Department of Health and Human Services

OFFICE OF

INSPECTOR GENERAL

HOSPICES INAPPROPRIATELY 

BILLED MEDICARE OVER 

$250 MILLION FOR GENERAL 

INPATIENT CARE

Daniel R. Levinson

Inspector General

March 2016

OEI-02-10-00491
69%

20%

10%

1%

31%

Inappropriate

Beneficiary did not need 

GIP at all during stay

No evidence that 

beneficiary elected hospice 

or had terminal illness

69%

20%

10%

1%

31%

Inappropriate

$268 million

Beneficiary did not 

need GIP at all during 

the stay

Beneficiary did not need 

GIP for part of the stay

No evidence that 

beneficiary elected 

hospice or had terminal 

illness

EXECUTIVE SUMMARY: HOSPICES INAPPROPRIATELY BILLED MEDICARE 

OVER $250 MILLION FOR GENERAL INPATIENT CARE 

OEI-02-10-00491 

WHY WE DID THIS STUDY 

Recent investigations by the Office of Inspector General have shown a number of instances in 

which hospices inappropriately billed Medicare for hospice general inpatient care (GIP). Misuse 

of GIP includes care being billed but not provided and beneficiaries receiving care they do not 

need. Such misuse has human costs for this vulnerable population as well as financial costs for 

Medicare. 

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

6 months or less to continue life with minimal disruptions and to support beneficiaries’ families 

and other caregivers. The care is palliative, rather than curative. Hospices must establish an 

individualized plan of care for each beneficiary. GIP is the second most expensive level of 

hospice care and is intended to be short-term inpatient care for symptom management and pain 

control that cannot be handled in other settings. 

HOW WE DID THIS STUDY 

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

GIP stays in 2012. We analyzed the results of the medical record review to estimate the 

percentage of GIP stays that were billed inappropriately. We also used Medicare Part D data to 

identify the drugs paid for by Part D and provided to beneficiaries during GIP stays. 

WHAT WE FOUND 

We found that hospices billed one-third of GIP stays inappropriately, costing Medicare 

$268 million in 2012. Hospices commonly billed for GIP when the beneficiary did not have 

uncontrolled pain or unmanaged symptoms. 

Percentage of Inappropriate GIP Stays, 2012

$754 million
For example, a hospice billed for GIP for a beneficiary with a circulatory disease who had no 

unmanaged symptoms. This beneficiary could have been cared for at home, but the hospice 

billed Medicare for 46 consecutive days of GIP. The hospice was paid just over $31,000 for the 

stay. 

Some States, such as Florida, had many inappropriate GIP stays. Hospices were more likely to 

inappropriately bill for GIP provided in skilled nursing facilities than GIP provided in other 

settings. For-profit hospices were more likely than other hospices to inappropriately bill for GIP. 

We also found that Medicare sometimes paid twice for drugs because they were paid for under 

Part D when they should have been provided by the hospice and covered under the hospice daily 

payment rate. Further, hospices did not meet all care planning requirements for 85 percent of 

GIP stays and sometimes provided poor-quality care. For example, one hospice provided GIP to 

a beneficiary with dementia for 16 days, but his pain was never brought under control. 

WHAT WE RECOMMEND 

The findings in this report make clear the need to address the misuse of GIP and hold hospices 

accountable when they bill inappropriately or provide poor-quality care. We recommend that the 

Centers for Medicare & Medicaid Services (CMS) (1) increase its oversight of hospice GIP 

claims and review Part D payments for drugs for hospice beneficiaries; (2) ensure that a 

physician is involved in the decision to use GIP; (3) conduct prepayment reviews for lengthy 

GIP stays; (4) increase surveyor efforts to ensure that hospices meet care planning requirements; 

(5) establish additional enforcement remedies for poor hospice performance; and (6) follow up 

on inappropriate GIP stays, inappropriate Part D payments, and hospices that provided poorquality care. CMS concurred with all six recommendations. 
TABLE OF CONTENTS

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

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

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

Findings........................................................................................................8

Hospices billed one-third of GIP stays inappropriately, costing 

Medicare $268 million in 2012........................................................8

Hospices billed inappropriately for about half of GIP stays in 

SNFs...............................................................................................10

For-profit hospices were more likely than other hospices to bill 

inappropriately for GIP..................................................................11

Medicare sometimes paid twice for drugs for beneficiaries 

receiving GIP .................................................................................12

Hospices did not meet care planning requirements for 85 percent 

of GIP stays....................................................................................13

Hospices sometimes provided poor-quality care and often did 

not provide intense services...........................................................14

Conclusion and Recommendations............................................................17

Agency Comments and OIG Response..........................................20

Appendixes ................................................................................................21

A: Detailed Methodology .............................................................21

B: Statistical Estimates and Confidence Intervals........................25

C: Chi-square Tests for Statistically Significant Differences .......29

D: Agency Comments...................................................................30

Acknowledgments......................................................................................34
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 1

OBJECTIVES

1. To determine the extent to which hospices inappropriately billed Medicare for 

general inpatient care (GIP) in 2012. 

2. To determine the extent to which hospices did not meet care planning 

requirements for beneficiaries receiving GIP in 2012.

3. To describe instances in which hospices provided poor-quality care.

BACKGROUND

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

expectancy of 6 months or less to continue life with minimal disruptions and to 

support beneficiaries’ families and other caregivers. The care is palliative, rather 

than curative. In 2013, Medicare paid $15.1 billion for hospice care for 

1.3 million beneficiaries.1 

The Office of Inspector General (OIG) has had concerns about the possible 

misuse of GIP, which is the second most expensive level of hospice care. For 

example, in 2014, the owner of a hospice chain was charged with fraud for 

engaging in a scheme to obtain higher Medicare payments by improperly billing 

GIP. The hospice was also allegedly paying nursing facilities $250 per day for 

every patient on GIP. 2 In 2012, a former hospice owner was sentenced to 

28 months in prison for defrauding Medicare of over $3 million by billing for GIP 

but providing a lower level of hospice care. 3 In 2011, a hospice agreed to pay 

$2.7 million for billing Medicare for GIP when it was not required.4

 In addition, 

previous OIG work has raised concerns about duplicate payments made by 

 ____________________________________________________________ 

1

 Medicare Payment Advisory Commission (MedPAC), Report to Congress: Medicare Payment 

Policy, March 2015, ch. 12. Accessed at 

http://medpac.gov/documents/reports/mar2015_entirereport_revised.pdf?sfvrsn=0 on May 11, 

2015.

2

 Federal Bureau of Investigation (FBI), “Illinois Hospice Executive Charged with Federal 

Healthcare Fraud for Allegedly Falsely Elevating Level of Patients’ Care” January 27, 2014. 

Accessed at http://www.fbi.gov/chicago/press-releases/2014/illinois-hospice-executive-chargedwith-federal-health-care-fraud-for-allegedly-falsely-elevating-level-of-patients-care on May 8, 

2015. 

3 FBI, “Former Hospice Owner Sentenced for Health Care Fraud” February 1, 2012. Accessed at 

http://www.fbi.gov/birmingham/press-releases/2012/former-hospice-owner-sentenced-for-healthcare-fraud on May 8, 2015. 

4 FBI, “Hospice Home Care to Pay $2,700,000 Settlement in Medicare Fraud Case,” December 9, 

2011. Accessed at http://www.fbi.gov/littlerock/press-releases/2011/hospice-home-care-to-pay-2-

700-000-settlement-in-medicare-fraud-case on May 8, 2015. 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 2

Medicare Part D for prescriptions that should have been covered under the 

hospice benefit.5

 

OIG also has had concerns about hospice beneficiaries receiving inadequate care 

planning and poor-quality care. Previous OIG reports have found that hospice 

oversight is lacking and that the most common deficiencies cited for hospices 

centered on patient care planning and quality. 6 

This report is part of OIG’s larger body of work on hospice care, which includes a 

companion report that describes the use of GIP in 2011.7 That report found that 

23 percent of Medicare hospice beneficiaries received GIP during the year and 

one-third of beneficiaries’ GIP stays exceeded 5 days, with 11 percent lasting 

10 days or more. Another companion report will assess election statements and 

certifications of terminal illness for Medicare beneficiaries who received GIP.8

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.9 Upon a 

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

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

conditions. 

Hospice care 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 

 ____________________________________________________________ 

5

 OIG, Medicare Could Be Paying Twice for Prescription Drugs for Beneficiaries in Hospice, 

A-06-10-00059, June 2012. 

6

 OIG, Medicare Hospices: Certification and Centers for Medicare & Medicaid Services 

Oversight, OEI-06-05-00260, April 2007. 

7

 OIG, Medicare Hospice: Use of General Inpatient Care, OEI-02-10-00490, May 2013. 

8

 OIG, Hospices Should Improve Their Election Statements and Certifications of Terminal Illness, 

OEI-02-10-00492, forthcoming. 

9

 Social Security Act, §§ 1814(a)(7)(A) and 1861(dd)(3)(A), 42 U.S.C. §§ 1395f(a)(7)(A) and 

1395x(dd)(3)(A); 42 CFR §§ 418.20 and 418.22. Certification is based on the physician’s or 

medical director’s clinical judgment regarding the normal course of the individual’s illness.
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 3

unrelated to the terminal illness. 10 Beneficiaries may revoke their election of 

hospice care and return to standard Medicare coverage at any time.11

Hospice General Inpatient Care

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

continuous home care, GIP, and inpatient respite care. GIP is the second most 

expensive level of hospice care and, next to routine home care, is the most 

commonly used. 

GIP is intended to be short-term and may be provided only in three settings: a 

hospice inpatient unit, a hospital, or a skilled nursing facility (SNF).12 A 

physician’s order is not required for GIP. GIP is for pain control or acute or 

chronic symptom management that cannot be managed in other settings, such as 

the beneficiary’s home.13 These acute hospice care services are to ensure that any 

new or worsening symptoms are intensively addressed so that the beneficiary can 

return to a lower level of hospice care.14

 As with all covered hospice services, 

hospices are required to provide GIP if it is needed by the beneficiary.15 Hospices 

may enter into arrangements with facilities to provide GIP.16 The hospice retains 

oversight of staff and services for all arranged services to ensure the provision of 

quality care.17

Medicare pays hospices a daily rate from the day a beneficiary elects hospice care 

to the day of discharge. GIP and the other levels of hospice care each has an allinclusive daily rate that is paid through Part A.18

 Medicare pays $672 per day for 

GIP, compared to $151 per day for routine home care, which is the most common 

level of care. The daily rate is paid to the hospice for each day that a beneficiary 

 ____________________________________________________________ 

10 Social Security Act, §§ 1812(d)(2)(A) and 1861(dd)(1), 42 U.S.C. §§ 1395d(d)(2)(A) and 

1395x(dd)(1); 42 CFR § 418.24(d). 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. See CMS, Medicare 

Care Choice Model. Accessed at http://innovation.cms.gov/initiatives/Medicare-Care-Choices/ on 

May 18, 2015. 

11 Social Security Act, § 1812(d)(2)(B), 42 U.S.C. § 1395d(d)(2)(B); 42 CFR § 418.28. 

12 42 CFR § 418.108(a) and (b). Note that Medicare regulations do not specify what is meant by 

short-term for GIP. 

13 42 CFR § 418.302(b)(4). 

14 79 Fed. Reg. 50451, 50455 (Aug. 22, 2014). Accessed at http://www.gpo.gov/fdsys/pkg/FR2014-08-22/pdf/2014-18506.pdf on June 19, 2015. 

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

16 42 CFR § 418.108. 

17 42 CFR § 418.100. 

18 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. 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. 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 4

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. Beneficiaries generally do not pay copays for hospice care.19

Table 1: Unadjusted Daily Medicare Hospice Payment 

Rates by Level of Care, FY 2012

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. 

Regardless of the level of care provided, the hospice must establish an 

individualized plan of care for each beneficiary it serves. The plan of care must 

be written by an interdisciplinary group that includes a physician, nurse, social 

worker, and pastoral or other counselor. The plan must include all services the 

beneficiary needs in relation to the terminal illness, including interventions to 

manage pain and symptoms, and the scope and frequency of the needed services. 

The hospice interdisciplinary group must review, revise and document the 

individualized plan as frequently as the patient's condition requires, but no less 

frequently than every 15 calendar days.20 

Hospice Drugs and the Medicare Part D Benefit

For all hospice beneficiaries, the hospice is required to provide drugs related to 

the palliation and management of the terminal illness and related conditions.21 

These drugs are used primarily for the relief of pain and symptom control.22 Their 

cost is covered by the all-inclusive daily rate paid to the hospice. 

The Medicare Part D program provides an optional prescription drug benefit to 

Medicare beneficiaries.23

 Under the program, private insurance companies—

referred to as sponsors—provide drug coverage to beneficiaries who choose to 

 ____________________________________________________________ 

19 Hospices may charge beneficiaries a 5 percent copay for inpatient respite care. See 42 CFR § 

418.400. 

20 42 CFR §§ 418.200, 418.56. 

21 42 CFR § 418.106; CMS, Medicare Benefit Policy Manual, Pub. No. 100-02, ch. 9, 

§ 40.5. 

22 42 CFR § 418.202(f). 

23 The Medicare Prescription Drug, Improvement, and Modernization Act of 2003, P.L. 108-173; 

Social Security Act, §§ 1860D-1 to 1860D-43, 42 U.S.C. §§ 1395w-101 to 1395w-153.
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 5

enroll.24 When a hospice beneficiary is enrolled in Part D, Part D pays for drugs 

unrelated to the terminal illness. The hospice is still required to provide drugs 

related to the palliation and management of the terminal illness and related 

conditions. The hospice is allowed to charge the beneficiary a copay, not 

exceeding $5, for each prescription.25

Because drugs related to the beneficiary’s terminal illness are covered under the 

hospice benefit, they are excluded from coverage under Part D.26 In 2014, CMS 

issued guidance to Part D sponsors that focused on some commonly used hospice 

drugs. The guidance strongly encouraged sponsors to place beneficiary-level 

prior authorization requirements on four categories of drugs that are typically 

used by hospice beneficiaries: analgesics, antinauseants, laxatives, and 

antianxiety drugs.27 CMS expects that hospices will routinely provide these types 

of drugs so Part D sponsors are instructed to reject claims for these drugs for 

hospice beneficiaries. 

CMS Oversight 

Hospices must be certified to participate in the Medicare program.28 CMS 

contracts with State Survey and Certification agencies to conduct onsite surveys 

of hospices at the time of initial certification, for recertification, and in response 

to complaints. These surveys determine whether the hospice meets Medicare 

requirements. For example, surveyors must determine whether plans of care are 

individualized, patient-specific, and developed by all members of the 

interdisciplinary group.29 

Surveyors must cite deficiencies when hospices fail to meet requirements. The 

only enforcement action that CMS can initiate against hospices that do not correct 

deficiencies is termination from the Medicare program.30 In contrast, CMS has a 

variety of enforcement actions available for other types of Medicare providers, 

such as nursing facilities and home health agencies. These actions include civil 

 ____________________________________________________________ 

24 Social Security Act, §§ 1860D-1(a)(1)(A), 42 U.S.C. § 1395 w-101(a)(1)(A) and 42 CFR § 

423.104. 

25 42 CFR § 418.400. 

26 Social Security Act, § 1860D-2(e)(2)(B), 42 U.S.C. § 1395w-102(e)(2)(B); 42 CFR § 423.100, 

Part D drug, (2)(i). 

27 CMS, Part D Payment for Drugs for Beneficiaries Enrolled in Medicare Hospice. Accessed at 

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/Hospice/Downloads/2014-

PartD-Hospice-Guidance-Revised-Memo.pdf on June 12, 2015.

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

29 CMS, State Operations Manual, Appendix M - Guidance to Surveyors: Hospice, Tag L545. 

Accessed at http://www.cms.gov/Regulations-andGuidance/Guidance/Manuals/Downloads/som107ap_m_hospice.pdf on June 19, 2015. 

30 42 CFR § 488.7(d) and 42 CFR § 489.53. 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 6

monetary penalties and denial of Medicare payments. 31 OIG has previously 

recommended that CMS seek legislation to establish additional enforcement 

remedies for poor hospice performance.32

Related Work 

This report is part of OIG’s larger body of work examining the Medicare hospice 

benefit. A recent OIG report found that Medicare payments for hospice care in 

assisted living facilities (ALF) 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 compared to beneficiaries in any 

other setting. 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.33 

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 compared to hospices nationwide.34 In addition, a series of OIG 

reports addressing CMS oversight of hospices found that 14 percent of hospices 

were past due for certification in 2005 and that the frequency of recertification 

had not improved by 2013.35 The Improving Medicare Post-Acute Care 

Transformation Act of 2014 (IMPACT Act) mandated surveys of hospices at least 

every 3 years.36

METHODOLOGY 

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

sample of 565 GIP stays in 2012. We also used Medicare Part D data to identify 

the drugs paid for by Part D and provided to beneficiaries during GIP stays. We 

considered a GIP stay to be claims for GIP for the same beneficiary in the same 

setting, from the same hospice, and the start date of a subsequent claim was the 

same day, or the next day, as the ending date of the previous claim. Unless 

otherwise stated, all differences noted in the findings are statistically significant. 

See Appendix A for more detailed information about the methodology. See 

 ____________________________________________________________ 

31 42 CFR § 488.406 and 42 CFR § 488.820. 

32 OIG, Medicare Hospices: Certification and Centers for Medicare & Medicaid Services 

Oversight, OEI-06-05-00260, April 2007. 

33 OIG, Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living 

Facilities, OEI-02-14-00070, January 2015. 

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

2011.

35 OIG, Medicare Hospices: Certification and Centers for Medicare & Medicaid Services 

Oversight, OEI-06-05-00260, April 2007. OIG, Frequency of Medicare Recertification Surveys 

for Hospices is Unimproved, OEI-06-13-00130, August 2013. 

36 42 U.S.C. §§ 1395x(dd)(4)(C). 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 7

Appendix B for all statistical estimates and 95-percent confidence intervals and 

Appendix C for chi-square tests for statistically significant differences. 

Limitations

This review determined whether hospice billing for GIP was appropriate. We did 

not independently verify the beneficiary’s prognosis for a life expectancy of 

6 months or less. In addition, this review focuses on instances in which the 

beneficiary did not receive the number of services that were needed based on an 

assessment of the medical record. It does not determine all instances of poorquality care. 

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.
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 8

69%

20%

10%

1%

31%

Inappropriate

$268 million

Beneficiary did not need 

GIP at all during stay

Beneficiary did not need 

GIP for part of the stay

No evidence that 

beneficiary elected hospice 

or had terminal illness

Chart 1: Percentage of Inappropriate GIP Stays, 2012

Source: OIG analysis of medical record review results, 2015. 

$754 million 

FINDINGS

Hospices billed one-third of GIP stays inappropriately, 

costing Medicare $268 million in 2012 

In 2012, hospices frequently billed Medicare for providing GIP to beneficiaries 

who did not need this level of care. GIP is solely for pain control or acute or 

chronic symptom management that cannot be provided in other settings. For 

20 percent of GIP stays in 2012, the beneficiary did not need GIP at all during the 

stay. See Chart 1. For an additional 10 percent of GIP stays, the beneficiary 

needed GIP at some point, but not for the entire stay. In these cases, the hospice 

commonly continued to bill GIP for many days after the beneficiary’s symptoms 

were under control. In 1 percent of stays, there was no evidence that the 

beneficiary elected hospice care or was even certified as having a terminal illness. 

Medicare inappropriately paid hospices $268.1 million for GIP in 2012.37 The 

inappropriate payments represent 26 percent of the $1.0 billion paid to hospices 

for GIP stays in 2012.38 For the vast majority of inappropriate GIP stays, the 

hospice should have billed for routine home care instead of GIP. GIP is 

 ____________________________________________________________ 

37 For stays in which there was no evidence that the beneficiary elected hospice care or was 

certified as having a terminal illness, we considered the entire amount Medicare paid for the GIP 

stay to be inappropriate. For other stays, we considered inappropriate the difference between the 

amount Medicare paid for GIP and the amount Medicare would have paid had the hospice billed 

for the level of care that the beneficiary needed. 

38 These numbers and others presented in the report are rounded. They cannot always be used to 

recreate percentages and totals presented in the report because our calculations for these figures 

are based on unrounded numbers. 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 9

reimbursed at a much higher rate than routine home care. In 2012, hospices were 

paid $672 per day for GIP whereas they were paid $151 per day for routine care.39

Hospices commonly billed for GIP when the beneficiary did not have 

uncontrolled pain or unmanaged symptoms 

In 89 percent of inappropriate GIP stays, the hospice billed for GIP even though 

the beneficiary did not have uncontrolled pain or unmanaged symptoms or the 

beneficiary received care that could have been provided at home. For example, 

one hospice billed GIP for 29 days for a beneficiary who was in no apparent 

distress and whose symptoms were managed with oral medications. The hospice 

received almost $21,000 from Medicare for this inappropriate GIP stay. In 

another example, a hospice billed for 6 days of GIP for an 85-year-old beneficiary 

with dementia. The hospice placed the beneficiary in GIP and did not change her 

plan of care or order new medications. The hospice received just over $3,700

from Medicare for this GIP stay. 

Hospices sometimes billed inappropriately for GIP because of caregiver issues. 

This occurred in 15 percent of the inappropriate GIP stays. Such issues include 

the caregiver being overwhelmed. GIP is not intended to be used in these 

situations. A different level of hospice care—inpatient respite care—is designed 

to provide relief to caregivers. The GIP daily rate is typically four times greater 

than the inpatient respite care daily rate. In 2012, hospices were paid a base rate 

of $672 per day for GIP and $156 per day for inpatient respite care.40 

Examples of inappropriate billing related to caregiver issues include a hospice 

billing for GIP when a beneficiary’s wife was exhausted, and a hospice billing for 

GIP when a beneficiary’s son needed a break. In the latter case, the physician had 

noted in the medical record that the beneficiary needed inpatient respite care, not 

GIP.

Some States had many inappropriate GIP stays 

Some States stand out for the number of inappropriate GIP stays found in our 

sample.41 For example, our sample included 99 GIP stays in Florida.42 More than 

half (52) of these stays were inappropriate. One of these inappropriate stays 

involved a 75-year-old man who had no complaints of discomfort and whose 

needs were met with basic nursing and hospice services. He did not need, nor did 

 ____________________________________________________________ 

39 These are the unadjusted daily payment rates for FY 2012. 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. Accessed at http://www.cms.gov/Outreach-andEducation/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7518.pdf on 

March 25, 2015. 

40 Ibid. 

41 Because of the size of our sample, we are not able to project these numbers to the population of 

all stays but can report only on the sample. 

42 Florida hospices billed for 21 percent of all GIP stays in 2012. 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 10

he receive, acute care during his GIP stay, yet the hospice billed 16 days of GIP 

for him, totaling more than $11,000. 

Ohio and Arizona also stood out. After Florida, these States had the highest 

number of inappropriate stays in our sample. In Ohio, 18 of the 33 sample GIP 

stays were inappropriate, including a six-day stay for a beneficiary with 

Alzheimer’s disease who did not have unmanaged symptoms. In Arizona, 17 of 

the 31 sample stays were inappropriate. In one inappropriate stay, the beneficiary 

requested bingo night on the first day. The beneficiary’s symptoms were 

controlled, yet she remained in GIP for 14 days, which cost Medicare more than 

$10,000. 

Hospices billed inappropriately for about half of GIP stays in 

SNFs

Hospices were more likely to inappropriately bill for GIP provided in SNFs than 

GIP provided in other settings, namely hospitals and hospice inpatient units. 

Forty-eight percent of GIP stays in SNFs were inappropriate compared to 

30 percent in other settings. See Chart 2. 

Chart 2: Inappropriate GIP Stays by Setting, 2012 

 Note: The difference between SNFs and other settings is statistically significant at the 95-percent confidence level. 

 Source: OIG analysis of medical record review results, 2015. 

30%

48%

0%

10%

20%

30%

40%

50%

60%

Other settings SNF

Percentage of GIP stays

Setting
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 11

For 39 percent of GIP stays in SNFs, the beneficiary did not need that level of 

care at all during the stay. For an additional 9 percent, the beneficiary needed GIP 

at some point, but not for the entire stay. For example, a hospice billed for 

13 days of GIP for a beneficiary whose symptoms were under control by the third 

day. The hospice received about $9,300 for this stay. 

The diagnoses of beneficiaries receiving GIP in SNFs differed from those of 

beneficiaries receiving GIP in other settings. GIP stays in SNFs were more likely 

to involve a beneficiary diagnosed with a mental disorder, ill-defined condition, or 

Alzheimer’s disease. In 36 percent of the GIP stays in SNFs, the beneficiary was 

diagnosed with one of these conditions compared to 22 percent of GIP stays in the 

other settings. Previous OIG work found that beneficiaries with these types of 

diagnoses typically receive less complex hospice care than beneficiaries with 

other diagnoses. 43

 This work also raised concerns about the potential for hospices 

to target beneficiaries with conditions associated with less complex care because 

they may offer hospices the greatest financial gain.

For-profit hospices were more likely than other hospices to 

bill inappropriately for GIP

For-profit hospices billed 41 percent of their GIP stays inappropriately. In 

comparison, other hospices, including nonprofit and government-owned hospices, 

billed 27 percent of their GIP stays inappropriately. 

For-profit hospices were more likely than other hospices to bill for GIP in the 

SNF setting. For-profit hospices accounted for one-third of all GIP stays but twothirds of GIP stays in SNFs.

 ____________________________________________________________ 

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

2011 and Medicare Hospices Have Financial Incentives To Provide Care in Assisted Living 

Facilities, OEI-02-14-00070, January 2015. 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 12

Medicare sometimes paid twice for drugs for beneficiaries 

receiving GIP 

The Medicare Part A hospice benefit covers drugs for beneficiaries through the 

daily rate paid to hospices. These drugs must be used primarily for the relief of 

pain and symptom control related to the hospice beneficiary's terminal illness.44 

They are supposed to be provided by the hospice. However, our sample of GIP 

stays included many instances in which Medicare Part D paid for these drugs for 

hospice beneficiaries. 

Specifically, Part D inappropriately paid for over half (110 of 198) of the drugs 

billed to Part D that were provided to beneficiaries in our sampled GIP stays.45 

The 110 drugs were used primarily for the relief of pain and symptom control 

related to the hospice beneficiary's terminal illness, and therefore, should have 

been provided by the hospice and covered under the daily rate. Medicare is 

paying twice when Part D pays for drugs that are already covered by the Part A 

hospice benefit. Also, beneficiaries may be paying for copays for the Part D 

drugs. 

In recent guidance, CMS has encouraged Part D sponsors not to pay for analgesic, 

antinausea, laxative, or antianxiety drugs for hospice beneficiaries because they 

are commonly used in hospice care and hospices are expected to provide them. 

 ____________________________________________________________ 

44 42 CFR §418.202 (f). 

45 Because of the size of our sample, we are not able to project these numbers to the population of 

all stays and report only on the sample. 

Examples of Inappropriate Billing by For-Profit Hospices

 A hospice billed for 51 days of GIP for a beneficiary who needed only routine 

home care. The beneficiary’s symptoms were under control and she needed 

assistance only with personal care, eating, and the administration of medication. 

Medicare paid the hospice almost $30,000 for over 7 weeks of GIP. 

 A hospice billed for GIP for a beneficiary with a circulatory disease who had no 

unmanaged symptoms. This beneficiary could have been cared for at home, but 

the hospice billed Medicare for 46 consecutive days of GIP in an inpatient unit. 

The hospice was paid just over $31,000 for the stay. 

 A hospice billed for GIP for a beneficiary in Florida who entered GIP for 

symptom management. Her symptoms were managed within 2 days, yet she 

remained in GIP for 15 additional days. Medicare paid close to $12,000 for this 

stay.
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 13

Although some of the inappropriately paid drugs associated with our sample were 

in these categories, many others were not. Of the 110 drugs, 30 were analgesic, 

antinausea, laxative, or antianxiety drugs. The remaining 80 drugs for which 

Part D inappropriately paid were in other categories, which included diuretics and 

anticonvulsants.

Hospices did not meet care planning requirements for 

85 percent of GIP stays 

Hospices are required to develop an individualized written plan of care for each 

beneficiary they serve. The plan of care must meet a number of requirements. 

For instance, it must include a detailed statement of the scope and frequency of 

needed services and must be developed by an interdisciplinary group.46 Care 

plans are important because they help ensure that beneficiaries receive the care 

and attention they need and that care is coordinated effectively. 

For 72 percent of GIP stays, the hospice care plan was missing at 

least one key element 

In 72 percent of GIP stays, the hospice did not include either the frequency or the 

scope of at least one type of main service in the care plan. These services include 

physician, nursing, and medical social services. 

In some instances, care plans included a general description of care and did not 

appear to take into account the individual needs of the beneficiary. For example, 

a hospice billed for 4 days of GIP for a beneficiary in an inpatient unit. The plan 

of care was not individualized, lacked details, and included general language,

such as “...to manage pain and other symptoms.”

In about half the stays, the hospice care plan was not developed by 

all the required parties 

For 49 percent of GIP stays, hospices did not involve all the required members in 

care planning.47 A pastoral or other counselor was missing in 44 percent of stays 

and a social worker was not involved in 34 percent of stays. In 12 percent of 

stays, hospices did not involve the physician in the care planning. A nurse was 

not involved in 5 percent of stays. It is important for all disciplines to be involved 

in the care planning to ensure that all of the needs of the beneficiary are planned 

for and met. 

 ____________________________________________________________ 

46 42 CFR § 418.56(b) and (c)(2). 

47 A number of stays had more than one required member who was not involved in the care 

planning. As a result, the sum of all the percentages that follow in the next few sentences does not 

equal 49 percent. 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 14

Hospices sometimes provided poor-quality care and often 

did not provide intense services 

In 9 percent of GIP stays, the hospice did not provide enough nursing, physician, 

or medical social services. These services are particularly important during GIP 

stays because this level of care is for pain control or acute or chronic symptom 

management that cannot be provided in other settings. For these stays, the 

hospices did not provide as many visits as the beneficiary needed or did not 

provide the care that the beneficiary needed during the visit. In some cases, these 

hospices were not able to effectively manage beneficiaries’ symptoms or 

medications.

Examples of Care Plans That Did Not Meet Requirements

 The plan of care developed by a for-profit hospice for an 85-year-old beneficiary 

with a disease of the nervous system did not include drugs and treatment 

necessary to meet the beneficiary’s needs. The only problem identified in the care 

plan was weakness. None of the required interdisciplinary team members were 

involved in developing the plan. The hospice billed for a 10-day GIP stay in a 

hospice inpatient unit, totaling about $7,500. 

 A nonprofit hospice billed for 5 days of GIP for a 91-year-old beneficiary in a 

SNF but did not establish an adequate care plan. The beneficiary was diagnosed 

with an ill-defined condition and was placed in GIP for both pain and symptom 

management. Only the nurse and the physician developed the care plan, which 

did not include the frequency of nursing services. The beneficiary’s pain 

remained uncontrolled for the first 4 days. Medicare paid the hospice nearly 

$3,600 for the GIP stay. 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 15

Examples of Poor-Quality Care During GIP Stays

 A 101-year-old beneficiary with dementia was cared for by a for-profit 

hospice in Alabama. His pain was never under control despite spending 16 

days in GIP in a SNF. The beneficiary suffered significant pain during 

personal care and wound care. The hospice did not change the pain 

medication until the last day, when the dosage was slightly increased. In 

addition, the beneficiary needed an alternating pressure mattress at the start of 

the GIP stay, but the hospice did not order it for more than a week. Medicare 

paid the hospice more than $9,500 for this stay. 

 An 86-year-old beneficiary under the care of a for-profit hospice in Arizona 

had end stage renal disease and suffered from severe pain. He was also at 

high risk for severe respiratory distress. The hospice did not change his 

medication for 3 days even though his symptoms had not improved. For 

instance, the beneficiary’s breathing was labored, but the hospice did not 

provide intervention or change his plan of care. Medicare paid the hospice 

over $5,000 for the GIP stay. 

 A 70-year-old beneficiary who had dementia was cared for by a hospice in 

Puerto Rico. The hospice billed Medicare for 17 days of GIP in a hospital. 

The hospice nurse did not provide any visits and instead called the patient’s 

family to find out how he was doing. Medicare paid almost $8,000 for the 

stay. 

 An 89-year-old beneficiary was under the care of a nonprofit hospice that 

billed for 16 days of GIP in a SNF. The beneficiary’s symptoms were 

uncontrolled for 14 days during which the hospice rarely changed his 

medication dosage. The patient continued to experience respiratory distress 

and anxiety. The hospice did not order any medical social services although 

the beneficiary and his family could have benefited from increased hospice 

services and emotional support. The hospice received just over $11,600 for 

this GIP stay. 

 A 66-year-old beneficiary with cancer was in pain throughout his GIP stay in 

a SNF. The beneficiary’s severe pain was not managed, and he did not have

frequent assessments and adjustments of his care plan to bring the pain under 

control. Also, more involvement from the interdisciplinary team members 

was needed during the stay. The hospice was paid more than $2,000 for this 

patient’s stay.
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 16

Hospices often did not provide intense services to beneficiaries in 

GIP

Subcutaneous and intravenous treatments are not requirements of GIP stays, nor 

are they always appropriate during GIP stays.48 However, these types of services 

may be provided in many cases, given that GIP is specifically for pain control or 

acute or chronic symptom management that cannot be managed in other settings.

Hospices did not provide any medication subcutaneously to beneficiaries in more 

than three-quarters of GIP stays. Hospices did not provide medication, 

electrolytes, vitamins, parenteral nutrition, fluids, or infusions intravenously to 

beneficiaries in more than half of GIP stays. Hospices did not provide treatment 

either subcutaneously or intravenously in approximately one-third of GIP stays. 

GIP stays in SNFs again stand out. Hospices did not provide treatment 

subcutaneously or intravenously in 70 percent of GIP stays in SNFs, compared to 

32 percent in other settings. 

 ____________________________________________________________ 

48 For the purpose of this finding, we refer to subcutaneous and intravenous treatments as “intense 

services.”
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 17

CONCLUSION AND RECOMMENDATIONS

Hospices inappropriately billed one-third of GIP stays in 2012; this misuse of GIP 

cost Medicare $268 million dollars. In some cases, hospices billed for GIP when 

the beneficiary did not have uncontrolled pain or unmanaged symptoms, a 

requirement of GIP. In other cases, the care the beneficiary needed could have 

been provided at home. Hospices were more likely to inappropriately bill for GIP 

provided in SNFs than in other settings. Also, for-profit hospices were more 

likely than other hospices to bill inappropriately. Medicare sometimes paid twice 

for drugs for hospice beneficiaries. This is because Part D paid for drugs that 

were already covered by the Part A hospice benefit. In addition, hospices did not 

meet care planning requirements for 85 percent of GIP stays. Finally, hospices 

sometimes provided poor-quality care.

The findings in this report make clear the need to address the misuse of GIP and 

hold hospices accountable when they bill inappropriately or provide poor-quality 

care. The IMPACT Act of 2014 will increase the number of hospice surveys 

conducted, but more needs to be done. This report shows that misuse of GIP has 

human costs for this vulnerable population as well as financial costs for Medicare. 

Ensuring that hospices provide the appropriate level of care in the most suitable 

setting is essential to meeting beneficiaries’ needs, providing them quality care, 

and protecting the integrity of Medicare’s hospice benefit. 

We recommend that CMS: 

Increase its oversight of hospice GIP claims and review Part D 

payments for drugs for hospice beneficiaries 

CMS should increase and better target its hospice program integrity efforts. CMS 

should instruct its contractors to conduct more medical reviews of hospice GIP 

claims and particularly focus on GIP provided in SNFs and GIP provided by forprofit hospices, given the higher rates at which their stays were inappropriate. As 

part of these efforts, contractors should identify hospices with recurring problems. 

They should target these hospices in their reviews. These efforts will help to 

ensure that hospice payments are appropriate for the level of care that the 

beneficiary needs and is receiving. 

Also, CMS should ensure that it does not pay twice for drugs that are covered 

under Part D and provided to beneficiaries in hospice care. It should ensure that 

hospices are paying for these drugs and that they are not being billed to Part D. 

As part of its efforts, CMS should instruct its contractors to identify hospices that 

have beneficiaries with high numbers of Part D drugs and target these hospices for 

further review. CMS could consider including measures that identify high 

amounts of Part D billing for hospice beneficiaries in its Fraud Prevention 

System.
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 18

Ensure that a physician is involved in the decision to use GIP

Involving physicians in the decisions to start and continue GIP would help ensure 

that GIP is used appropriately. One way to accomplish this is to require that 

hospices obtain a physician’s order to change the level of care to GIP and include 

the ordering physician’s National Provider Identifier on the hospice claim. The 

hospice should also have the physician sign off on the level of care at reasonable 

intervals during the GIP stay. These intervals should be determined by 

CMS. Making the physician more accountable and requiring some record of the 

physician’s involvement would add another safeguard for ensuring that the 

beneficiary needs GIP.

Conduct prepayment reviews for lengthy GIP stays

When a beneficiary has a long stay in GIP, it raises questions about whether GIP 

is the appropriate level of care and, if it is, whether the beneficiary’s symptoms 

are being effectively managed. CMS should conduct prepayment reviews for GIP 

stays exceeding a reasonable threshold, such as 7 days. CMS should determine 

this threshold by consulting hospice and palliative care experts and analyzing data 

on the length of GIP stays. These reviews, based on information provided by the 

hospice, would determine whether GIP was appropriate for each day of the stay or 

if another level of care, such as routine home care or inpatient respite care, was 

more appropriate. Conducting prepayment reviews of lengthy GIP stays would 

establish additional safeguards to ensure appropriate duration of care and help 

prevent inappropriate payments for GIP stays. These reviews could also promote 

effective symptom management and reduce the time beneficiaries’ pain and other 

symptoms are unmanaged. 

Increase surveyor efforts to ensure that hospices meet care planning 

requirements

State surveyors are CMS’s primary tool to verify that hospices are meeting care 

planning requirements and to enforce these requirements. CMS should increase 

surveyor efforts to make hospices more accountable. It should train surveyors to 

ensure that they appropriately cite hospices with deficiencies when their care 

planning is not individualized, does not include the scope and frequency of 

services, and is not developed by the required parties. Care planning that meets 

requirements is essential for delivering high-quality services for beneficiaries and 

their families. 

Establish additional enforcement remedies for poor hospice 

performance

CMS’s only enforcement remedy against poorly performing hospices is 

termination from the Medicare program. Although potentially very serious, 

problems with care planning and quality may not always merit termination. 

Termination can disrupt care for beneficiaries and families. As we have 

recommended previously, CMS should seek authority to establish less severe 

remedies to address performance problems. A potential array of enforcement 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 19

measures could include directed plans of correction, directed in-service training, 

denials of payment for new admissions or for all patients, civil monetary 

penalties, and imposition of temporary management.

Follow up on inappropriate GIP stays, inappropriate Part D 

payments, and hospices that provided poor-quality care

In a separate memorandum, we will provide CMS information about the stays that 

were inappropriate and the inappropriate Part D payments in which Medicare paid 

twice for drugs for beneficiaries receiving GIP. CMS should review this 

information and take appropriate action. Appropriate actions could include, but 

are not limited to: (1) recoupment of any inappropriate payments or (2) provider 

education on how to properly bill for GIP stays.

We will also provide CMS with a list of the hospices in our sample that provided 

poor-quality care. CMS should provide the list to State Survey and Certification 

agencies so they can prioritize these hospices for review.
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 20

AGENCY COMMENTS AND OFFICE OF INSPECTOR GENERAL 

RESPONSE

CMS concurred with all six of our recommendations. 

CMS concurred with our first recommendation to increase its oversight of hospice 

GIP claims and review Part D payments for drugs for hospice beneficiaries. CMS 

stated that it is procuring a national Durable Medical Equipment and Home 

Health/Hospice Recovery Audit contractor that will conduct claim reviews and 

recoup overpayments and pay underpayments, as necessary. 

CMS concurred with our second recommendation to ensure that a physician is 

involved in the decision to use GIP. CMS stated that it has concerns that 

requiring a physician’s order for GIP could affect access for patients and will 

work with the hospice community to explore other options for expanding 

physician involvement. OIG agrees that access to care is crucial. However, 

requiring a physician’s order for GIP should not affect access. The hospice 

physician should already be actively involved in the care of a beneficiary, 

especially if the beneficiary has symptoms severe enough that they cannot be 

controlled at home. In addition, hospices must make physician services routinely 

available on a 24-hour basis 7 days a week. Requiring a physician’s order for GIP 

for beneficiaries who need that level of care should not place an undue burden on 

the physician or the hospice. It makes the physician more accountable and adds 

another safeguard for ensuring that the beneficiary needs GIP. 

CMS concurred with our third recommendation to conduct prepayment reviews 

for lengthy GIP stays. CMS stated that it will work with its contractors to conduct 

such reviews. 

CMS concurred with our fourth recommendation to increase surveyor efforts to 

ensure that hospices meet care planning requirements. CMS stated that it will 

revise the Basic Hospice Training for surveyors to emphasize care planning 

reviews. 

CMS concurred with our fifth recommendation to establish additional 

enforcement remedies for poor hospice performance. CMS stated that it will 

consider submitting a proposal as part of the budget process that would seek 

authority to establish additional enforcement remedies. 

Finally, CMS concurred with our sixth recommendation to follow up on 

inappropriate GIP stays, inappropriate Part D payments, and hospices that 

provided poor-quality care. CMS stated that it will determine an appropriate 

number of claims to review. CMS also plans to instruct State Survey and 

Certification agencies to review the hospices identified in this report as having 

provided poor-quality care and take appropriate action. CMS also stated that it 

will reiterate its guidance to Part D sponsors concerning prior authorization of the 

four categories of drugs. 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 21

APPENDIX A 

Detailed Methodology

Selection of Statistical Sample for Medical Record Review

Using CMS’s National Claims History file, we extracted all Medicare Part A 

hospice claims that had service dates in 2012 and were received through 

December 2012. The claims included information about the level of hospice care, 

such as GIP, and the setting, such as a SNF. We combined the claims to identify 

all GIP stays. We considered a GIP stay to be claims for GIP for the same 

beneficiary in the same setting, from the same hospice, and the start date of a 

subsequent claim was the same day, or the next day, as the ending date of the 

previous claim. We identified 282,225 GIP stays in 2012 for 252,759 

beneficiaries. 

We selected a stratified simple random sample of 570 GIP stays from this file. We 

stratified the sample by whether GIP was provided in SNFs or in other settings to 

determine whether there were any statistical differences between estimates for 

these two groups at the 95-percent confidence level. We also stratified the sample 

by Medicare payments to enhance the precision of our statistical estimates.49 The 

sample included 5 strata. See Table A-1.

Table A-1: Population, Strata, and Sample Size

Stratum Number of Stays 

in the Population

Number of Stays 

in the Sample

GIP stays in SNFs 18,030 116

GIP stays in other settings for which the paid 

amount was at most $3,000 152,086 120

GIP stays in other settings for which the paid 

amount was more than $3,000, but at most $7,000 82,096 171

GIP stays in other settings for which the paid 

amount was more than $7,000, but at most $16,000 26,502 120

GIP stays in other settings for which the paid 

amount was more than $16,000 3,511 43

Total 282,225 570

Source: OIG analysis of medical record review, 2015.

 ____________________________________________________________ 

49 The dollar amounts in each stratum were determined by the distribution of the universe of GIP 

stays. 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 22

We did not contact the hospices that billed for five of the stays in our sample 

because these hospices were under investigation by OIG. Our final sample 

included 565 stays. 

Next, we matched the hospice provider numbers from the claims data with the 

Certification and Survey Provider Enhanced Reports to determine the ownership 

status of each hospice (e.g., for-profit or nonprofit). 

Lastly, we used the Medicare Part D data to identify the drugs paid for by Part D 

for the beneficiaries in the sampled GIP stays. To do this, we matched each 

beneficiary’s Health Insurance Claims Number to the Part D prescription drug 

event data for 2012. 

Medical Record Review

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

each sampled stay. We received a 100-percent response rate from the hospices we 

contacted. 

For each stay, we requested that the hospice provide all medical records relating 

to the hospice services provided to the beneficiary during the GIP stay identified 

for review. The documentation included the hospice election statement, all 

certifications of terminal illness that cover the review period, clinical information 

and other documentation that support the medical prognosis, all assessments that 

cover the review period, all plans of care that cover the review period, including 

any updates or changes to the plans, and a record of all hospice services provided 

during the review period, including those provided under arrangement or contract 

with the hospice. Hospices are required to keep all of this information in the 

clinical record that they establish for every individual receiving care and 

services.50 The contractor identified stays for which the hospice did not provide 

an election statement or certification of terminal illness. 

The contracted reviewers included four registered nurses, each of whom had 

experience providing and managing hospice care. For each stay, they used a 

standardized instrument based on Medicare coverage requirements and CMS 

guidance to review the beneficiary’s care planning and services provided by the 

hospice.

For each day in each GIP stay, the reviewers determined whether GIP was 

appropriate for the beneficiary based on his or her needs. GIP is solely for pain 

control or acute or chronic symptom management that cannot be provided in other 

settings. If the reviewers determined that GIP was not appropriate, they 

determined the appropriate level of care (e.g., routine home care). In addition, for 

stays in which Part D paid for a drug for the beneficiary, the reviewers determined 

 ____________________________________________________________ 

50 42 CFR § 418.104. 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 23

whether the drugs were related to the palliation and management of the terminal 

illness or related conditions. 

The reviewers also determined whether the physician and nursing services 

provided during the GIP claim period met the beneficiary’s needs or whether the 

beneficiary needed more services or services of a higher level of intensity. They 

also determined whether the beneficiary needed more medical social services than 

were provided.51

Lastly, for each stay, the reviewers determined whether the plan of care met key 

Medicare requirements.52 Specifically, they determined whether it included a 

detailed scope and frequency of the services and whether the services met the 

beneficiary’s needs. The reviewers also determined whether the plan of care was 

developed by the required members of an interdisciplinary group that included a 

physician, nurse, social worker, and pastoral or other counselor. The reviewers 

also described any instances of poor-quality care. 

Analysis

We analyzed the results of the medical record review to estimate the percentage of 

GIP stays that were billed inappropriately. We included stays in which the 

beneficiary did not need GIP at all, and stays in which the beneficiary did not 

need GIP for part (e.g., two or more consecutive days) of the stay. We also 

counted as inappropriately billed all stays in which the hospice did not provide an 

election statement or certification of terminal illness.

We estimated the amount that inappropriate stays cost Medicare. For stays in 

which the beneficiary did not elect hospice or was not certified as having a 

terminal illness with a prognosis of 6 months or less, we considered the entire 

amount Medicare paid for the GIP stay to be inappropriate. For stays in which the 

beneficiary elected hospice and was certified as having a terminal illness but did 

not need GIP for part or all of the stay, we considered inappropriate the difference 

between the amount Medicare paid for GIP and the amount Medicare would have 

paid had the hospice billed the appropriate level of care.

We estimated the percentage of inappropriate stays that were in SNFs and the 

percentage that were in other settings, namely hospitals and hospice inpatient 

units. We also estimated the percentage of inappropriate stays that were billed by 

for-profit hospices and the percentage that were billed by other types of hospices, 

such as nonprofits or those that were government owned. We used a chi-square to 

test for statistically significant differences between GIP stays provided in SNFs 

and those provided in other settings. We also tested for statistically significant 

differences between GIP stays in for-profit hospices and those in all other 

 ____________________________________________________________ 

51 A service could be provided directly by hospice staff or under arrangement with the hospice. 

52 The reviewers took into account the plan of care and any updates that covered the GIP stay 

identified for review. 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 24

hospices. Unless otherwise stated, all differences noted in the findings are 

statistically significant at the 95-percent confidence level. 

We also analyzed the results of the medical record review to determine the 

number of drugs associated with our sample that Part D paid for inappropriately. 

We then determined how many of these drugs were included in the four categories 

addressed in CMS guidance: analgesics, antinauseants, laxatives, and antianxiety 

drugs.53 Because of the size of our sample, we are not able to project these 

numbers to the population of all stays, so the numbers presented are solely based 

on the sample.

We also determined whether hospices provided beneficiaries with subcutaneous or 

intravenous treatment, which we refer to as “intense services.” These services are 

not required for beneficiaries receiving GIP, but are commonly provided, given 

that GIP is for pain control or acute or chronic symptom management that cannot 

be managed in settings other than inpatient.

Lastly, we analyzed the plans of care to determine whether hospices met the 

Medicare coverage requirements. Specifically, we analyzed the percentage of 

stays that were missing required elements in care plans.54 We also analyzed the 

percentage of stays that had plans of care that were not developed by all required 

members of an interdisciplinary group.55 

 ____________________________________________________________ 

53 These categories were also used in a prior OIG study. See OIG, Medicare Could Be Paying 

Twice for Prescription Drugs for Beneficiaries in Hospice (A-06-10-00059). 

54 According to Federal requirements, the plan of care must include a detailed statement of the 

scope and frequency of needed services. See 42 § 418.56(c)(2). 

55 According to Federal requirements, the interdisciplinary group must include a physician, nurse, 

social worker, and pastoral or other counselor. See 42 CFR §§ 418.200, 418.56(a). 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 25

APPENDIX B

Statistical Estimates and Confidence Intervals 

Table B-1: Sample Sizes, Point Estimates, and Confidence Intervals for Inappropriate Billing 

Estimate Characteristic

Sample 

Size Point Estimate

95-Percent Confidence Interval

Lower Limit Upper Limit

Percentage of GIP stays billed inappropriately 565 31.4% 27.0% 36.2%

Percentage of GIP stays in which the beneficiary did 

not need GIP at all during the stay 565 20.3% 16.4% 24.8%

Percentage of GIP stays in which the beneficiary 

needed GIP at some point, but not the entire stay 565 9.7% 7.6% 12.4%

Percentage of GIP stays in which the hospice did not 

have evidence that the beneficiary elected hospice 

care or was certified as having a terminal illness

565 1.4% 0.5% 3.6%

Percentage of GIP stays for which hospices billed 

Medicare appropriately 565 68.6% 63.8% 73.0%

Dollar amount paid inappropriately 565 $268,090,214 $235,669,213 $300,511,215

Percentage of total GIP payments that Medicare 

inappropriately paid 565 26.2% 23.2% 29.3%

Percentage of inappropriate GIP stays for which the 

hospice should have billed some or all days as routine 

care

233 93.0% 85.9% 96.7%

Percentage of inappropriate GIP stays in which the 

beneficiary did not have unmanaged symptoms or 

received care that could have been provided at home

233 88.6% 81.2% 93.4%

Percentage of inappropriate GIP stays in which the 

beneficiary received GIP because of caregiver issues 233 14.7% 9.6% 21.8%

continued on the next page
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 26

Table B-1: Sample Sizes, Point Estimates, and Confidence Intervals for Inappropriate Billing 

(Continued)

Estimate Characteristic

Sample 

Size 

Point 

Estimate

95-Percent Confidence Interval

Lower Limit Upper Limit

Percentage of GIP stays in SNFs that were 

inappropriate 113 47.8% 38.7% 57.1%

Percentage of GIP stays in other settings that were 

inappropriate 452 30.3% 25.6% 35.4%

Percentage of GIP stays in SNFs in which the 

beneficiary did not need GIP at all during the stay 113 38.9% 30.3% 48.3%

Percentage of GIP stays in SNFs in which the 

beneficiary did not need GIP for part of the stay 113 8.8% 4.8% 15.8%

Percentage of GIP stays in SNFs in which the 

beneficiary was diagnosed with a mental disorder, illdefined condition, or Alzheimer's disease113 36.3% 27.9% 45.6%

Percentage of GIP stays in other settings in which the 

beneficiary was diagnosed with a mental disorder, illdefined condition, or Alzheimer's disease452 22.1% 17.7% 27.2%

Percentage of GIP stays in for-profit hospices that were 

billed inappropriately 200 41.4% 32.7% 50.7%

Percentage of GIP stays in other types of hospices, 

including nonprofit and government-owned hospices, 

that were billed inappropriately 

365 27.4% 22.4% 33.1%

Source: OIG analysis of medical record review results, 2015.
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 27

Table B-2: Sample Sizes, Point Estimates, and Confidence Intervals for Care Planning 

Requirements 

Estimate Characteristic

Sample 

Size

Point 

Estimate

95-Percent Confidence Interval

Lower Limit Upper Limit

Percentage of GIP stays that did not meet care 

planning requirements 565 84.6% 80.7% 87.8%

Percentage of GIP stays that were missing at least one 

key element of the care plan 565 72.3% 67.2% 76.8%

Percentage of GIP stays that did not involve all the 

required parties in developing the care plan 565 49.0% 43.6% 54.3%

Percentage of GIP stays in which a pastoral or other 

counselor was not involved in development of the care 

plan

565 44.4% 39.1% 49.8%

Percentage of GIP stays in which a social worker was 

not involved in development of the care plan 565 34.4% 29.4% 39.8%

Percentage of GIP stays in which a physician was not 

involved in development of the care plan 565 11.9% 8.5% 16.3%

Percentage of GIP stays in which a nurse was not 

involved in development of the care plan 565 5.3% 3.5% 8.0%

Source: OIG analysis of medical record review results, 2015.
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 28

Table B-3: Sample Sizes, Point Estimates, and Confidence Intervals for Quality-of-Care 

Concerns 

Estimate Characteristic Sample 

Size

Point 

Estimate

95-Percent Confidence Interval

Lower Limit Upper Limit

Percentage of GIP stays that did not provide enough 

nursing, physician, or medical social services 565 9.5%1 6.8% 13.1%

Percentage of GIP stays in which the hospice did not 

provide subcutaneous treatment 565 75.8% 70.9% 80.1%

Percentage of GIP stays in which the hospice did not 

provide intravenous treatment 565 50.8% 45.4% 56.1%

Percentage of GIP stays in SNFs in which the hospice did 

not provide subcutaneous or intravenous treatment 113 69.9% 60.7% 77.7%

Percentage of GIP stays in other settings in which the 

hospice did not provide subcutaneous or intravenous 

treatment

452 32.3% 27.4% 37.7%

1The point estimate was 9.49 percent, which rounded to 9 percent as a whole number in the text.

Source: OIG analysis of medical record review results, 2015.
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 29

APPENDIX C

Chi-square Tests for Statistically Significant Differences 

Table C-1: Chi-square Test Comparing GIP Stays in SNFs and Other Settings

Percentage of GIP 

Stays Provided in SNFs

Percentage of GIP 

Stays Provided in Other 

Settings P-Value1

Percentage of GIP stays billed to Medicare 

inappropriately 47.8% 30.3% 0.0008

Percentage of GIP stays in which the beneficiary was 

diagnosed with a mental disorder, ill-defined condition, 

or Alzheimer's disease 

36.3% 22.1% 0.0037

Percentage of GIP stays in which the hospice did not 

provide intravenous and subcutaneous treatment 69.9% 32.3% <.0001

1Differences between percentages of stays provided in SNFs and other settings were statistically significant at the 95-percent confidence 

level.

Source: OIG analysis of medical record review results, 2015.

Table C-2: Chi-Square Test Comparing GIP stays in For-profit Hospices and all Other 

Hospices, including Nonprofit and Government Owned

Percentage of GIP 

Stays in For-profit 

Hospices

Percentage of GIP 

Stays in all Other 

Hospices P-Value1

Percentage of GIP stays that were billed inappropriately 41.4% 27.4% 0.0087

1Differences between percentages of stays in for-profit hospices and all other hospices were statistically significant at the 95-percent 

confidence level.

Source: OIG analysis of medical record review results, 2015.
APPENDIX D

Agency Comments

•••••• ''"'','1-, l4- DEPARTMENT OF HEALTIl & IllJMAN SERVICES Centers for Medicare & Medicaid Services

200 Independence Avenue SW

Washington, DC 20201

To: Daniel R, Levinson

Inspector General

Office of Inspector General

From: Andrew M. Slavitt

Acting Administrator

Centers for Medicare & Medicaid Services

Subject: Hospices Inappropriately Billed Medicare Over $250 Million for General

Inpatient Care (OEI-02-10-00491)

The Centers for Medicare & Medicaid Services (CMS) thanks you for your continued work on

hospice, and appreciates the opportnnity to review and comment on the Office of Inspector

General's (OIG) draft report. CMS's mission is to provide Medicare beneficiaries with access to

high quality health care while protecting taxpayer dollars. CMS is concerned about the possible

misuse of hospice generally, including care being billed for but not provided, long lengths of

slay, and beneficiaries receiving unnecessary care. I However, Medicare payments for General

Inpatient Care (OIP) account for only 1.5% of Medicare hospice expenditures, Additionally,

CMS analysis of OIP claims finds that utilization of this level of care is low and has remained

flat over several years. CMS is also concerned that Medicare beneficiaries continue to have

access to this important hospice service and CMS is working to improve appropriate use. As a

result, CMS is developing a strategy that targets improper payments without unnecessarily

increasing documentation and audit burden on legitimate providers.

Due to concerns over potential fraud, waste, and abuse in hospice, eMS has made significant

changes in hospice payment policy in recent years to reward providers that provide high quality

care and reduce improper payments. The Affordable Care Act (ACA) gave eMS the authority to

reform hospice payment policies, and established a quality reporting program for hospices. In

accordance with the ACA, starting in FY 2014, hospices that have failed to meet quality

reporting requirements may receive a reduction to their payment. The ACA also authorized the

Secretary to collect additional data and information determined appropriate to revise payments

for hospice care and to reform how Medicare pays for hospice services.

eMS has implemented the requirement in the Improving Medicare Post-Acute Care

Transformation Act of2014 (IMPACT Act) that Medicare-certified hospices have mandatory

surveys every 36 months. In addition, CMS now requires hospices to report and share

standardized assessment data, which allows providers to facilitate more coordinated care, with

the goal of improving Medicare beneficiary outcomes.

j h!1Jl.iLQ!g.hhs.gov!oei[reporlf;!oei-02-10-00490.pdf

Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 30

APPENDIX D 

Agency Comments 

~SfJIV!Ci:s.!\-, 

( t# DEPARTMENT OF HEALTH & HUMAN SERVICES 

~S~ Centers for Medicare & Medicaid Services 

To: 

From: 

Subject: 

Daniel R. Levinson 

Inspector General 

Office of Inspector General 

Andrew M. Slavitt 

Acting Administrator 

Centers for Medicare & Medicaid Services 

200 Independence Avenue SW 

Washington, DC 20201 

Hospices Inappropriately Billed Medicare Over $250 Million for General 

Inpatient Care (OEI-02-10-00491) 

The Centers for Medicare & Medicaid Services (CMS) thanks you for your continued work on 

hospice, and appreciates the opportunity to review and comment on the Office oflnspector 

General's (OIG) draft report. CMS's mission is to provide Medicare beneficiaries with access to 

high quality health care while protecting taxpayer dollars. CMS is concerned about the possible 

misuse of hospice generally, including care being billed for but not provided, long lengths of 

stay, and beneficiaries receiving unnecessary care. 1 However, Medicare payments for General 

Inpatient Care (GIP) account for only 1.5% of Medicare hospice expenditures. Additionally, 

CMS analysis of GIP claims finds that utilization of this level of care is low and has remained 

flat over several years. CMS is also concerned that Medicare beneficiaries continue to have 

access to this important hospice service and CMS is working to improve appropriate use. As a 

result, CMS is developing a strategy that targets improper payments without unnecessarily 

increasing documentation and audit burden on legitimate providers. 

Due to concerns over potential fraud, waste, and abuse ii}. hospice, CMS has made significant 

changes in hospice payment policy in recent years to reward providers that provide high quality 

care and reduce improper payments. The Affordable Care Act (ACA) gave CMS the authority to 

refonn hospice payment policies, and established a quality reporting program for hospices. In 

accordance with the ACA, starting in FY 2014t hospices that have failed to meet quality 

reporting requirements may receive a reduction to their payment. The ACA also authorized the 

Secretary to collect additional data and infonnation detennined appropriate to revise payments 

for hospice care and to reform how Medicare pays for hospice services. 

CMS has implemented the requirement in the Improving Medicare Post~Acute Care 

Transformation Act of 2014 (L.\1P ACT Act) that Medicare.certified hospices have mandatory 

surveys every 36 months. In addition, CMS now requires hospices to report and share 

standardized assessment data, which allows providers to facilitate more coordinated care, with 

the goal of improving Medicare beneficiary outcomes. 

1 bJlQJ,lQ!g.hhs.gov/oei/reports/oei-02-10-00490.pdf 

Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEl-02-10-00491) 30 
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 31
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 32
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 33
Hospices Inappropriately Billed Medicare Over $250 Million for General Inpatient Care (OEI-02-10-00491) 34

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 and Jenell Clarke-Whyte 

served as co-team leaders for this study. Other Office of Evaluation and 

Inspections staff from the New York regional office who conducted the study 

include Jennifer Karr, Michael Rubin, and Sarah L. Stefanski. Central office staff 

who provided support include Kevin Farber and Berivan Demir Neubert. 
Office of Inspector General 

http://oig.hhs.gov

The mission of the Office of Inspector General (OIG), as mandated by Public Law 95452, 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 individuals 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 individuals. 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.