MassHealth's Administration of the Hospice Benefit Executive Summary

The OIG examined claims for hospice and end-of-life care.

Executive Summary: MassHealth's Administration of the Hospice Benefit

Hospice care provides for the palliation and management of terminal illnesses, but does not provide for curative treatment of an illness or injury.  Palliative treatment is patient- and family-centered care that makes quality of life the priority by anticipating, preventing, and treating suffering.  To that end, hospice care involves a group of comprehensive services that address physical, intellectual, spiritual, and emotional needs, and which facilitate patient autonomy, access to information, and choice.  Hospice providers care for patients wherever they live, including private homes, assisted living facilities, and skilled nursing facilities.

The Office examined claims for hospice and other end-of-life care for MassHealth members and HSN users.  The goal of the review was to determine whether there were any systemic issues that made the hospice program vulnerable to fraud, waste, or abuse by providers.  In this review, the Office examined hospice claims for 10,117 MassHealth members with dates of service from January 1, 2015 through December 31, 2016.  For this period, 67 hospice providers submitted claims to MassHealth, and MassHealth paid these providers over $153 million for 10,176 hospice stays.  MassHealth paid an average of $15,186 per member who received hospice services during this time.

Initial findings.  The Office initially found that MassHealth members stand out in three ways from hospice patients nationally.  First, MassHealth members with dementia-related primary diagnoses received hospice care more than members with other primary diagnoses, and at a higher rate than nationally.  Second, MassHealth members with cancer and heart- and lung-related diagnoses used hospice care at a lower rate than patients across the nation.  Finally, MassHealth members leave hospice care as live discharges at higher rates than in other states.

In-depth analysis.  After conducting this initial overview, the Office conducted an in-depth analysis of a number of issues, including the length of hospice stays, types of diagnoses on hospice claims, and hospices with multiple indicators of potential fraud, waste, or abuse of the hospice program.  Overall, the Office’s review did not find widespread fraud, waste, or abuse in the hospice program. There were, however, instances in which the Office noted that certain providers’ claim histories raised questions regarding compliance with the hospice regulations.  The Office has given the names of those providers to MassHealth for additional review.  In addition, the Office recommends a number of measures that would assist MassHealth in identifying fraud, waste, and abuse in the hospice program. 

Long-term hospice stays.  For example, the Office identified seven hospices that provided hospice care to members for substantially longer than expected – some by as much as 80% longer.  The Office recommends that MassHealth conduct an in-depth review of the hospice providers that the Office identified to determine whether those providers are committing fraud, waste, or abuse.   The Office also recommends that MassHealth consider requiring a physician to conduct a face-to-face examination of members remaining on hospice longer than the anticipated life expectancy set out by the regulations (180 days). 

Hospice care for members with dementia-related illnesses.  The Office further found that members with dementia-related diagnoses accounted for the largest share of MassHealth payments in the review, and received hospice care at a higher rate than in other states. The Office therefore recommends that MassHealth evaluate those hospices that provided services for shorter than the average length of service to determine if they are providing appropriate clinical care for members with dementia at the end of life.  If so, the Office recommends that MassHealth determine whether and how other providers can replicate their approval processes and the resulting hospice services. 

Moreover, MassHealth must ensure that those members with dementia-related diagnoses are receiving care in the appropriate clinical setting and are not receiving hospice care for the convenience of the provider or for fraudulent billing purposes.  The Office also recommends that MassHealth consider implementing specific guidelines for hospice admission, either adopting the Medicare guidelines or another set of objective measures, to help providers determine when a person with dementia should begin receiving hospice care. 

Hospice and skilled nursing facility collaborations.  The Office identified four pairs of hospice providers and skilled nursing facilities that frequently collaborated in providing care to members receiving hospice services.  As a result, the Office recommends that MassHealth review collaborations that this report identified to determine whether these hospices are providing services in a manner that is consistent with the regulatory requirements of the program.  The Office also recommends that MassHealth consider reviewing frequent skilled nursing facility and hospice collaborations as one possible indicator of fraud, waste, or abuse of the program.

Multiple indicators of potential fraud, waste, or abuse.  Finally, the Office looked at multiple indicators of potential fraud, waste, or abuse and found several providers who scored high on five or more indicators.  Accordingly, the Office recommends that MassHealth add to its program integrity activities by analyzing multiple fraud indicators to more effectively identify potential fraud, waste, or abuse by hospice providers.

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