Monday, August 1, 2016

OIG Advisory Approves SNF/Hospice Arrangement

Dianne De La Mare

In a recent HHS, Office of Inspector General (OIG) Advisory Opinion, the agency determined that a hospice provider would not activate administrative sanctions by making supplemental payments to nursing facilities for room and board expenses of residents who are dually eligible for Medicare and Medicaid.

Under the proposal, the hospice provider would make supplemental payments to nursing facilities for dually eligible hospices that, combined with the payment from the managed care organization (MCO), would equal the amount the facilities would have received if the residents had not elected hospice.

The OIG referenced a 1998 fraud alert, indicating that a hospice provider could pay a nursing facility for a dually eligible resident’s room and board as long as the amount didn’t exceed what the facility would have received directly from Medicaid if the resident was not enrolled in hospice. Thus, OIG concluded that the hospice proposal was at low risk for fraud and abuse because the supplemental payment would result in the nursing facility receiving the same amount as it would have been paid had the dually eligible patient not elected hospice. OIG also noted that the total reimbursement to the nursing facility would never exceed the state Medicaid program's daily nursing facility rate.

By way of background, for dually eligible hospice residents residing in nursing facilities, Medicare pays for the hospice care while the state Medicaid program pays for the nursing facility room and board expenses. The state's payment must be at least 95% of the daily rate for patients who have not elected to receive hospice care. Further, the state’s Medicaid program pays the hospice for the dually eligible patient’s room and board. The hospice then reimburses the nursing facilities at a negotiated rate.

No comments:

Post a Comment