Hospice Care Claims and Fiscal Agent Contract
Learn how the AI-generated research projects were createdOverall Conclusion
The Division lacks adequate controls to ensure hospice care provider payments comply with federal and state Medicaid policies.
Source Document
Audit Scope
Audit covered calendar years 2020-2022 and prior years, examining MMIS hospice care claims, service-rate billing, death-date processing, and fiscal agent contracting practices as administered by the Division of Health Care Financing and Policy.
Key Findings Summary
The Division lacks adequate controls to ensure hospice care provider payments comply with federal and state Medicaid policies, leading to improper payments.
Hospice Providers Improperly Paid for Duplicate Room and Board Services: identification of 115 duplicate dates of service (2% of 5,509 claims) with estimated overpayments exceeding $155,000 during calendar years 2020-2022 due to MMIS controls gaps.
Improper Use of the Higher Routine Home Care Rate: conservatively estimated overpayments of about $114,000 for 2020-2022 due to billing the higher routine home care rate beyond the initial 60 days.
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AI-Assisted
AI Scope Summary
Future Medicaid audits should build on these findings to strengthen MMIS data integrity and billing controls, ensure strict rate-time rules for hospice services, verify proper treatment of service intensity add-ons, retrofit retroactive checks for date-of-death claims, and enforce competitive fiscal agent procurement to maximize value and protect federal funds.
AI-Generated Insight
This audit highlights critical gaps in Nevada’s MMIS controls and contracting practices that allowed improper hospice payments (notably duplicate room and board, higher routine home care rates, and service intensity add-ons) during 2020-2022. The Division has since implemented several controls and recouped overpayments, but the report emphasizes the need for ongoing system enhancements, stronger contract governance, and timely death-date processing to prevent future improper payments and improve program integrity.