If your hospice claims raise red flags, Medicare reviewers may initiate an investigation. Whether the concern stems from patient eligibility or billing volume, a probe can lead to delayed payments or worse. That is why it is crucial to adhere to Medicare rules regarding documentation, eligibility and billing accuracy.
Common problems include admitting patients who are not eligible, maintaining incomplete records or billing practices that do not align with trends seen among other hospices in your area.
Failing to prove patient eligibility
Your facility must provide hospice Medicare benefits only to terminally ill patients who meet the eligibility guidelines. If a patient did not exhibit signs of decline at the time of admission—such as weight loss, reduced mobility, frequent hospitalizations, ongoing pain or cognitive changes—your documentation may raise concerns.
Missing physician notes or expired certifications put you at further risk. For every new admission, include a full diagnosis, symptom updates and evidence of decline. You also need to keep files updated as your patient’s condition changes.
Medicare expects your records to support the services you bill. When your notes remain unchanged for extended periods or use vague terms, reviewers may question the type of care you provide. Here are a few record-keeping issues that often lead to red flags:
- Files that are not updated after each recertification
- Progress notes that fail to justify hospice-level care
- Billing forms that do not match clinical documentation
Every chart should reflect a patient’s condition. Your clinical notes must line up with the claims you submit.
Submitting unusual or excessive billing
Significant or sudden increases in billing can trigger fraud investigations or audits. Medicare reviewers look at your billing for continuous care or inpatient services and compare it with other providers in your area. For instance, a pattern of switching patients from routine to inpatient services without supporting documentation may raise concerns.
You cannot predict when a review will begin. Still, detailed documentation can help you mitigate risks. Conduct regular audits, weekly or monthly, depending on your claim volume. These audits can help you catch issues early and resolve them before they lead to reviews, delayed reimbursements or payment holds.
If your hospice comes under investigation for possible fraud, a lawyer familiar with Medicare probes can help you engage with reviewers, avoid common missteps and assert your administrative rights.