Hospital-to-Hospice Transfers: When the Symptoms Change but the Billing Does Not

Hospital to hospice GIP billing fraud can arise when a hospice knowingly bills Medicare for inpatient care that the patient’s symptoms do not require. The hospital record describes the patient leaving acute care. The hospice record must explain the need for general inpatient care and its continuation. If you work on either side of that handoff, you may know when the patient’s condition changed while the higher billing continued.

This form of hospice fraud leaves Medicare paying for intensive care the patient no longer needs. Hospital and hospice health care workers may see the improvement that never reaches the bill. The admission decision matters. So does every day after it.

What Are the Criteria for a GIP Hospice?

General inpatient care covers short-term inpatient care for pain control or acute or chronic symptom management that cannot be managed in another setting. It can take place in a hospice inpatient unit, a hospital or a skilled nursing facility.

Medicare hospice eligibility requires a physician’s certification of a life expectancy of six months or less if the illness runs its normal course. Being eligible for hospice is one question. Needing inpatient symptom management today is another.

The purpose of general inpatient care is to address new or worsening symptoms intensively so the patient can return to a lower level of hospice care. For a hospital discharge planner or hospice nurse, the clinical story is specific: what symptoms needed inpatient management, what care addressed them and how the patient responded.

Why the Discharge Handoff Changes the Payment

The hospital and hospice operate under different payment structures. The Congressional Research Service’s 2017 Medicare Primer describes payment to most acute care hospitals as an amount determined for each discharge, adjusted in part by the patient’s diagnosis-related group. That group reflects the relative cost of patients in it.

Hospice payment follows the enrolled day and the level of care. The hospice takes financial responsibility for care related to the terminal illness. Routine hospice payment continues even on days without a visit, while general inpatient care carries a much higher daily rate. The distinction gives the discharge date, hospice election date and billed care level financial significance.

The Centers for Medicare & Medicaid Services’ fiscal year 2027 rates put general inpatient care at $1,232 a day and routine home care during the first 60 days at $236. These are national base rates for hospices meeting quality-reporting requirements, before local wage adjustments. Each unnecessary day at the higher level increases the payment for that patient.

For hospice billing fraud, the important comparison is the billed day against the care that day required. We examine the hospital’s stay and discharge record alongside the hospice’s explanation for starting and continuing inpatient care. A calendar supplies the sequence. The symptom record supplies the reason for the care.

Where the Hospital and Hospice Records Meet

The handoff becomes visible when the hospital discharge record, hospice assessment and Medicare claim describe the same patient over the same dates. We connect the hospital diagnosis, length of stay and discharge condition to the hospice election, terminal certification, care plan and billed level.

For someone in healthcare billing, that level appears in the revenue code. Milliman’s Hospice Medicare Margins, published in 2019, lists revenue code 0656 for general inpatient care and 0651 for routine home care. The code identifies what the hospice charged Medicare for the day.

We read the nursing notes, medication orders and claim side by side. An admission assessment may describe uncontrolled symptoms while later notes describe improvement. The care plan specifies the scope and frequency of services and changes with the patient’s condition. Those records let us connect the patient’s changing needs to the decision to keep billing the inpatient level.

An insider’s account can connect those records to the decision. Who reviewed the improvement? Who chose to continue GIP? What explanation went to billing? We work through those questions with the people who know how the transfer and subsequent care actually happened.

What the General Inpatient Level Audit Found

The HHS Office of Inspector General’s March 2016 review estimated that 31% of general inpatient stays in 2012 were billed inappropriately. Its medical-record review projected $268.1 million in inappropriate payments, representing 26% of Medicare’s payments for those stays that year. Reviewers assessed the need for inpatient care for each day of the stay.

The distinction between starting and continuing care mattered. In 20% of stays, the patient did not need general inpatient care at any point. In another 10%, the patient needed it for only part of the stay. Hospices commonly kept billing after symptoms were controlled.

In one example, a patient’s symptoms were managed within two days, yet she remained in GIP for 15 additional days. The clinical reason for inpatient care had ended while the billing carried on.

What Is Not Appropriate for General Inpatient Hospice?

Caregiver relief belongs under inpatient respite care. General inpatient care pays for pain or symptoms that require inpatient management. In the Inspector General’s review, hospices sometimes charged for that higher level because a caregiver was overwhelmed. In one case, the physician’s record called for respite care while the hospice billed GIP.

The distinction can get lost when everyone agrees that a patient needs somewhere to stay. The care plan needs to explain the symptom-management work that requires the inpatient level. In the review, most inappropriate stays should have been billed at the routine home care level.

Can a Patient Leave GIP Hospice Care?

Yes. A patient can move from general inpatient care to a lower level of hospice care as symptoms come under control. The hospice election can continue while the care level changes.

The later notes matter as much as the admission assessment. They can show why the patient no longer needed the level Medicare was still paying for.

The Hospice Keeps Responsibility for Hospital Care

A hospice that arranges inpatient care in a hospital retains oversight of the staff and services supplied under that arrangement. The hospital provides the setting, while the hospice remains responsible for coordinating the patient’s hospice care.

The Inspector General’s July 2019 report on hospice deficiencies described a hospice using a local hospital for short-term inpatient care without the required contract. Another hospice’s agreement with a nursing facility lacked key terms, and the providers failed to coordinate care:

The agreement assigns responsibilities. The orders and service records show what happened to the patient. We examine both sides of the arrangement with the insider who saw where care broke down.

When the Facility’s Care and the Hospice’s Claim Diverge

Hospice Home Care agreed to a $2.7 million settlement in December 2011 after another hospice, Arkansas Hospice, accused it of billing Medicare for general inpatient care when patients received only routine care. According to the Justice Department’s account of the government’s complaint, Hospice Home Care lacked its own inpatient facility and contracted with Parkview Rehabilitation and Healthcare Center. The allegation connected the facility arrangement to the level the hospice charged.

A whistleblower complaint against SouthernCare described a similar alleged gap between a hospital stay and the hospice’s claim:

The complaint puts the hospital payment inside the alleged scheme. The arrangement, the patient’s needs and the hospice’s claim belong in the same account. That is where hospital and hospice insiders can each supply something the other side never saw.

Hospice whistleblowers can bring the clinical decisions and billing instructions together in a False Claims Act case. A whistleblower case under the False Claims Act can pay 15% to 30% of what the government recovers.

When You Know Why GIP Continued

If you handle hospital discharges, hospice nursing, facility coordination or billing and know why GIP continued after the patient’s needs changed, speak with our whistleblower experts about that decision. We work with you to build your strongest hospice whistleblower case connecting the transfer, the care and the claims, and bring in hospice fraud whistleblower lawyers who understand hospital billing and inpatient care. We stay beside you through the case.