We recommend that the Centers for Medicare & Medicaid Services take the following actions, which could have saved Medicare an estimated $190.1 million in payments made to acute-care
hospitals for outpatient services provided to hospice enrollees and could have saved enrollees an estimated $43.6 million in deductibles and coinsurance that may have been incorrectly collected from them or from someone on their behalf during our audit period:
Direct MACs or other appropriate contractors, such as Recovery Audit Contractors, to: (1) analyze Medicare claims data to identify acute-care hospitals that have aberrant billing patterns for condition code 07, and conduct Targeted Probe and Educate reviews of these acute-care hospitals; and (2) conduct prepayment or postpayment reviews of acute-care hospital claims for outpatient services provided to hospice enrollees and billed with condition code 07.