Navigating New Requirements in the 2025 Proposed Hospice Rule

If the U.S. Centers for Medicare and Medicaid Services’ (CMS) proposed 2025 hospice rule is finalized as written, hospices may encounter some hurdles implementing some of the new requirements.

CMS late last month issued its proposed hospice rule for 2025. The proposal called for a 2.6% increase in hospice per diem base rates, a number that many stakeholders say is insufficient in today’s economic climate.

But the rule contains more than payment rates. One key element is the planned 2025 implementation of the Hospice Outcomes & Patient Evaluation (HOPE) tool, which will replace the Hospice Item Set.

New ways to measure quality

While hospice organizations have expressed support for the new tool, contingent upon effective implementation, it could also bring some challenges as providers adapt to a new quality reporting system, according to Katy Barnett, director of home care and hospice operations for LeadingAge.

“With any new tool implementation, there are challenges. [In the HOPE tool] the majority of the questions are nurse focused, so they’ll have to look at how they’re staffing their nurses in terms of the initial visits and doing the hospice update visits and making sure that their nurses can complete everything in a timely manner,” Barnett told Hospice News. “It’s a new way of thinking about collecting data on patients, and they are going to have to do in-services and training of their entire staff for what this means to the flow of everyday business at the hospice.”

This could mirror to some extent the experience of home health providers, who encountered some technical issues with changes to their OASIS quality reporting system in recent years, she indicated.

Also, CMS is doing away with the free software that many hospices use to report data for the Hospice Item Set. This will require some new investments in technology and working with vendors to get those systems up and running, Barnett said.

“Providers need to review the HOPE tool as there are new items and revised items,” Katie Wehri, director of home care and hospice regulatory affairs for the National Association of Home Care & Hospice (NAHC), told Hospice News in an email. “There is also a new timepoint and not all HOPE items are completed at each timepoint. As with any standardized tool it is essential that they review the HOPE manual to ensure they understand how to correctly complete the items.” 

Some elements of the HOPE tool will require some logistical legwork, Patrick Harrison, senior director of regulatory and compliance at the National Hospice and Palliative Care Organization (NHPCO), and Sarah Simmons, director of quality for NHPCO, told Hospice News in a joint email.

“Overall, hospice providers seem pleased that HOPE will provide a new avenue of capturing assessment data related to the quality of care that hospices provide to their patients, specifically regarding pain and non-pain symptoms,” they said in the email. “One challenge will be the operationalization of Hospice Update Visits, particularly since providers are still looking for clarity on which disciplines can complete those visits. Another challenge is that, as proposed, telehealth reassessments are not permitted for the HOPE-based process measures.”

Silence on program integrity

Providers are also in the dark regarding future regulatory action designed to reinforce program integrity in the Medicare Hospice Benefit. The 2025 proposal contained nothing new related to those widespread problems.

The hospice space has been plagued by instances of fraud and other malfeasance in recent years. After a flurry of regulation activity last year, some hospice stakeholders were surprised that the proposed 2025 rule did not address these issues any further.

Investigations have shown that potentially hundreds of newly licensed hospices have bilked Medicare of millions of dollars during the past several years, all while providing egregiously poor care or none at all. Some of these providers engaged in referral kickback schemes, enrolled patients who were not eligible for hospice and lied to them about being terminally ill.

In some instances, multiple hospices have been operating out of the same address without a corresponding increase in the population of eligible patients. Some individuals also hold management positions at several of these hospices simultaneously.

The lack of any updated information or data is “disappointing,” according to David Baird, vice president for hospice policy for NAHC.

“We continue to see challenges in fraud hotspot states, and we need to understand how CMS’ [program integrity (PI)] policy changes from the last few years are being implemented and what impact they are having,” Baird told Hospice News. “We don’t know yet if the home health rule will have any hospice-related PI provisions or updates, but it is possible – we would welcome more information and action from the agency to ensure the remaining oversight gaps are shored up, and we look forward to continuing to partner with them to keep the momentum up.”

During the last two years, CMS has addressed some of the hospice issues via provisions in its home health final rules. The 2024 home health rule, for example, contained major updates, such as a 36-month stay on change of ownership for hospices and the implementation of the Special Focus Program for those providers.

But, while CMS has the option to include hospice components in its home health rule, which has not yet been released, whether or not the agency will do so remains uncertain.

In January 2023, a coalition of four industry organizations made 34 recommendations to CMS and Congress for strengthening hospice oversight. These included NAHC, NHPCO, LeadingAge and the National Partnership for Healthcare and Hospice Innovation (NPHI). CMS to date has adopted 17 of those organizations, Harrison and Simmons indicated.

This means more work is needed, according to Mollie Gurian, vice president of home-based and HCBS public policy for LeadingAge.

“We don’t have an indication if they’re moving forward with any additional recommendations. They’ve certainly taken up a lot of the recommendations that the associations put forward last January, but there are still some outstanding ones,” Gurian told Hospice News. “We’d like to see some additional Conditions of Participation around marketing of services and making sure that the right people are getting on to hospice and understand what they’re giving up with and what they’re receiving.”