When an organization identifies that Medicare has overpaid a claim

When an organization identifies that Medicare has overpaid a claim, it is the organization’s responsibility to ensure repayment is made within 60 days of confirming the overpayment or the date of their cost report.  Most providers choose one option to be consistent and ensure compliance. In most cases, providers choose the 60 day option.

 

Read the attached document

Is a repayment required from the health care provider?

• If repayment is required, what necessary self-disclosures would you make?

HCR 460: Investigations and Disclosures

Assignment 2: Reporting Protocols

Scenario

 

Background

You are a Compliance Officer for Compassion Hospice located at 324 Fernwood Drive, Phoenix, Arizona.

Organization CCN #: 23-3894

Organization NPI #: 293827183

Organization Tax ID:  39-493837

Physician NPI #: 28736353

 

As part of your annual audit plan you include some audit areas which are found in the Office of the Inspector General Annual Work Plan.  One of those audit areas includes hospice.  Please review Review of Hospices’ Compliance with Medicare Requirements on page 11 of the OIG Work Plan.  You may view the plan by clicking on the following link:

https://oig.hhs.gov/reports-and-publications/archives/workplan/2017/HHS%20OIG%20Work%20Plan%202017.pdf

Assignment 

Locate and review the requirements for the election of hospice services.  You may do so by accessing the conditions of coverage (Hint: you may want to conduct an internet search for Medicare Benefit Policy Manual, Chapter 9 Coverage of Hospice Services Under Hospital Insurance).

Please read the following patient medical record reviews and determine if the medical record information is compliant with hospice coverage requirements.  Your assignment is to identify all compliance issues with the election, eligibility, and recertification requirements for hospice services.   After you have identified your findings, determine whether a repayment is required. If a repayment is required please follow the appropriate reporting protocol (form) to report any overpayments. (NOTE:  You can type in the information to the reporting form or you can handwrite the information; however, you will need to scan the completed form and upload it along with your assignment.

For each area of noncompliance you must identify the following:

1. State the Medicare requirement
2. State why the patient review information does or does not meet the Medicare requirement
3. If the Medicare requirement has not been met, identify what requirement/documentation is missing to support the requirement
4. For those claims that do not meet the above-mentioned Medicare requirements concerning election of hospice services, eligibility and recertification, identify the dollar amount of the repayment.
5. Complete the reporting form for any identified repayments which are required and upload the form along with analysis of the Medical Record reviews on the following page.  Break down the review per patient.

 

 

 

Medical Record Review

 

Patient Name	Notice of Election	Initial Benefit Period Start Date	Certification of Terminal Illness (CTI)	Does patient meet eligibility for hospice services?	Recertification Periods	Notes
Eileen Worsham	Yes, signed by Medical Power of Attorney	04/30/2017	Oral certification by medical director noted in medical record.  No written Certification of Terminal Illness found in the medical record for initial 90 day benefit period.	Yes, based on oral certification	None	Claim amount:  $34,500 Claim submitted and paid Written Certification of Terminal Illness not on file prior to submission of claim.
Jason Ober	Yes, signed by family member	April 1, 2017	CTI is in medical record and complete.  Entered within 2 day requirement, states terminal illness and signed by medical director.	Based on completed CTI patient meets eligibility requirements for hospice services	Yes, first recertification benefit period began 07/01/2017.	Claim amount: $15,200 Claim has been submitted and paid.
Tony Finley	Notice of Election of hospice services not found in medical record	January 2, 2017	CTI found in medical record; however, it is incomplete.   CTI was submitted on January 15th.  No oral certification noted in medical record.	CTI is incomplete. No documentation that supports eligibility for hospice services.	None	Claim amount: $25,235 Claim submitted, not yet paid. Medical record does not contain a valid and completed CTI.

Note:  If a health care provider finds an error on a claim and has not received payment for that claim, they can submit a corrected claim. In this instance no repayment process is required.