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DEPARTMENT OF HEALTH &. HUMAN S,ERVICES Office of Inspector General

Washington, D.C. 20201

SEP - 4 2009

TO: Charlene Frizzera

Acting, Administrator

Centers for Medicare & Medicaid Services

FROM: Stuar Wright

Deputy Ins~ectorGeneral for

Evaluation and Inspections

SUBJECT: Memorandum Re~ort: "Medicare Hospice Care: Services Provided to

Beneficiaries Residing in Nursing Facilities," OEI-02-06-00223

This memorandum report detennines the proportion of Medicarehos~ice beneficiaries

residing in nursing facilties in 2006 and describes the natue and extent of hospice

services ~rovided to them. The Medicarehos~ice benefit allows a beneficiary with a

terminal ilness to forgo curative treåtmentforthe ilness and instead receive palliative

care, which is the relief of pain and other uncomfortble syi~toms. The number of

Medicare beneficiaries receiving hos~ice care has increased significantly in recent years.

In fiscal year 2001, about 580,000 beneficiaries received hos~ice care. In 2006, this

number increased by 62 percent to 939,000 beneficiaries. Medicare s~ending on hospice

care rose from $3.6 bilion in 2001 to $9.2 bilion in 2006. i

Some studies suggest that the use of hospìcecareisgrowingmost ra~idly in nursing

facilties.2 In addition, ~revious OIG work has :raised questionsaboutthehos~ice benefit

for nursing facilty residents. ForeXtan~le, OlGreportedthat in 1995,~a~mentlevels for

hospice care in nursing facilities may have been eXtcessive.3 However, little subsequent

research has been done to examine hospice care for these beneficiaries and almost no

1 Centers for Medicare & Medicaid Services (CMS), "Medicare Hospice Expenditues and Units of Care."

A vailable online at

htt://www .cms.hhs,gov/ProspMedicareFeeSvcPmtGen/downloads/FYQ_5..update, hospice e~gim.es an

d units of care.pdf. Accessed on March 27, 2009; CMSanalysis of Medicare Health Care Information

System data for calendar year 2006 claims. Provided by CMS on May 5, 2009.

2 Offce of 

the Assistant Secretary for Planiiing and Evaluation (ASPE),"'Use of Medicare's Hospice

Benefit by Nursuig Facility Residents," March 2000; Medicare Payment Advisory Commission, "Report to

the Congress: Medicare Beneficiaries' Accessto Hospice," May 2002, p. 5.

3 OIG, "Hospice Patients in Nursing Homes," OEI-05-95-00250, September 1997.

OEl -02-06-00223 Medicare Hospice Care: Services Provided to Beneficiaries

Residing in Nursing Facilties
Page 2 – Charlene Frizzera 

beneficiary-specific data exist.4

 In fact, a recent report from the Medicare Payment 

Advisory Commission noted that Medicare “has virtually no information on the hospice 

care it purchases, in terms of either the specific services provided or the quality of care 

obtained.”5

 It also stated that substantially more data will be needed to modernize 

Medicare’s payment system for hospice. 

A 2009 OIG report determined the extent to which hospice claims for beneficiaries in 

nursing facilities met Medicare coverage requirements.6

 The report found that 82 percent 

of hospice claims for beneficiaries in nursing facilities did not meet at least one Medicare 

coverage requirement. Medicare paid approximately $1.8 billion for these claims. The 

report also found that for 31 percent of claims, hospices provided fewer services than 

outlined in beneficiaries’ plans of care. 

In this evaluation, we found that 31 percent of Medicare hospice beneficiaries resided in 

nursing facilities in 2006. Medicare paid $2.59 billion for their hospice care, at an 

average of $960 per week for each hospice beneficiary residing in a nursing facility. 

Hospices most commonly provided nursing, home health aide, and medical social 

services. They furnished an average of 4.2 visits per week for these three services 

combined. They also commonly provided drugs. The results in this memorandum report 

can help CMS and other decisionmakers determine whether the types and frequencies of 

hospice services provided to beneficiaries in nursing facilities meet the goals of the 

hospice benefit and whether current payment rates are aligned with the hospice services 

being provided. 

BACKGROUND 

The Medicare Hospice Benefit 

The Tax Equity and Fiscal Responsibility Act of 1982 created the Medicare hospice 

benefit for eligible beneficiaries under Medicare Part A.7

 The goals of hospice care are 

to help terminally ill beneficiaries continue life with minimal disruption and to suppo

beneficiaries’ families and other caregivers throughout the process. The care may be 

provided to individuals and their families in the home or other places of residence, such 

as a skilled or other nursing facility. The care provided to families and other caregivers 

includes counseling and training to provide care for the individual and bereavement 

counseling. 

rt 

 

4

 Government Accountability Office (GAO), “Medicare Hospice Care: Modifications to Payment 

Methodology May Be Warranted,” GAO-05-42, October 15, 2004, pp. 4 and 20; ASPE, “Synthesis and 

Analysis of Medicare’s Hospice Benefit,” March 2000. 

5

 Medicare Payment Advisory Commission, “Report to the Congress: Reforming the Delivery System,” 

June 2008, Chapter 8, p. 224. 

6

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

Coverage Requirements,” OEI-02-06-00221. 

7 The Tax Equity and Fiscal Responsibility Act of 1982, § 122, P.L. No. 97-248 § 122, 96 Stat. 324, 356, 

42 U.S.C. § 1395x(dd). 

OEI-02-06-00223 Medicare Hospice Care: Services Provided to Beneficiaries 

Residing in Nursing Facilities 
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To be eligible for Medicare hospice care, a beneficiary must be entitled to Part A of 

Medicare and be certified as having a terminal prognosis 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. The beneficiary waives all rights to Medicare payment for services related 

to the treatment of the terminal condition or a related condition but retains rights to 

Medicare payment for services to treat conditions unrelated to the terminal illness.8

 

Hospice services. A plan of care must be established as set forth in regulations before 

services are provided, and the services must be consistent with the plan of care.9 

Pursuant to Federal statutes and regulations, Medicare covers the following hospice 

services: 

• nursing care provided by, or under the supervision of, a registered nurse; 

• physical or occupational therapy or speech-language pathology services; 

• medical social services under the direction of a physician; 

• home health aide and homemaker services; 

• medical supplies (including drugs and biologicals) and the use of medical 

appliances; 

• physician services; 

• short-term inpatient care (including both respite care and procedures necessary for 

pain control and acute and chronic symptom management); 

• counseling (including dietary counseling) with respect to care of the terminally ill 

individual and adjustment to the individual’s death; and 

• any other service that is specified in the plan of care as reasonable and necessary 

for the palliation and management of the terminal illness and related conditions 

and for which payment may otherwise be made under Medicare.10

Levels of care and payment. The Medicare hospice benefit has four levels of care, and 

each level has an all-inclusive, prospectively determined daily rate. The rate is paid to 

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

services furnished. The four levels of care are: routine home care, continuous home 

care, respite care, and general inpatient care. Routine home care is the most common 

level of care and includes, but is not limited to, nursing and home health aide services. 

Appendix A provides detailed information on the four levels of care and the payment 

rates.

In addition, Medicare pays for physician services for hospice beneficiaries. This 

reimbursement may be through Part A or Part B, depending on the physician’s 

 

8

 42 CFR § 418.24. 

9

 42 CFR § 418.200. 

10 42 CFR § 418.202.

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relationship with the hospice. Medicare pays the hospice for physician services under 

Part A when the beneficiary’s attending physician is an employee of or is under contract 

with the hospice provider.11 The hospice compensates the physician through salary or 

some other arrangement. Medicare pays the physician for physician services under Part 

B when the beneficiary’s attending physician does not have a payment arrangement with 

the hospice. 

Hospice care in nursing facilities. When a beneficiary resides in a nursing facility, the 

hospice is responsible for providing the hospice services to the beneficiary. The nursing 

facility provides room and board and care unrelated to the terminal illness. Medicare 

reimburses the hospice according to the level of care provided, and the beneficiary or a 

third-party payer pays the nursing facility for room and board costs.12

Related Work 

An earlier OIG report found that 28 percent of Medicare hospice beneficiaries resided in 

nursing facilities while they received hospice care in 2005.13 These beneficiaries were 

more than twice as likely as beneficiaries in other settings to have terminal diagnoses of 

ill-defined conditions, mental disorders, or Alzheimer’s disease. Another report found a 

number of cases in which the use of respite care for nursing facility beneficiaries may 

have been inappropriate; these cases were referred to CMS for appropriate action.14 

METHODOLOGY 

To conduct this study, we used complete claims data for all Medicare beneficiaries who 

received hospice care in 2006. We also used data from a medical record review of a 

stratified random sample of hospice claims for beneficiaries in nursing facilities. We 

selected a stratified random sample of 470 hospice claims from this file, and our final 

sample included 450 hospice claims. See Appendix B for detailed information about our 

sample selection. 

Medical Record Review 

We used a contractor to collect and review the medical records associated with each 

sampled claim. The contracted reviewers recorded all hospice services provided to the 

beneficiary during the claim period, with the exception of physician services.15 The 

reviewers also recorded whether drugs were provided to the beneficiary but did not 

identify the drugs or record dosages provided. The reviewers did not record services 

provided to family members. 

 

11 The beneficiary’s attending physician may be a nurse practitioner. 

12 “Medicare Benefit Policy Manual,” chapter 9, section 20.3. Available online at 

http://www.cms.hhs.gov/manuals/Downloads/bp 102c09.pdf. Accessed on February 10, 2009. 

13 OIG, “Medicare Hospice Care: A Comparison of Beneficiaries in Nursing Facilities and Beneficiaries in 

Other Settings,” OEI-02-06-00220, December 2007. 

14 OIG, “Hospice Beneficiaries’ Use of Respite Care,” OEI-02-06-00222, March 2008. 

15 Services provided by beneficiaries’ attending physicians are not always included in the hospice records. 

OEI-02-06-00223 Medicare Hospice Care: Services Provided to Beneficiaries 

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The contractor reviewed a total of 447 claims. For the other three claims, the hospices 

did not provide any documentation to review.16 Because no information on services was 

available for these claims, they were excluded from our analysis. 

Analysis 

Using the complete National Claims History file, we calculated the total number of 

Medicare beneficiaries who received hospice care in 2006.17 Hospice claims typically 

cover a 1-month period but could be for shorter periods of time. After matching this file 

to the Minimum Data Set file, we calculated the total number of Medicare hospice 

beneficiaries who resided in nursing facilities in 2006. We determined the total dollars 

and the average weekly amount Medicare paid for their hospice care, not including 

physician payments. In addition, we determined the percentage of claims for these 

beneficiaries by the levels of care provided. 

Based on our medical record review of sampled claims, we calculated the percentage of 

claims for which drugs, nursing services, home health aide and homemaker services 

(hereinafter referred to as “home health aide services”), medical social services, 

counseling, volunteer and other miscellaneous services, physical therapy, occupational 

therapy, or speech-language pathology services were furnished. The use of medical 

appliances and supplies was not included in our analysis.18 Because a hospice could have 

provided an appliance before the sampled claim period, the use of that appliance may not 

have appeared in the collected medical records. 

We calculated the average number of visits hospices provided per week for nursing, 

home health aide, and medical social services. We described the average length of these 

visits among sampled claims that covered routine care only. Durations were not recorded 

for a significant percentage of visits, so projecting the average length of visits from our 

sample was unfeasible. Finally, we compared the types of services provided by 

not-for-profit hospices and for-profit hospices. We were unable to compare types and 

frequencies of services by level of care provided, because most of the claims in our 

sample were for routine care only. We tested for statistically significant differences and 

noted in our findings when these differences occurred. 

See Appendix C for selected point estimates and their confidence intervals, and see 

Appendix D for the results of our statistical tests. 

 

16 We contacted the hospices by telephone and certified mail, but they did not provide the requested 

records. We have referred these cases to CMS for appropriate action. 

17 We excluded claims that were for physician services only. 

18 Appliances may include durable medical equipment as well as other self-help and personal comfort items 

related to the palliation or management of the patient’s terminal illness. See 42 CFR § 418.202(f). 

OEI-02-06-00223 Medicare Hospice Care: Services Provided to Beneficiaries 

Residing in Nursing Facilities 
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Limitations 

This memorandum report is based on a medical record review of sampled claims. These 

claims were also the basis for another OIG report, which found that 82 percent of claims 

did not meet at least one Medicare coverage requirement.19 For this memorandum report, 

we presented information on the types and frequencies of services provided by hospices 

to beneficiaries in nursing facilities. We did not assess whether individual services were 

appropriate. 

STANDARDS 

This review was conducted in accordance with the “Quality Standards for Inspections” 

issued by the President’s Council on Integrity and Efficiency and the Executive Council 

on Integrity and Efficiency (now Council of the Inspectors General on Integrity and 

Efficiency). 

 

19 OIG, “Medicare Hospice Care for Beneficiaries in Nursing Facilities: Compliance With Medicare 

Coverage Requirements,” OEI-02-06-00221. 

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RESULTS 

Thirty-One Percent of Medicare Hospice Beneficiaries Resided in Nursing Facilities 

in 2006; Medicare Paid $2.59 Billion for Their Hospice Care 

Based on claims data for all Medicare beneficiaries receiving hospice care, we found that 

31 percent of hospice beneficiaries resided in nursing facilities in 2006, compared to 28 

percent in 2005.20 In 2006, 289,544 beneficiaries received hospice care while residing in 

nursing facilities. 

Medicare paid hospices approximately $2.59 billion for care provided to beneficiaries 

residing in nursing facilities in 2006. On average, Medicare paid $960 per week for each 

hospice beneficiary in a nursing facility. This amount did not cover physician services, 

which were paid for separately from 

the daily rate. Table 1: Percentage of Claims by Levels of 

Care for 2006 

Level of Care Percentage of 

Claims 

Routine care only 91% 

General inpatient care only 3% 

Routine and general inpatient care only 3% 

Routine and continuous care only 2% 

All other levels or combinations 

of levels of care 1% 

Source: OIG analysis of hospice claims, 2008. 

By far, the most common level of 

hospice care provided to these 

beneficiaries was routine care. 

Ninety-one percent of their hospice 

claims were for routine care only. 

Another 3 percent were for general 

inpatient care only. Most of the 

remaining claims were for a 

combination of routine care and one or 

more other levels of care. See Table 1. 

Hospices Most Commonly Provided Nursing, Home Health Aide, and Medical 

Social Services; They Also Commonly Provided Drugs 

Based on the medical record review, hospices provided nursing services to beneficiaries 

for 96 percent of claims in 2006. Hospices furnished home health aide services to 

beneficiaries for 73 percent of claims and medical social services for 68 percent of 

claims. Hospices provided counseling for 58 percent of claims. Volunteer and other 

miscellaneous services were provided to a lesser extent. Physical therapy, occupational 

therapy, and speech-language pathology services occurred only in rare instances. See 

Table 2. In addition to these services, drugs were provided to beneficiaries for 96 percent 

of claims. 

 

20 OIG, “Medicare Hospice Care: A Comparison of Beneficiaries in Nursing Facilities and Beneficiaries in 

Other Settings,” OEI-02-06-00220, December 2007, p. 8. 

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The medical record review revealed some differences between the types and frequencies 

of services provided by for-profit hospices and those provided by not-for-profit hospices. 

Home health aide services were 

furnished for a higher percentage 

of claims from for-profit hospices 

than from not-for-profit hospices. 

These services were provided for 

79 percent of for-profit hospice 

claims, compared to 67 percent of 

not-for-profit hospice claims. By 

contrast, volunteer and other 

miscellaneous services were 

furnished for a lower percentage of 

claims from for-profit hospices 

than from not-for-profit hospices, 

8 percent and 21 percent, 

respectively. These differences 

were statistically significant at the 

95-percent confidence level. 

Table 2: Percentage of Claims by Types of 

Services Provided 

Type of Service Percentage 

of Claims* 

Nursing services 96% 

Home health aide services 73% 

Medical social services 68% 

Counseling (including spiritual, pastoral, 

or chaplain services) 58% 

Volunteer and other miscellaneous services 14% 

Physical therapy, occupational therapy, or 

speech-language pathology services <1% 

Source: OIG analysis of medical record review results, 2008. 

*Percentages are not mutually exclusive.

Hospices Provided an Average of 4.2 Visits Per Week for the Three Most Common 

Services Combined 

Hospices provided an average of 4.2 visits per week for nursing services, home health 

aide services, and medical social services combined. Although nursing services were 

furnished for the greatest percentage of claims, they did not occur the most frequently. 

Home health aide services were provided more often, at an average of 2.2 times per 

week. For over half of the claims, beneficiaries received about 1 to 3 home health aide 

visits per week. Nursing services 

averaged 1.7 visits per week, with 

beneficiaries receiving about 1 to 

2 nursing visits per week for 

two-thirds of the claims. Medical 

social services usually occurred on a 

monthly or bimonthly basis, averaging 

about 1.7 visits per month or 0.4 visits 

per week. See Table 3. 

As noted in the methodology, 

durations were not recorded for a 

significant percentage of visits, so 

projecting the average length of visits 

from our sample was unfeasible. Based on the limited number of visits whose lengths 

were recorded and which were for routine care only, we found that home health aide 

visits were 65 minutes on average, although their duration ranged from 2 minutes to 

Table 3: Average Number of Visits Per Week 

for the Most Common Services 

Type of Service Average Number of 

Visits Per Week* 

Home health aide services 2.2 

Nursing services 1.7 

Medical social services 0.4 

All three services combined 4.2 

Source: OIG analysis of hospice claims, 2008. 

*The averages for individual services do not sum to the average for all 

three services combined because of rounding. 

OEI-02-06-00223 Medicare Hospice Care: Services Provided to Beneficiaries 

Residing in Nursing Facilities 
Page 9 – Charlene Frizzera 

8 hours. Nursing services were shorter, at 53 minutes on average, and ranged from 

5 minutes to 4 hours. Medical social service visits were shorter still, at 43 minutes on 

average, and ranged from 5 minutes to 2.6 hours. 

CONCLUSION 

We found that 31 percent of Medicare hospice beneficiaries resided in nursing facilities 

in 2006. Medicare paid hospices approximately $2.59 billion for care provided to 

beneficiaries in nursing facilities in 2006. On average, Medicare paid $960 per week for 

hospice care for each hospice beneficiary in a nursing facility, not including payment for 

physician services. This care most commonly included nursing, home health aide, and 

medical social services. Hospices furnished an average of 4.2 visits per week for these 

three services combined. They also commonly provided drugs. 

The results of this memorandum report can help CMS and other decisionmakers 

determine whether the types and frequencies of hospice services provided to beneficiaries 

in nursing facilities meet the goals of the hospice benefit. The results can also help 

decisionmakers determine whether current payment rates are aligned with the hospice 

services being provided. 

This report is being issued directly in final form because it contains no recommendations. 

If you have comments or questions about this report, please provide them within 60 days. 

Please refer to report number OEI-02-06-00223 in all correspondence.

OEI-02-06-00223 Medicare Hospice Care: Services Provided to Beneficiaries 

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Page 10 – Charlene Frizzera 

APPENDIX A

HOSPICE PAYMENT RATES 

The Centers for Medicare & Medicaid Services (CMS) publishes general hospice 

payment rates annually to be used for each level of care.21 The rates are adjusted based 

on the beneficiary’s geographic location. The levels of care and the fiscal year 2006 

Medicare unadjusted daily rates for each are as follows: 

• Routine Home Care ($126.49): The routine home care rate is paid to the hospice 

for each day that the beneficiary is under the care of the hospice and is not 

receiving one of the other categories of care. Routine home care includes, but is 

not limited to, nursing and home health aide services. Routine home care may be 

provided in the home or other places of residence, such as a nursing facility. 

• Continuous Home Care ($738.26): Continuous home care is allowed only during 

periods of crisis in which a beneficiary requires continuous care to achieve 

palliation or management of acute medical symptoms. It is covered only as 

necessary to maintain the terminally ill beneficiary at home. The care must be 

predominantly nursing care. Continuous home care may be provided in the home 

or other places of residence, such as a nursing facility. The continuous home care 

rate is divided by 24 hours to determine an hourly rate. A minimum of 8 hours 

must be provided. 

• Respite Care ($130.85): Respite care is short-term inpatient care provided to the 

beneficiary when necessary to relieve the beneficiary’s caregiver(s). Respite care 

may be provided only on an occasional basis and is not reimbursed for more than 

5 consecutive days. Respite care may be provided in a Medicare- or 

Medicaid-certified hospice inpatient facility, hospital, skilled nursing facility, or 

nursing facility.

• General Inpatient Care ($562.69): General inpatient care is for pain control and 

symptom management that cannot feasibly be provided in other settings. General 

inpatient care may be provided in a Medicare- or Medicaid-certified hospice 

inpatient facility, hospital, or skilled nursing facility.

 

21 CMS, “Medicare Claims Processing Manual,” Pub. No. 100-04, ch. 11, Transmittal 663, Change Request 

3977. Available online at http://www.cms.hhs.gov/transmittals/downloads/R663CP.pdf. Accessed on 

January 28, 2009. 

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APPENDIX B 

METHODOLOGY 

We based this study on data from a medical record review of a stratified random sample 

of hospice claims for beneficiaries in nursing facilities. 

Sample Selection 

Using the National Claims History file, we extracted all Medicare hospice claims that had 

service dates in 2006 and were received through December 2006. Hospice claims 

typically cover a 1-month period but could be for shorter periods. We matched the 

claims data to the Medicare Enrollment Database by health insurance claim number to 

identify the Social Security number for each beneficiary. 

Because hospice claims in 2006 did not include place of service, we used the Minimum 

Data Set (MDS) to identify nursing facility stay dates. The MDS includes assessments 

on all residents in Medicare- or Medicaid-certified nursing facilities. We used the MDS 

assessments received from January 2004 through December 2006 to create a record for 

each beneficiary of the dates when he or she resided in a nursing facility. 

We matched the hospice claims to these nursing facility stay dates by the beneficiaries’ 

Social Security numbers to identify claims for beneficiaries while they resided in nursing 

facilities. We created a file that included all hospice claims that corresponded to 

beneficiaries’ nursing facility stays. This file included 812,668 hospice claims for 

231,978 beneficiaries.22

We selected a stratified random sample of 470 hospice claims from this file. We 

stratified the sample to ensure that we included claims for beneficiaries who had 

high-dollar-amount claims and had received hospice care while in a nursing facility for 

an extended period. This stratum comprised all claims for hospice beneficiaries with an 

average hospice reimbursement of $400 or more per day for at least 60 days while in a 

nursing facility during 2006. The other two strata comprised claims for all remaining 

beneficiaries who received hospice care while in a nursing facility: one stratum included 

all claims for beneficiaries with a maximum claim amount of $3,000 or less, and the 

other included all claims for beneficiaries with a maximum claim amount of more than 

$3,000. We then selected a random sample of claims from each stratum. See Table B-1. 

 

22 These numbers were based on claims received through December 2006. 

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Table B-1: Sample Selection 

 Description of Strata Population Initial 

Sample 

Final 

Sample 

Claims for beneficiaries with high 

average daily claim amounts and 

extended nursing home stays 

Average claim 

amount > $400/day 

for at least 60 days 

1,441 35 33 

Maximum claim 

amount < $3,000 279,697 85 82 

Claims for all other beneficiaries 

with nursing home stays Maximum claim 

amount > $3,000 531,530 350 335 

 Total claims 812,668 470 450 

We excluded 12 claims from our sample because the hospices were currently under 

investigation by the Office of Inspector General. We excluded an additional claim 

because the beneficiary’s nursing facility stay information was incomplete and an 

additional three claims because we were unable to locate the hospices.23 We also 

excluded another four claims because the contractor erred in record collection.24 Our 

final sample included 450 claims. 

As a last step, we identified the names and addresses of the hospices associated with each 

sampled claim by using the Online Survey and Certification Reporting System (OSCAR). 

We matched the hospice provider numbers in the claims file with the OSCAR data. We 

also identified hospices that were for-profit and those that were not-for-profit using a 

variable that indicated the type of provider ownership. In total, 43 percent of claims were 

from not-for-profit hospices and 53 percent of claims were from for-profit hospices. The 

remaining 4 percent were for services provided by government hospices. 

Medical Record Review 

We used a contractor to collect and review the medical records associated with each 

sampled claim. For each claim, we requested that the hospices provide the relevant 

hospice election statement, plan(s) of care,25 record of services provided (including those 

furnished under arrangement or contract with the hospice), certification(s) of terminal 

illness, and clinical information and other documentation that supported the medical 

 

23 The hospices’ telephone numbers were disconnected and the hospices could not be reached by certified 

mail. We have referred these cases to CMS for appropriate action. 

24 The contractor collected records for the wrong claim period in three cases and contacted the wrong 

provider in one case. 

25 Although only one plan of care is in effect at any given time, some beneficiaries had more than one plan 

of care during the claim period. 

OEI-02-06-00223 Medicare Hospice Care: Services Provided to Beneficiaries 

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prognosis. Hospices are required to keep all of this information in the clinical record that 

they establish for every individual receiving care and services.26 We requested these 

records for the claim period and, if possible, for the 30 days preceding and the 30 days 

following the claim period. 

 

26 42 CFR § 418.74. 

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APPENDIX C 

CONFIDENCE INTERVALS FOR SELECTED ESTIMATES 

Type of Service n Point Estimate 95-Percent 

Confidence Interval 

Nursing services 447 96.3% 93.3% – 97.9% 

Home health aide services 447 73.0% 68.1% – 77.4% 

Medical social services 447 68.0% 63.0% – 72.7% 

Counseling (including spiritual, pastoral, 

or chaplain services) 447 57.6% 52.4% – 62.6% 

Volunteer and other miscellaneous 

services 447 14.4% 11.3% – 18.2% 

Physical therapy, occupational therapy, 

or speech-language pathology services 447 0.6% 0.2% – 1.8% 

Source: Office of Inspector General (OIG) analysis of medical record review results, 2008. 

n Point Estimate 95-Percent 

Confidence Interval 

Drugs* 446 96.1% 93.5% – 97.8% 

Source: OIG analysis of medical record review results, 2008. 

*Reviewers did not indicate for one claim whether drugs were provided. 

Type of Service n Average Number of 

Visits Per Week 

95-Percent 

Confidence Interval 

Home health aide services 447 2.16 2.01 – 2.32 

Nursing services 447 1.68 1.59 – 1.77 

Medical social services 447 0.38 0.35 – 0.42 

All three services combined* 447 4.23 4.03 – 4.42 

Source: OIG analysis of medical record review results, 2008. 

*The averages of individual services do not sum to the average for all three services combined because of rounding. 

OEI-02-06-00223 Medicare Hospice Care: Services Provided to Beneficiaries 

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OEI-02-06-00223 Medicare Hospice Care: Services Provided to Beneficiaries 

Residing in Nursing Facilities 

APPENDIX D 

WEIGHTED CHI-SQUARE TEST COMPARING NOT-FOR-PROFIT AND 

FOR-PROFIT HOSPICES 

Type of Service 

Percentage of Claims 

From Not-for-Profit 

Hospices for Which 

Services Were 

Provided 

Percentage of Claims 

From For-Profit 

Hospices for Which 

Services Were 

Provided 

P-Value 

Nursing services 97.6% 96.5% 0.55 

Home health aide services* 67.0% 78.6% 0.02 

Medical social services 67.5% 69.6% 0.69 

Counseling (including spiritual, 

pastoral, or chaplain services) 59.0% 57.9% 0.83 

Volunteer and other 

miscellaneous services* 21.2% 8.3% 0.0005 

Physical therapy, occupational 

therapy, or speech-language 

pathology services** 

0.9% 0.4% N/A 

Source: Office of Inspector General (OIG) analysis of medical record review results, 2008. 

* Differences between percentages of claims from not-for-profit hospices and those from for-profit hospices were statistically 

significant at the 95-percent confidence level. 

**Percentages for these services were too small for statistical testing. 

Percentage of Claims 

From Not-for-Profit 

Hospices for Which 

Services Were 

Provided 

Percentage of Claims 

From For-Profit 

Hospices for Which 

Services Were 

Provided 

P-Value 

Drugs 96.3% 96.6% 0.88 

Source: OIG analysis of medical record review results, 2008.