Department of Health and Human Services 

OFFICE OF 

INSPECTOR GENERAL 

MEDICARE HOSPICES HAVE 

FINANCIAL INCENTIVES TO 

PROVIDE CARE IN ASSISTED 

LIVING FACILITIES 

Daniel R. Levinson 

Inspector General 

January 2015 

OEI-02-14-00070 
 

EXECUTIVE SUMMARY: MEDICARE HOSPICES HAVE FINANCIAL 

INCENTIVES TO PROVIDE CARE IN ASSISTED LIVING FACILITIES 

OEI-02-14-00070 

WHY WE DID THIS STUDY 

Medicare hospice care is intended to help terminally ill beneficiaries continue life with 

minimal disruption and to support families and caregivers. Care may be provided in 

various settings, including a private home or other places of residence, such as an assisted 

living facility (ALF). Pursuant to the Patient Protection and Affordable Care Act, the 

Centers for Medicare & Medicaid Services (CMS) must reform the hospice payment 

system, collect data relevant to revising payments, and develop quality measures. This 

report provides information to inform those decisions and is part of the Office of 

Inspector General’s (OIG) larger body of work on hospice care. While the report focuses 

on ALFs, many of the issues identified pertain to the hospice benefit more broadly. 

HOW WE DID THIS STUDY 

We based this study on an analysis of all Medicare hospice claims from 2007 through 

2012. We used Certification and Survey Provider Enhanced Reports data and Healthcare 

Cost Report Information System reports for information on hospice characteristics. 

WHAT WE FOUND 

Medicare payments for hospice care in ALFs more than doubled in 5 years, totaling 

$2.1 billion in 2012. Hospices provided care much longer and received much higher 

Medicare payments for beneficiaries in ALFs than for beneficiaries in other settings. 

Hospice beneficiaries in ALFs often had diagnoses that usually require less complex care. 

Hospices typically provided fewer than 5 hours of visits and were paid about $1,100 per 

week for each beneficiary receiving routine home care in ALFs. Also, for-profit hospices 

received much higher Medicare payments per beneficiary than nonprofit hospices. This 

report raises concerns about the financial incentives created by the current payment 

system and the potential for hospices to target beneficiaries in ALFs because they may 

offer the hospices the greatest financial gain. Together, the findings in this and previous 

OIG reports show that payment reform and more accountability are needed to reduce 

incentives for hospices to focus solely on certain types of diagnoses or settings. 

WHAT WE RECOMMEND 

We recommend that CMS, as part of its ongoing hospice reform efforts: (1) reform 

payments to reduce the incentive for hospices to target beneficiaries with certain 

diagnoses and those likely to have long stays, (2) target certain hospices for review, (3) 

develop and adopt claims-based measures of quality, (4) make hospice data publicly 

available for beneficiaries, and (5) provide additional information to hospices to educate 

them about how they compare to their peers. CMS concurred with all five 

recommendations. 
TABLE OF CONTENTS 

Objectives ....................................................................................................1 

Background..................................................................................................1 

Methodology................................................................................................6 

Findings........................................................................................................9 

Medicare payments for hospice care in ALFs more than doubled 

in 5 years, totaling $2.1 billion in 2012 ...........................................9 

Hospices provided care much longer and received much higher 

Medicare payments for beneficiaries in ALFs ................................9 

Most beneficiaries in ALFs had diagnoses that typically require 

less complex care ...........................................................................12 

Hospices typically provided fewer than 5 hours of visits per week 

and were paid about $1,100 per week for each beneficiary 

receiving routine home care in an ALF ..........................................13 

For-profit hospices received much higher Medicare payments per 

beneficiary than nonprofit hospices...............................................15 

Many for-profit hospices targeted ALFs ........................................17 

Conclusion and Recommendations ............................................................18 

Agency Comments and Office of Inspector General Response .................21 

Appendix A: Agency Comments ..............................................................23 

Acknowledgments......................................................................................27 
 

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OBJECTIVES 

1.	 To describe the trends in Medicare payments for hospice care provided 

in assisted living facilities (ALFs). 

2.	 To describe the characteristics of beneficiaries who receive hospice 

care in ALFs. 

3.	 To determine the types and frequency of hospice services provided to 

beneficiaries residing in ALFs. 

4.	 To determine the extent to which some hospices receive a high 

percentage of their Medicare reimbursement from care provided in 

ALFs. 

BACKGROUND 

The goals of hospice care are to help terminally ill beneficiaries with a life 

expectancy of 6 months or less continue life with minimal disruption and 

to support beneficiaries’ families and other caregivers throughout the 

process. The care may be provided to individuals and their families in 

various settings, including a skilled nursing facility; a private home; or 

other places of residence, such as an ALF. 

Little is known about hospice care provided in ALFs; however, some 

concerns exist. According to the Medicare Payment Advisory 

Commission (MedPAC),1 long hospice stays among ALF residents are not 

understood and bear further monitoring and examination.2 MedPAC also 

found that, under the current payment system for Medicare hospice, very 

long stays in hospice care are more profitable for providers than shorter 

stays.3 Hospices are paid a daily rate for every day a beneficiary is in 

hospice care, regardless of whether services are provided on a particular 

day. Therefore, a hospice stands to gain financially if it provides minimal 

services to a beneficiary over a long period of time. 

Pursuant to the Patient Protection and Affordable Care Act (ACA), the 

Centers for Medicare & Medicaid Services (CMS) must reform the 

hospice payment system, collect data relevant to revising hospice 

payments, and develop quality measures for hospices.4 This report 

provides data that will help inform CMS’s decisions as it fulfills these 

ACA requirements. 

1

 MedPAC is an independent Congressional agency that advises Congress on issues 

affecting the Medicare program.
 2

 MedPAC, Report to the Congress: Medicare Payment Policy, March 2012, ch. 11. 3

 MedPAC, Report to the Congress: Reforming the Delivery System, June 2008, ch. 8.
 4

 ACA, P.L. 111-148, §§ 3004(c) and 3132. 

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This report is part of the Office of Inspector General’s (OIG’s) larger body 

of work on hospice care. While it focuses on ALFs, many of the issues in 

this report pertain to the hospice benefit more broadly. They are similar to 

those that both OIG and MedPAC have identified in other hospice 

settings, such as nursing facilities.5 

The Medicare Hospice Benefit 

To be eligible for Medicare hospice care, a beneficiary must be entitled to 

Medicare Part A and be certified as having a terminal illness with a life 

expectancy of 6 months or less if the disease runs its normal course. Upon 

a beneficiary’s election of hospice care, the hospice agency assumes the 

responsibility for medical care related to the beneficiary’s terminal illness 

and related conditions. This care is palliative, rather than curative. It 

includes, among other things, nursing care, medical social services, 

hospice aide services, medical supplies (including drugs and biologicals), 

and physician services. The beneficiary waives all rights to Medicare 

payment for services related to the curative treatment of the terminal 

condition or related conditions but retains rights to Medicare payment for 

services to treat conditions unrelated to the terminal illness.6 Beneficiaries 

may revoke their election of hospice care and return to standard Medicare 

coverage at any time.7 

Beneficiaries are entitled to receive hospice care for two 90-day periods, 

followed by an unlimited number of 60-day periods.8 The benefit periods 

need not be consecutive. At the start of each period of care, a hospice 

physician must certify that the beneficiary is terminally ill and has a life 

expectancy of 6 months or less. Beginning in 2011, for the third and all 

subsequent benefit periods, a hospice physician or hospice nurse 

practitioner must perform a face-to-face visit and explain why the clinical 

5

 OIG, Medicare Hospices That Focus on Nursing Facility Residents, OEI-02-10-00070, 

July 2011; MedPAC, Report to the Congress: Medicare and the Health Care Delivery 

System, June 2013, ch. 5. 6

 CMS has developed the Medicare Care Choices Model, a demonstration program that 

will allow certain beneficiaries to receive palliative care services from certain hospice 

providers while concurrently receiving services provided by their curative care providers. 

The Model will enable CMS to study whether access to such services improves quality of 

life, increases patient satisfaction, and reduces Medicare expenditures. 7 Social Security Act, §§ 1812(d)(2), 1814(a)(7)(A) and 1861(dd)(1), 42 U.S.C. §§ 

1395d(d)(2), 1395f(a)(7)(A), and 1395x(dd)(1); 42 CFR §§ 418.20, 418.22, 418.24(d) 

and 418.28. 

8

 Social Security Act, § 1812(a)(4), 42 U.S.C. § 1395d(a)(4); 42 CFR § 418.21. Prior to 

1990, Medicare provided hospice coverage for a maximum of 210 days. 

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findings support a life expectancy of 6 months or less.9 For care to be 

covered under Part A, hospices must be certified by Medicare.10 

The Medicare hospice benefit has four levels of care: routine home care, 

continuous home care, general inpatient care, and inpatient respite care. 

Not all levels of care are allowed in all settings. For instance, routine 

home care and continuous home care are allowed in ALFs, but general 

inpatient care and inpatient respite care are not. 

Each level has an all-inclusive daily rate that is paid through Part A. For 

continuous home care, the hospice is paid an hourly rate based upon the 

number of hours of continuous care furnished to the beneficiary on that 

day.11 For all other levels of care, the daily rate is paid to the hospice for 

each day that a beneficiary is in hospice care, regardless of the amount of 

services furnished on a particular day. The rates are adjusted on the basis 

of the beneficiary’s geographic location. See Table 1 for the unadjusted 

payment rates for each level of care in fiscal year (FY) 2012. 

Table 1: Unadjusted Daily Medicare Hospice Payment 

Rates by Level of Care, FY 2012 

Level of Care Unadjusted 

FY 2012 Rate 

Routine Home Care $151.03 

Continuous Home Care $881.46 

General Inpatient Care $671.84 

Inpatient Respite Care $156.22 

Source: CMS, “Update to Hospice Payment Rates, Hospice Cap, Hospice Wage Index, 

and the Hospice Pricer for FY 2012,” Transmittal 2260, Change Request 7518, July 29, 2011. 

Routine home care is the most common level of hospice care provided. 

Medicare reimburses the hospice at this rate for each day that the 

beneficiary is under the care of the hospice and is not receiving one of the 

other levels of care. Continuous home care is allowed only during brief 

periods of crisis (i.e., when a beneficiary requires continuous home care to 

achieve palliation or management of acute medical symptoms) and only as 

necessary to maintain the individual at home. General inpatient care is for 

pain control or symptom management that cannot be managed in other 

9 Social Security Act, § 1814(a)(7)(D), 42 U.S.C. § 1395f(a)(7)(D); 

42 CFR §§ 418.22(a)(4) and (b)(3)(v). 

10 Social Security Act, §§ 1814(a) and 1866, 42 U.S.C. §§ 1395f(a) and 1395cc. 

11 The daily continuous home care rate is divided by 24 hours to determine an hourly rate. 

A minimum of 8 hours of predominantly nursing care must be provided. CMS, Medicare 

Claims Processing Manual, Pub. 100-04, ch. 11, § 30.1. 

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settings, such as the beneficiary’s home.12 Inpatient respite care is shortterm inpatient care provided to the beneficiary when necessary to relieve 

the beneficiary’s caregiver(s).13 

Some physician services relating to the terminal illness are paid separately, 

in addition to the daily rate.14 If the beneficiary’s attending physician is an 

employee of or is under contract with the hospice provider, Medicare pays 

the hospice for physician services under Part A and the hospice 

compensates the physician through salary or some other arrangement.15 In 

these instances, the Part A hospice claim will include a code for physician 

services in a line item separate from the daily rate. 

Hospice Utilization in ALFs 

ALFs cover a wide range of facility types and care types and are typically 

for seniors who need some assistance with daily living. No Medicare 

standards for ALFs exist; each State defines and regulates ALFs 

differently. Some ALFs may be referred to as “adult foster homes” or 

“residential care facilities.” ALFs generally provide housekeeping 

services, meals, and assistance with activities of daily living. 

Given the lack of consistent terminology, policymakers have had difficulty 

identifying the number of ALFs and the total number of beds in ALFs. A 

report by the AARP Public Policy Institute estimated the number of beds 

in these types of facilities in 2010 to be 1.2 million.16 AARP also cited an 

earlier study by the Assistant Secretary for Planning and Evaluation that 

reported almost 1 million ALF beds in 2007. 

Many Medicare beneficiaries reside in ALFs, but Medicare does not pay 

for ALF services. However, Medicaid may pay for ALF services for 

Medicaid beneficiaries under certain circumstances, such as a home and 

community-based waiver.17 

12 42 CFR § 418.302(b)(4). It is intended to be short-term and may be provided in one of 

three settings: a Medicare-certified hospice inpatient unit, a hospital, or a skilled nursing 

facility. See 42 CFR § 418.108. 

13 42 CFR § 418.302(b); 42 CFR § 418.204(a) (defining “periods of crisis”); and CMS, 

Medicare Claims Processing Manual, Pub. 100-04, ch. 11, § 30.1. 14 42 CFR § 418.304. While the daily rate includes hospice physicians’ medical director
 

supervisory services and administrative services, including plan of care services, other 

physician services are billed separately. 

15 A nurse practitioner can be designated as the attending physician. See 42 CFR § 

418.304(e)(1).
 16 Robert Mollica, Ari Houser, and Kathleen Ujvari, AARP Public Policy Institute, 

Insight on the Issues: Assisted Living and Residential Care in the States in 2010, July 

2012, p. 1. Accessed at 

http://www.aarp.org/content/dam/aarp/research/public_policy_institute/ltc/2012/residenti 

al-care-insight-on-the-issues-july-2012-AARP-ppi-ltc.pdf on August 7, 2014. 17 For information on Medicaid reimbursement to ALFs, see OIG, Home and CommunityBased Services in Assisted Living Facilities, OEI-09-08-00360, December 2012. 

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Medicare pays hospices for certain levels of hospice care provided in 

ALFs. The hospice agency is responsible for providing the hospice care. 

Medicare currently pays hospices the same rate for those levels of care 

provided in ALFs as it does for other settings, such as private homes. 

Changes to Hospice Benefit 

ACA requires CMS to reform the hospice payment system no earlier than 

October 2013.18 CMS is gathering information and conducting studies as 

it considers payment reform options. Also, ACA established a quality 

reporting program for hospices.19 CMS must develop quality measures for 

hospices, and hospices must report these data to CMS. Hospices began 

using the Hospice Item Set (HIS) in July 2014 to collect and submit 

standardized data on each patient they admit and discharge. The HIS will 

be used to calculate quality measures involving pain management and 

other treatment issues. In addition, CMS will begin implementing the 

hospice Experience of Care Survey in 2015 to gather information on the 

experiences of hospice patients and their caregivers with hospice 

services.20 

Related Work 

This report is part of OIG’s continuing work on Medicare hospice care. In 

2013, OIG found that more than 900 hospices did not provide any general 

inpatient care to Medicare beneficiaries and more than 400 hospices did 

not provide any level of hospice care other than routine home care.21 

In 2011, OIG issued a report that found that hospices with a high 

percentage of their Medicare beneficiaries residing in nursing facilities 

received more Medicare payments per beneficiary and served beneficiaries 

who spent more time in hospice care.22 Another report determined that 

Medicare paid an average of $960 per week for hospice care for each 

beneficiary in a nursing facility in 2006.23 This care most commonly 

included nursing, home health aide (also known as hospice aide), and 

medical social services. Hospices provided an average of 4.2 visits per 

week for these three services combined. 

18 ACA, P.L. 111-148 § 3132. 

19 ACA, P.L. 111-148 § 3004(c). 

20 78 Fed. Reg. 48234, 48257-62 (Aug. 7, 2013). CMS plans to develop additional 

measures to be used in future years. 

21 OIG, Medicare Hospice: Use of General Inpatient Care, OEI-02-10-00490, May 

2013. 

22 OIG, Medicare Hospices That Focus on Nursing Facility Residents, OEI-02-10-00070, 

July 2011. 

23 OIG, Medicare Hospice Care: Services Provided to Beneficiaries Residing in Nursing
 

Facilities, OEI-02-06-00223, September 2009. Payment for physician services was not
 

included in the analysis. 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 5 
 

 

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OIG also has conducted several studies identifying inappropriate Medicare 

payments in hospice. In 2009, OIG found that 82 percent of hospice 

claims for beneficiaries in nursing facilities did not meet Medicare 

coverage requirements.24 In addition, in a 2008 report, OIG identified a 

number of cases in which the use of inpatient respite care for beneficiaries 

in nursing facilities may have been inappropriate.25 

METHODOLOGY 

We used data from three sources: (1) National Claims History file for 

Medicare hospice claims, (2) Certification and Survey Provider Enhanced 

Reports (CASPER) data to describe hospice characteristics (e.g., for-profit 

or nonprofit), and (3) Healthcare Cost Report Information System reports 

for supplementary information on hospice characteristics (e.g., when 

CASPER did not indicate a hospice’s ownership status). 

We analyzed all Medicare hospice claims from 2007 (the first year that 

hospice claims indicated place of service) through 2012. We used the 

Healthcare Common Procedure Coding System (HCPCS) codes on the 

claims to identify the setting where the care was provided, such as an 

ALF, private home, or nursing facility. We determined total Medicare 

spending on hospice and the amount and percentage of Medicare spending 

for hospice care provided in ALFs for each year. We compared the 

increase in and total spending on hospice care provided in ALFs to 

hospice care provided in all other settings. 

Next, we identified the beneficiaries who received care in ALFs in 2012. 

We used the claims from 2007 through 2012 to determine their total time 

in hospice care. We used the HCPCS codes on the claims to identify the 

primary settings where the beneficiaries received hospice care. The 

primary setting is where the beneficiary spent more of his or her time from 

2007 through 2012. For the purposes of this report, we refer to 

beneficiaries who spent more of their time in hospice care in ALFs than in 

any other setting as “beneficiaries in ALFs.” We determined the median 

amount Medicare paid and the median number of days in hospice care per 

beneficiary for each of the main settings in which hospice care was 

provided. These settings include: ALFs, nursing facilities, private homes, 

and skilled nursing facilities. 

We then determined the extent to which beneficiaries in ALFs (those 

beneficiaries whose primary setting was an ALF) had long lengths of stay 

24 OIG, Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance 

With Medicare Coverage Requirements, OEI-02-06-00221, September 2009. 25 OIG, Hospice Beneficiaries’ Use of Respite Care, OEI-02-06-00222, March 2008. 

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on hospice care. We calculated the percentages of these beneficiaries who 

received care between 180 and 365 days and more than 365 days. We 

compared these results to results for beneficiaries in other settings. We 

also determined how the most common terminal illnesses of beneficiaries 

in ALFs differed from those of beneficiaries in other settings and which 

illnesses were associated with less complex care.26 

Next, we determined the percentage of days that hospices provided routine 

home care and continuous home care in ALFs. We then analyzed the 

number of visits that hospices provided in ALFs in 2012 to beneficiaries 

receiving routine home care. These visits were for nursing, hospice aide, 

and medical social services. We determined the average number of hours 

of visits provided to beneficiaries per week, as well as the way in which 

these hours were distributed on different days of the week. We also 

determined what percentage of beneficiaries received visits while in ALFs 

from hospice physicians and how many hospices provided these types of 

visits. 

We analyzed the extent to which hospice care provided in ALFs differed 

on the basis of the ownership status of the hospice. We used CASPER to 

determine the ownership status of the hospice.27 When CASPER did not 

indicate the hospice’s ownership status, we used Healthcare Cost Report 

Information System reports. For hospices that provided care in ALFs, we 

analyzed payments and days on hospice by ownership status. 

Lastly, we determined the extent to which some hospices received a high 

percentage of their Medicare reimbursement from care provided in ALFs. 

This analysis was limited to hospices that provided care in ALFs to at least 

10 beneficiaries in 2012. We identified the hospices that had more than 

half of their Medicare payment amounts from care provided in ALFs as 

those targeting ALFs. We then described the characteristics of these 

hospices, including their ownership status, their locations, and their sizes.28 

We also grouped these hospices into national chains on the basis of the 

hospice names and information on their public Web sites. 

Limitations 

Medicare hospice claims do not include any information about the ALFs 

where services were provided. Also, information about ALFs, such as the 

26 On the basis of their terminal illnesses, we compared the complexity of hospice care 

that beneficiaries received. We considered hospice care less complex if beneficiaries 

were less likely to have received the general inpatient or continuous home levels of care. 27 For beneficiaries who received care from more than one hospice, we used the 

ownership status of the hospice that provided most of the beneficiary’s care. 

28 We considered a hospice to be large if it provided care to more than 320 Medicare 

beneficiaries in 2012, medium if it provided care to between 91 and 320 Medicare 

beneficiaries, and small if it provided care to 90 or fewer beneficiaries. 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 7 
 

 

name, size, and services available, is not available on a national basis. For 

this reason, we could not make any statements about the characteristics of 

ALFs where hospice care was provided. 

For this report, we present information on the types and frequencies of 

services provided by hospices in ALFs. We did not assess eligibility status 

for the hospice benefit or assess whether services were appropriate. 

Standards 

This study was conducted in accordance with the Quality Standards for 

Inspection and Evaluation issued by the Council of the Inspectors General 

on Integrity and Efficiency. 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 8 
 

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FINDINGS 

Medicare payments for hospice care in ALFs more 

than doubled in 5 years, totaling $2.1 billion in 2012 

Medicare paid $2.1 billion for hospice care provided in ALFs in 2012, an 

increase of 119 percent since 2007. See Figure 1. During that time, 

Medicare spending for hospice care provided in settings other than ALFs 

increased 38 percent, from $9.3 billion to $12.9 billion.29 Overall, 

Medicare spending for all hospice care increased 46 percent, from $10.3 

billion to $15.0 billion. 

Figure 1: Medicare Hospice Spending in ALFs, 2007-2012 

0% 

3% 

6% 

9% 

12% 

15% 

$0 

$500 

$1,000 

$1,500 

$2,000 

$2,500 

2007 2008 2009 2010 2011 2012 

Percentage of All Hospice Spending 

Spending (in millions) 

ALF Dollars ALF Percentage 

Source: OIG analysis of CMS data, 2013 

In 2012, Medicare payments for care in ALFs accounted for 14 percent of 

total Medicare spending on hospice care. Ten percent of Medicare hospice 

beneficiaries received at least some care in ALFs. Seventy-three percent 

of Medicare hospices provided care in ALFs during the year. 

Hospices provided care much longer and received 

much higher Medicare payments for beneficiaries in 

ALFs 

Of those who received hospice care in 2012, a total of 

120,444 beneficiaries received care primarily in ALFs. That is, they spent 

more of their time in hospice care in ALFs than in any other setting from 

29Medicare spending for hospice care provided in settings other than ALFs increased 

from $9,293,069,781 in 2007 to $12,868,920,994 in 2012. 

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120 

Median Days in Hospice Care 100 

80 

60 

40 

20 

0 

ALF 

98 

50 45 

30 

Nursing Facility Home Skilled Nursing 

Facility 

Primary Setting of Hospice Care 

2007 through 2012.30 The vast majority of these beneficiaries were in 

ALFs for at least 90 percent of their time in hospice care. 

Hospices provided care to beneficiaries in ALFs much longer than to 

beneficiaries in any other setting. Beneficiaries in ALFs received hospice 

care for a median of 98 days, which is almost twice as long as that 

received by beneficiaries in nursing facilities and more than twice as long 

as that received by beneficiaries at home. See Figure 2. 

Figure 2: Median Days in Hospice Care per Beneficiary, by Setting 

Source: OIG analysis of CMS data, 2013. 

Note: Includes beneficiaries who received hospice care in 2012. 

 Includes beneficiaries’ total time in hospice care from 2007 through 2012 

Over one-third of beneficiaries in ALFs received hospice care 

for more than 180 days 

Beneficiaries in ALFs were the most likely to have very long stays in 

hospice care. Thirty-six percent of beneficiaries in ALFs spent more than 

180 days in hospice care, compared to 28 percent of beneficiaries in 

nursing facilities and 22 percent of beneficiaries at home. See Figure 3. 

30 Hereafter, we refer to these beneficiaries as “beneficiaries in ALFs.” 

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181-365 days >365 days 

20% 

Percentage of Beneficiaries 16% 

12% 

8% 

4% 

0% 

ALF 

18% 18% 

14% 

13% 

12% 12% 

10% 11% 

Nursing Facility Home Skilled Nursing 

Facility 

Primary Setting of Hospice Care 

Figure 3: Percentage of Beneficiaries With Long Lengths of Stay, by 

Setting 

Source: OIG analysis of CMS data, 2013. 

Note: Includes beneficiaries who received hospice care in 2012. 

 Includes beneficiaries’ total time in hospice care from 2007 through 2012. 

Because of rounding, the percentages in the table do not sum to the percentages referenced in the text. 

Eighteen percent of beneficiaries in ALFs received hospice care for more 

than a year. In comparison, 14 percent of beneficiaries in nursing facilities 

and 10 percent of beneficiaries at home received hospice care for more 

than a year. Five percent of beneficiaries in ALFs received hospice care 

for 2 years or more. 

Medicare paid twice as much for care for beneficiaries in ALFs 

than for beneficiaries in other settings 

Medicare paid much more for hospice care provided to beneficiaries in 

ALFs than for hospice care provided to beneficiaries in other settings. 

The median amount Medicare paid for hospice care provided from 2007 

through 2012 to beneficiaries in ALFs was $16,195, more than twice as 

much as the median amounts for beneficiaries in nursing facilities and 

beneficiaries at home. See Table 2. 

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Table 2: Medicare Payments per Beneficiary, by Setting 

Primary Setting of 

Hospice Care 

Number of 

Beneficiaries Median Payment per Beneficiary 

ALF 120,444 $16,195 

Nursing Facility 195,820 $8,077 

Home 673,312 $7,526 

Skilled Nursing Facility 87,282 $5,635 

Source: OIG analysis of CMS data, 2013. 

Note: Includes beneficiaries who received hospice care in 2012. 

Includes payments made during beneficiaries’ total time in hospice care from 2007 through 2012. 

The long lengths of stay in hospice care for beneficiaries in ALFs explain 

the higher Medicare payments for these beneficiaries. Medicare payments 

are a function of time spent in hospice care. Medicare pays a hospice for 

every day starting from the day a beneficiary elects hospice care and 

ending with the day of discharge, regardless of the amount of services 

furnished on a particular day. 

Most beneficiaries in ALFs had diagnoses that 

typically require less complex care 

Sixty percent of beneficiaries who received care primarily in ALFs had 

diagnoses of ill-defined conditions, mental disorders, or Alzheimer’s 

disease as their terminal illness.31 Mental disorders include dementia. Illdefined conditions include, among other things, adult failure to thrive, 

senility without psychosis, and unspecified debility.32 Beneficiaries with 

these types of diagnoses typically receive less complex hospice care than 

beneficiaries with other diagnoses. 

Beneficiaries in ALFs were six times more likely to have these diagnoses 

than a diagnosis of cancer. Beneficiaries with cancer often require 

complex care and receive hospice care for substantially fewer days than 

beneficiaries with diagnoses such as ill-defined conditions. 

31 The International Classification of Diseases, 9th Revision, Clinical Modification, 

categorizes several diagnoses as “symptoms, signs, or ill-defined conditions.” This report 

refers to all diagnoses listed under “symptoms, signs, or ill-defined conditions” as “illdefined conditions.” 

32 Beginning on October 1, 2014, hospices are no longer allowed to report debility or 

adult failure to thrive as a beneficiary’s principal diagnosis. Hospices will be able to 

indicate these diagnoses as secondary, but CMS will require hospices to identify a more 

definitive principal diagnosis. See 78 Fed. Reg. 48234, 48246 (Aug. 7, 2013). 

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Beneficiaries in ALFs were more likely than beneficiaries in any other 

settings to have diagnoses of ill-defined conditions, mental disorders, or 

Alzheimer’s disease. The largest difference was between beneficiaries in 

ALFs and beneficiaries in the home. Beneficiaries in ALFs were more 

than twice as likely as beneficiaries in the home to have one of these 

diagnoses. They were also far less likely than beneficiaries in the home to 

have a diagnosis of cancer. See Table 3. 

Table 3: Medicare Beneficiaries’ Terminal Illness Diagnoses, by Setting 

Primary Setting of 

Hospice Care 

Percentage of Beneficiaries 

With Diagnoses of Ill-Defined 

Conditions, Mental Disorder, or 

Alzheimer’s Disease 

Percentage of 

Beneficiaries With 

Diagnosis of Cancer 

ALF 60% 10% 

Nursing Facility 54% 13% 

Skilled Nursing Facility 52% 15% 

Home 27% 38% 

Source: OIG analysis of CMS data, 2013. 

Note: Includes beneficiaries who received hospice care in 2012. 

Hospices typically provided fewer than 5 hours of

visits per week and were paid about $1,100 per week 

for each beneficiary receiving routine home care in an 

ALF 

Routine home care accounted for nearly all the care hospices provided in 

ALFs in 2012. Hospices billed for routine home care for 99 percent of the 

days they provided care in ALFs during the year.33 Medicare paid an 

average of $156 per day for this care, amounting to $1,091 per week for a 

beneficiary receiving routine home care in an ALF. Hospices provided an 

average of 4.8 hours of visits per week to these beneficiaries. These visits 

ranged from 0 to 66 hours per week. 

In addition to covering visits and services such as care planning, the daily 

payment covers medical appliances and supplies, including drugs that are 

used primarily for the relief of pain and symptom control related to the 

individual's terminal illness or related conditions. Hospices are required to 

provide these services as needed. A hospice is paid for every day a 

beneficiary is under its care, regardless of how many services it provides. 

33 Hospices billed for continuous home care for the remaining 1 percent of days. 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 13 
 

 

____________________________________________________________ 

Twenty-five hospices did not report making any visits to their 

beneficiaries receiving routine care in ALFs in 2012. This involved 210 

beneficiaries. The hospices received a total of $2.3 million from Medicare 

for these beneficiaries. 

Hospices provided mostly aide visits 

Most hospice visits were from aides. On average, of the 4.8 hours of visits 

per week to beneficiaries, 2.8 hours were for hospice aide services, 1.7 

hours were for nursing services, and 0.3 hours were for medical social 

services. See Figure 4. Nursing and medical social services are core 

hospice services.34 Hospice aide services include personal care services, 

such as bathing, and household services, such as light cleaning and 

laundering. 

Figure 4: Average Hours per Week of Hospice Visits Provided to 

Beneficiaries Receiving Routine Home Care in ALFs, 2012 

Aide Visits 

2.8 hours 

per week 

Nursing Visits 

1.7 hours 

per week 

Medical Social 

Service Visits 

0.3 hours 

per week 

Source: OIG analysis of CMS data, 2013. 

Hospice physicians rarely saw beneficiaries who received care 

in ALFs 

The daily rate Medicare pays to hospices includes general supervisory 

services and plan of care services by hospice physicians. Other services 

by hospice physicians are billed separately. In 2012, hospices billed 

physician services for 20 percent of the beneficiaries they served in ALFs. 

Therefore, 80 percent of beneficiaries were not provided hospice physician 

services while they were in ALFs other than supervisory and/or care 

34 A hospice must routinely provide substantially all core services directly by hospice 

employees. 42 CFR § 418.64. 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 14 
 

 

 

 

____________________________________________________________ 

planning services. Two-thirds of hospices did not provide other physician 

services to any of the beneficiaries they served in ALFs in 2012. 

Hospices seldom provided services in ALFs on weekends 

Hospices must make services available, as needed, on a 24-hour basis.35 

In 2012, hospices provided the great majority of their visits in ALFs 

during the workweek and rarely on weekends. Specifically, between 18 

and 20 percent of visit hours in ALFs were provided on each of the 

weekdays. In contrast, only four percent of the hours were provided on 

Saturdays and three percent on Sundays. See Figure 5. 

Figure 5: Percentage of Visit-Hours Provided to Beneficiaries Receiving 

Routine Home Care in ALFs by Day of the Week, 2012 

25% 

Percentage of All Visit Hours 20% 

15% 

10% 

5% 

0% 

20% 19% 18% 18% 19% 

4% 3% 

Monday Tuesday Wednesday Thursday Friday Saturday Sunday 

Days of the Week 

Source: OIG analysis of CMS data, 2013. 

Note: Totals do not sum to 100 percent because of rounding. 

For-profit hospices received much higher Medicare 

payments per beneficiary than nonprofit hospices 

In 2012, there were 2,709 Medicare hospices that provided care in ALFs. 

Of these, 62 percent were for-profit and 33 percent were nonprofit.36 

For-profit hospices received a total of $1.4 billion for care in ALFs in 

2012. 

35 Social Security Act, § 1861(dd)(2)(A)(i), 42 U.S.C. § 1395x(dd)(2)(A)(i). 

36 The remaining hospices either were Government owned or were categorized as 

“Other.” 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 15 
 

 

 

 

 

 

For-profit hospices received thousands of dollars more than nonprofits per 

beneficiary in ALF. The median amount Medicare paid for-profit hospices 

was $18,261 per beneficiary in ALF for care from 2007 through 2012. In 

comparison, the median for nonprofits was $13,941. 

Beneficiaries in ALFs who were served by for-profit hospices were in 

hospice care longer than those who were served by nonprofit hospices. 

The median time in hospice care for the for-profit hospices’ beneficiaries 

was almost 4 weeks longer than the median for nonprofit hospices. The 

median for for-profit hospices was 111 days, in contrast to the median of 

85 days for nonprofit hospices. See Table 4. 

Table 4: Median Days in Hospice per Beneficiary in ALF by Hospice 

Ownership 

Hospice Ownership Number of Beneficiaries Median Days in Hospice 

For Profit 72,627 111 

Nonprofit 44,238 85 

Government 2,317 67 

Other 1,097 71 

Source: OIG analysis of CMS data, 2013. 

Note: Includes beneficiaries who received hospice care in 2012 and were primarily in ALFs. 

 Includes beneficiaries’ total time in hospice care from 2007 through 2012. 

We were unable to determine the hospices’ ownership for 165 beneficiaries in ALFs. 

In addition, for-profit hospices received a higher percentage of their 

Medicare reimbursement from care in ALFs. In 2012, for-profit hospices 

received a median of 11 percent of their Medicare reimbursement for care 

provided in ALFs, compared to 7 percent for nonprofit hospices. 

Some for-profit hospices stand out for their use of the most 

expensive level of hospice care 

Continuous home care is the most expensive level of hospice care and is 

rarely provided in ALFs. However, one large national for-profit chain 

stands out for its use of continuous home care in ALFs. In 2012, hospices 

in this chain received far more Medicare payments for continuous home 

care in ALFs than all other hospices combined. Hospices in this chain 

received a total of $41.7 million for continuous home care in ALFs, which 

is 64 percent of all Medicare payments for this level of care in ALFs 

during the year. In comparison, the hospices in this chain received 

11 percent of Medicare payments for all routine home care provided in 

ALFs during the year. 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 16 
 

 

Many for-profit hospices targeted ALFs 

Ninety-seven hospices relied on ALFs for most of their Medicare 

payments. For these hospices, care provided in ALFs accounted for more 

than half of the Medicare payments they received in 2012. The majority 

of these (90 of 97) were for-profit hospices. 

Medicare paid these for-profit hospices $193 million in 2012 for care 

provided in ALFs. Most of the hospices were medium or large in size, 

serving at least 150 Medicare hospice beneficiaries during the year. 

Almost half of the 90 hospices were part of hospice chains. Notably, eight 

of the nine hospices with the highest Medicare payment amounts for care 

provided in ALFs were part of hospice chains. In 2012, Medicare paid 

each of these hospices between $4.6 million and $12.2 million for care 

provided in ALFs. 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 17 
 

CONCLUSION AND RECOMMENDATIONS 

While the growth in ALFs in general appears limited, Medicare spending 

for hospice care in ALFs more than doubled over 5 years to $2.1 billion in 

2012. Hospices provided care much longer and received much higher 

Medicare payments for beneficiaries in ALFs than for beneficiaries in 

other settings. Hospice beneficiaries in ALFs often had diagnoses that 

usually require less complex care. Hospices typically provided fewer than 

5 hours of visits per week and were paid about $1,100 per week for each 

beneficiary receiving routine home care in ALFs. Also, for-profit hospices 

received much higher Medicare payments per beneficiary than nonprofit 

hospices, and many for-profit hospices targeted ALFs. 

This report raises concerns about the financial incentives created by the 

current payment system and the potential for hospices to target 

beneficiaries in ALFs who have long lengths of stay or have certain 

diagnoses because they may offer the hospices the greatest financial gain. 

It also raises questions about whether Medicare is paying appropriately for 

hospice care in ALFs and whether beneficiaries are receiving the services 

they need during their last months of life. We have identified similar 

concerns in other parts of the benefit. Notably, a previous OIG report 

raised these concerns regarding beneficiaries in nursing facilities. 

Previous OIG reports also have found that hospices often did not provide 

the number of services outlined in the plans of care they established and 

that several hundred hospices did not provide any level of hospice care 

other than routine home care. 

Together, the findings in this and previous OIG reports show that payment 

reform and more accountability are needed to reduce incentives for 

hospices to focus solely on certain types of diagnoses or settings and 

ensure that hospices are providing quality care to those who are eligible. 

Hospice is an important benefit for Medicare beneficiaries and should be 

appropriately safeguarded. 

We recommend that CMS, as part of its ongoing hospice reform efforts: 

Reform payments to reduce the incentive for hospices to 

target beneficiaries with certain diagnoses and those likely to 

have long stays 

Under ACA, CMS is required to reform the hospice payment system. 

These reforms should be structured to reduce the incentive for hospices to 

target certain beneficiaries and ensure that hospices are providing high 

quality care to those who are eligible. One way to do this is to tie payment 

rates to beneficiaries’ needs. 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 18 
 

 

 

Currently, hospices must conduct for each beneficiary a comprehensive 

assessment that identifies the beneficiary’s need for hospice care and 

services and the need for physical, psychosocial, emotional, and spiritual 

care. These needs and others that affect the care a beneficiary requires 

could be considered in setting payment rates. 

Target certain hospices for review 

CMS should focus its reviews on certain hospices. These should include 

hospices that receive a high percentage of their payments from providing 

care to beneficiaries in ALFs, hospices with a high percentage of 

beneficiaries receiving care for over 180 days, hospices with a high 

percentage of beneficiaries with certain diagnoses, and hospices with a 

high percentage of beneficiaries who rarely receive hospice visits. 

CMS should include these measures in its Fraud Prevention System to 

identify these hospices for further review. 

Develop and adopt claims-based measures of quality 

To meet ACA requirements, CMS has adopted several quality measures 

that will be calculated using data collected and reported by hospices. 

Currently, these measures address pain management and other treatment 

matters. In addition, CMS should develop and adopt measures that 

address issues raised in this report. These additional measures would be 

based on information obtained from claims submitted by hospices for 

Medicare payment. As discussed in MedPAC’s report to Congress, 

hospice experts have also supported a claims-based approach. Claimsbased measures could include the average number of services the hospice 

provides, the types of services, how often physician visits are provided, 

and how often a hospice provides services on the weekend. 

Make hospice data publicly available for beneficiaries 

For a variety of other types of providers, CMS provides information to 

beneficiaries and the public on the Medicare.gov Web site. CMS should 

do the same for hospices. While CMS continues to develop and test 

quality measures, it should take the interim step of making other hospice 

data available through a Hospice Compare feature on the Medicare.gov 

Web site. This could include information similar to the information 

included in this report, but for individual hospices. For example, it could 

include information on the services provided, such as the average number 

of services the hospice provided, the types of services, how often 

physician visits are provided, and how often a hospice provided services 

on the weekend. 

This information would enable beneficiaries, their caregivers, and the 

public to compare hospices. It also would educate them about the benefit 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 19 
 

 

and help them make informed choices about which hospices best meet 

their needs. 

Provide additional information to hospices to educate them 

about how they compare to their peers 

CMS provides hospices with comparative information annually in its 

Program for Evaluating Payment Patterns Electronic Reports. The goal of 

these reports is to help hospices guide their internal auditing and 

monitoring activities. Currently, however, CMS includes only two target 

areas in these reports: live discharges and long lengths of stay. 

CMS should provide hospices with additional information to further 

educate them about how they compare with other Medicare hospices. 

CMS could include other target areas in these reports, such as the 

percentage of beneficiaries in specific settings or with certain diagnoses 

and the percentage of beneficiaries receiving higher levels of hospice care. 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 20 
 

 

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE 

In comments on our draft report, CMS concurred with all five of our 

recommendations. 

CMS concurred with our first recommendation, to reform payments to 

reduce the incentive for hospices to target beneficiaries with certain 

diagnoses and those likely to have long stays. CMS stated that it is 

analyzing possible reform options that focus on new payment models as a 

result of recommendations from MedPAC. MedPAC has recommended a 

model in which the per diem rates would be higher at the beginning and 

end of a beneficiary’s time in hospice care and lower in the middle. In 

addition, we encourage CMS to consider other options, particularly those 

that tie the specific needs of the beneficiary–as identified in the 

beneficiary’s comprehensive assessment–to payment rates and take into 

account the number and types of hospice visits and services needed, 

regardless whether they are at the beginning or end of the beneficiary’s 

time in hospice care. 

CMS concurred with our second recommendation, to target certain 

hospices for review. It stated that it supports the development of Fraud 

Protection System models targeting hospices that have a high percentages 

of beneficiaries who rarely receive visits, as well as considering hospices 

that provide high percentages of their beneficiaries at the continuous care 

level. 

CMS concurred with our third recommendation, to develop and adopt 

claims-based measures of quality. CMS stated that it will consider 

including claims-based measures as part of its measure development, such 

as the average number of services the hospice provides, the types of 

services, how often physician visits are provided, and how often a hospice 

provides services on the weekend. 

CMS concurred with our fourth recommendation, to make hospice data 

publicly available for beneficiaries. CMS stated that it plans to publicly 

report data from the Hospice Item Set as well as any future measures to be 

developed in the Hospice Quality Reporting Program. We support these 

plans and reiterate that while CMS continues to develop and test quality 

measures, it should take the interim step of making available to the public 

claims-based hospice data regarding the number and types of services a 

hospice provides, including physician services and services on the 

weekend. 

Lastly, CMS concurred with our fifth recommendation, to provide 

additional information to hospices to educate them about how they 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 21 
 

 

compare to their peers. CMS stated that the development and 

implementation of a standardized data set for hospices must precede 

providing information to hospices about how they compare to their peers 

or for public reporting of hospice quality measures. CMS said that 

hospice review and public reporting may occur during the FY 2018 

Annual Payment Update Year. We urge CMS to consider analyzing and 

making available measures based on the claims data as a first step so that 

hospices have some ability to see how they compare to their peers more 

immediately. 

The full text of CMS’s comments is provided in Appendix A. 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 22 
APPENDIX A 

Agency Comments 

(~·4""'"'~·~ DEPARTMENT OF HEALTH & HUMAN Centers for Medicare & Medicaid Services SERVfCES 

'"t;,, 'J'<~r~o.,.,o Administrator 

Washington, DC 20201 

DATE: OCT 2 7 2014 

TO: 	 Daniel R. Levinson 


Inspector General 


FROM: 	 Marilyn Tavenner 


Administrator 


SUBJECT: 	 Office ofinspector General (OIG) Draft Report: Medicare Hospices Have Financial 

Incentives to Provide Care in Assisted Living Facilities (OEI-02-14-00070) 

Thank you for the opportunity to review and comment on the above-subject OIG draft. The 


objective ofthis study was to describe the trends in Medicare payments for hospice care 


provided in assisted living facilities (ALFs), to describe the characteristics ofbeneticiaries who 


receive hospice care in ALFs, to determine the types and frequency of hospice services provided 


to beneficiaries residing in ALFs, and to determine the extent to which some hospices receive a 


high percentage oftheir Medicare reimbursement from care provided in ALFs. 


The OIG recommendation and the Centers for Medicare & Medicaid Services' (CMS) response 


are discussed below. 


OIG Recommendation 


The OIG recommends that CMS reform payments to reduce the incentive for hospices to target 


beneficiaries with certain diagnoses and those likely to have long stays. 


CMS Response 


The CMS concurs with the recommendation, which directly aligns with CMS' charge under the 


Affordable Care Act, to retorm the hospice payment system, collect data relevant to revising 


hospice payments, and develop quality measures for hospices. OIG's report provides useful data 


and related recommendations that will help inform CMS' decisions as it fulfills these Affordable 


Care Act requirements. 


As part ofits hospice payment reform efforts, CMS is working with several research contractors 


conducting comprehensive data analysis on hospice utilization trends. As a part of this analysis, 


our contractor developed a technical report titled, "Medicare Hospice Payment Reform: 


Analyses to Support Payment Reform", dated May 1, 2014 (hereafter, referred to as the May 


2014 Technical Report). The May 2014 Technical Report, and an updated literature review, is 


available on our hospice center web page at http://www.cms.goc!Center/Provider-Tvoe!Hospice­


Ccnter.html in the "Research and Analyses" section. 


Medicare Hospices Have Financial incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 23 
 

 

 

 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 24 
 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 25 
 

 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 26 
 

ACKNOWLEDGMENTS 

This report was prepared under the direction of Jodi Nudelman, Regional 

Inspector General for Evaluation and Inspections in the New York regional 

office. 

Deputy Regional Inspector General Nancy Harrison served as the team 

leader for this study. Other Office of Evaluation and Inspections staff 

from the New York regional office who conducted the study include Jenell 

Clarke-Whyte, Jennifer Karr, and Michael Rubin. Central office staff who 

provided support include Heather Barton, Berivan Demir Neubert, and 

Christine Moritz. 

Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living Facilities (OEI-02-14-00070) 27 
 

Office of Inspector General

http://oig.hhs.gov 

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95-452, as 

amended, is to protect the integrity of the Department of Health and Human Services 

(HHS) programs, as well as the health and welfare of beneficiaries served by those 

programs. This statutory mission is carried out through a nationwide network of audits, 

investigations, and inspections conducted by the following operating components: 

Office of Audit Services 

The Office of Audit Services (OAS) provides auditing services for HHS, either by conducting 

audits with its own audit resources or by overseeing audit work done by others. Audits 

examine the performance of HHS programs and/or its grantees and contractors in carrying 

out their respective responsibilities and are intended to provide independent assessments of 

HHS programs and operations. These assessments help reduce waste, abuse, and 

mismanagement and promote economy and efficiency throughout HHS. 

Office of Evaluation and Inspections 

The Office of Evaluation and Inspections (OEI) conducts national evaluations to provide 

HHS, Congress, and the public with timely, useful, and reliable information on significant 

issues. These evaluations focus on preventing fraud, waste, or abuse and promoting 

economy, efficiency, and effectiveness of departmental programs. To promote impact, OEI 

reports also present practical recommendations for improving program operations. 

Office of Investigations 

The Office of Investigations (OI) conducts criminal, civil, and administrative investigations 

of fraud and misconduct related to HHS programs, operations, and beneficiaries. With 

investigators working in all 50 States and the District of Columbia, OI utilizes its resources 

by actively coordinating with the Department of Justice and other Federal, State, and local 

law enforcement authorities. The investigative efforts of OI often lead to criminal 

convictions, administrative sanctions, and/or civil monetary penalties. 

Office of Counsel to the Inspector General 

The Office of Counsel to the Inspector General (OCIG) provides general legal services to 

OIG, rendering advice and opinions on HHS programs and operations and providing all 

legal support for OIG’s internal operations. OCIG represents OIG in all civil and 

administrative fraud and abuse cases involving HHS programs, including False Claims Act, 

program exclusion, and civil monetary penalty cases. In connection with these cases, OCIG 

also negotiates and monitors corporate integrity agreements. OCIG renders advisory 

opinions, issues compliance program guidance, publishes fraud alerts, and provides other 

guidance to the health care industry concerning the anti-kickback statute and other OIG 

enforcement authorities.