Hospice Care Claims and Fiscal Agent Contract

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.

Service Intensity Add-On (SIA) Rate Used Inappropriately: improper payments estimated at about $117,000 for 2020-2022; issues include use before the last 7 days of life, dates of death, and daily hour limits being exceeded.

Fiscal Agent Contracting Process Can Be Improved: frequent contract amendments since 2011 increasing the maximum to $803 million (from $176 million) without competitive bids; multiple amendments and lack of formal RFP process.

The Division lacks adequate controls to ensure hospice care provider payments comply with federal and state Medicaid policies, leading to improper payments.

Inadequate Controls Allowed Service Payments for Deceased Recipients: four dates of service in 2020-2022 claimed after death, with immaterial amounts but potential significance across all claims.

MMIS System Modernization and Controls Gaps: older system controls not fully carried over to MMIS modernization, contributing to improper payments.

Analyze hospice provider claims to identify those providers that received overpayments for duplicate hospice room and board services and recoup the overpayments.

Create MMIS system controls to prevent providers from receiving payment for the higher hospice routine home care rate if the recipient is continuously enrolled in hospice care for over 60 days.

Analyze hospice provider claims to identify those providers that received overpayments for the higher hospice routine home care rate and recoup the overpayments.

Create MMIS system controls to prevent improper payment of the service intensity add-on rate.

Modify the Medicaid Service Manual for hospice services to include the proper use of the service intensity add-on rate.

Modify the MMIS system controls to limit the service intensity add-on amount paid to only 4 hours per day.

Develop a process to identify improper payments for services claimed to be rendered after a recipient’s date of death and recoup any improper payments identified.

Work with the Department of Administration, Purchasing Division to identify, document, and update specifications so an effective RFP can be prepared before the expiration of the current contract in June 2028.

Competitively solicit bids for a fiscal agent before the current contract term ends, in compliance with state policies.

Create MMIS system controls to prevent hospice providers from receiving payment for duplicate hospice room and board services.