coordinated with any services the member may be authorized to receive from the MassHealth Personal Care Attendant Program and such services may be used only to the extent that the hospice would routinely use the services of a hospice member's family in implementing the plan of care.
EOHHS and MassHealth state,
It is unrealistic to envision a scenario in which the provider of Medicare covered hospice services was not coordinating its delivery of care with the member’s residential habilitation services.
However, CMS is aware that there is a lack of coordination between hospices and non-hospice providers. In Federal Register 84, No. 151 (2019), CMS states,
We have also received anecdotal reports from hospices who state they were unaware that patients had received care from non-hospice providers. In these reports, the hospice would first learn of this outside care when non-hospice providers would contact the hospice seeking reimbursement. If this care was related to the terminal illness and related conditions and the hospice did not make arrangements for such care, the beneficiary would be liable for the costs of receiving that care.
Additionally, if non-hospice providers bill Medicare for services that potentially should have been the coverage responsibility of hospice, Medicare could be making duplicative payments for care related to the terminal illness and related conditions.
In addition to the anecdotal reports, management at many of the hospices we visited stated, as mentioned above, that they were unaware that services outside their plans of care had been performed, since they never received any requests from the non-hospice providers for reimbursement for them. This indicates a lack of coordination of services.
EOHHS points that Medicare hospice services are meant to supplement personal care services, not replace them. OSA does not dispute this, but again, all services are required to be coordinated by a member’s hospice.
Additionally, the system edits described above reduce improper payments and help ensure that MassHealth is the payer of last resort. Although this can be done by reviewing claims after they have been paid to determine whether payments were proper, the most effective way to minimize unnecessary payments for hospice services is to prevent them from occurring by ensuring that proper controls over claim processing have been established and are functioning as intended. This is particularly important for dual-eligible members who have elected the hospice benefit, since billing for the services they receive can be more complicated (e.g., some services are both Medicaid and Medicare reimbursable).
Regardless of the amount of the questionable claims we identified during this audit, during our audit period there were significant claim processing issues for hospice that put millions of dollars of hospice claims at risk of being improper. EOHHS needs to address this issue.
Based on its response, EOHHS is taking measures to address our concerns on this matter.
| Date published: | July 20, 2021 |
|---|