Hospices’ CERT Improper Payment Rate Up In 2022
The payment rate was way up, while the HHA error rate was down.
If you’re wondering how much review pressure your hospice is likely to encounter this year, Medicare’s recent Comprehensive Error Rate Testing (CERT) report may tell you. Hospices clocked in with a 12.04 percent improper payment rate for 2022, equaling an estimated $2.9 billion in improper payments, said the Department of Health and Human Services (HHS) in its Agency Financial Report for fiscal year 2022. That’s up sharply from a rate of 7.77 percent last year.
The Numbers Are In
Until 2021, hospice improper payment rates as measured by Medicare’s CERT program had been declining for years: 10.7 percent for 2015, then spiking to 15.9 percent for 2016, then falling again to 14.7 percent for 2017, 11.7 percent for 2018, 9.7 percent for 2019, and 6.69 percent for 2020.
The Centers for Medicare & Medicaid Services (CMS) is quick to point out that improper payments don’t necessarily equal fraud or abuse. “While fraud and abuse are improper payments, not all improper payments represent fraud,” CMS says in a fact sheet about this year’s figures. “Improper payment estimates are not fraud rate estimates,” the agency emphasizes. But that nuance may go unnoticed by contractors setting review priorities or lawmakers looking for places to trim budget fat, hospices and their representatives fear.
Hospice spending is a relatively small piece of the Medicare spending pie, meaning that big review efforts would yield comparatively small results. But hospices rank relatively high on the error rate list — sixth on the list of non-inpatient hospital Part A providers — CMS says in its 2022 Medicare Fee-for-Service Supplemental Improper Payment Data report. (The highest rate on that list is for comprehensive outpatient rehab facilities at 47.4 percent, the lowest is for end-stage renal dialysis facilities at 1.2 percent.) And, of course, hospices have been the subject of numerous mainstream press articles decrying the for-profit takeover of the industry, etc.
The biggest-dollar problem CERT reviewers found with hospice claims is for medical necessity, CMS data highlights. Nonhospital-based hospice claims had a 4.8 percent improper payment rate for that denial reason, landing them at the top of Medicare’s list for overall improper payments at 3.3 percent. (The next-highest amount of improper payments due to medical necessity was for Part A hospital services at 3.0 percent, then HHA services at 2.3 percent). But the most common type of hospice claim error was for inadequate physician certification or recertification. Reviewers assigned that error to 34 claims, the highest amount of the sample.
Other common hospice claim errors were for lack of medical necessity (31 claims), missing Service Intensity Add-on documentation (18 claims), an inadequate beneficiary election form (11 claims), inadequate physician narrative (10 claims), inadequate SIA documentation (nine claims), inadequate face-to-face documentation (seven claims), missing cert/recert (seven claims), missing F2F (six claims), and physician signature dated after the claim was submitted (six claims).
Hospices ranked relatively high on the list for percentage of claims containing errors (16.1 percent for nonhospital-based and 22.6 percent for hospital-based), by type of bill. That compares to the list-high 30.9 percent for hospital Part B claims.
Lack of Medical Necessity
HHAs saw their improper payment rate fall this year, but just barely. They registered a 10.15 percent improper payment rate for 2022, equaling an estimated $1.8 billion in improper payments, according to the HHS report. That’s down a bit from last year’s 10.24 percent, although HHS is quick to point out “this change is not statistically significant.”
Last year’s rate was the first rise for HHAs in years. HHAs had a whopping 59 percent error rate in 2015, falling to 42 percent for 2016; 32 percent for 2017; 17.6 percent for 2018; 12.1 percent for 2019; and 9.30 percent for 2020.
The overwhelming reason for home health claim errors in 2022 was lack of medical necessity (124 claims), trailed by inadequate physician cert/recert (26 claims), inadequate “All required content” of the cert/recert (21 claims), incorrect HIPPS code (15 claims), inadequate face-to-face attestation (14 claims), missing HIPPS code supporting documentation (12 claims), missing records from certifying physician or facility (nine claims), physician signature after claim was submitted (nine claims), missing F2F documentation (eight claims), and inadequate plan of care (eight claims).
CMS singles out the 14 states with the highest number of home health and hospice payment errors combined in their own chart. Topping the list are Texas (23.1 percent error rate), Oklahoma (19.7 percent), and Georgia (17.9 percent).
In comparison: The overall Medicare improper payment rate for 2022 was 7.46 percent, equaling $31.56 billion, HHS notes. Skilled nursing facilities’ improper payment rate shot up from 7.79 percent in 2021 to 15.10 percent in 2022.
“HHS has developed preventive measures for specific service areas with high improper payment estimates, such as SNF, hospital outpatient, hospice, and home health,” the organization says. “HHS believes targeted actions will prevent and reduce improper payments in these areas.” HHS mentions the Review Choice Demonstration, Targeted Probe and Educate audits, and Recovery Audit Contractor reviews as examples.
You can find more payment error rate data in the HHS report at www.hhs.gov/sites/default/files/fy-2022-hhs-agency-financial-report.pdf and the CMS report at www.cms.gov/files/document/2022-medicare-fee-service-supplemental-improper-payment-data.pdf. Previous years’ reports are available at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/CERT/CERT-Reports.
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