Hospice Audits-Webinar Slides

Pdf Summary

The document summarizes the current hospice audit climate as one of heightened scrutiny. Hospice is now viewed as a high-risk Medicare benefit, especially for agencies with long lengths of stay, high rates of non-cancer diagnoses, and frequent use of higher levels of care such as GIP and continuous care.<br /><br />It outlines major audit and oversight entities, including MAC/TPE, UPIC, RAC, SMRC, CERT, and OIG, and explains that each reviews hospice claims differently, with some focused on eligibility, level of care, or fraud risk.<br /><br />Key audit triggers now include prolonged stays beyond the third benefit period, diagnosis patterns involving dementia or neurologic conditions, live discharges, billing for higher levels of care without strong documentation, non-hospice spending, and data outliers compared with peers. The document stresses that live discharges are a major enforcement focus and can alone lead to payment suspension if an agency’s rate is outside normal ranges. CMS is especially attentive in certain states, including California, and new hospices in selected states face enhanced prepayment review.<br /><br />The document also introduces CMS’s new Hospice Service and Spending Variation Index (SSVI), finalized in the FY2027 rule. SSVI is a claims-based risk scoring framework that measures variation in utilization and spending, not clinical quality. It includes nine components such as long length of stay, live discharge rate, direct care time, visit frequency, weekend coverage, and non-hospice spending.<br /><br />The main takeaway is that hospices should strengthen audit readiness through routine quality and compliance processes, prebilling chart review, and documentation that clearly supports eligibility and the need for higher levels of care.

Meta Tag

Concept Hospice Benefit

Concept Live Discharge

Concept Audit

Concept Program Integrity

Concept Medicare Administrative Contractor

Keywords

hospice audit

Medicare scrutiny

audit triggers

live discharges

length of stay

higher levels of care

documentation compliance

SSVI

claims-based risk scoring

prebilling chart review

Hospice Benefit

Live Discharge

Audit

Program Integrity

Medicare Administrative Contractor