CMS to Resume Audits, Medical Reviews in August

The U.S. Centers for Medicare & Medicaid Services (CMS) will resume enforcement activities, including targeted probe and education audits, on Aug. 3, regardless of the status of the federally declared COVID-19 national emergency. The agency had suspended audits and medical reviews by Medicare Administrative Contractors (MACs) as of March 30.

Hospice utilization among Medicare decedents rose to exceed 50% for the first time during 2018, according to CMS. As utilization climbs, so does the amount of dollars CMS spends on hospice care, spurring the agency to step up enforcement in an effort to control costs. Medicare hospice expenditures rise by about $1 billion annually.

CMS indicated that hospices that are selected for review should discuss any hardships stemming from the outbreak with their contractor if their ability to respond to the audit in a timely fashion is uncertain. Nevertheless, hospice providers are uncertain about the prospect of facing an audit during a pandemic. This includes concerns about staff safety as they return to the office to pull documents.


“Staff are already being pushed to the limits. We’re operating with constraints in terms of how we can access patients. We’re operating mostly virtually right now, which is cumbersome,” Peter Brunnick, president and CEO of Hospice & Palliative Care Charlotte Region told Hospice News. “To add the audit process, which would require getting staff in-house pulling records and sitting down with auditors, is counter to everything we’re doing now trying to be socially distant and practice safety.”

Hospices have faced intensifying scrutiny from regulators in recent years.

The Office of Inspector General (OIG) at the U.S. Department of Health and Human Services in late 2018 issued a report on payment-related vulnerabilities in the Medicare hospice program. Based on its findings, OIG recommended that CMS strengthen the survey process and improve oversight to “identify hospices that engage in practices that raise concerns.” This was the first in a series of OIG reports throughout 2018 and 2019 that identified payment and quality-related problems in U.S. hospices.


CMS often treats issues such as longer lengths of stay, live discharges and recertification of a patient for hospice as red flags that could trigger an audit. Documentation – such as certification and recertification statements, hospice election statements and others – is a key component of each of these processes.

“While we understand the desire by CMS to return to pre-pandemic audit activity, we would urge caution to return to any such activity for the near future,” Michael Pearson, president of Lumicare Hospice, told Hospice News. “Resuming full audit enforcement activities will redirect necessary focus away from where it should be at this time – patients, families, and Hospice caregivers.  They deserve all of our attention while we continue to navigate these unexpected times and continue to provide care at the highest level possible.

Many hospice providers express uncertainty about their ability to weather an audit. Even prior to the pandemic, fewer than 50% of hospices indicated that they were ready for a federal audit or additional document request, according to a 2019 survey of 170 organizations by Optima Health

“We recognize that oversight, even in a pandemic, is important, and we have no patience or tolerance for fraud and abuse. On the other hand, asking a compliant provider to take time out of providing care to their population in the middle of a global pandemic is not the best idea,” said National Hospice & Palliative Care Organization President and CEO Edo Banach. “We are not in August going to be in a place where providers are going to be forgetting about [COVID] testing and [personal protective equipment]. There is a lot of consternation out there about the possibility that individuals are going to be pulled out of the field into the office and sift through records at a time when really all hands are needed on deck.”

As MACs review hospices’ compliance with CMS rules, some providers have also expressed concern that the contractors may not be up to speed regarding the evolving regulatory landscape brought on by the pandemic. CMS issued a number of 1135 waivers to relax regulations to allow hospices to focus on patient care rather than administrative compliance activities.

For the duration of the COVID-19 national emergency declaration, hospices are exempt from requiring a registered nurse or other skilled professional to make an annual, onsite supervisory visit for each aide.

CMS also modified the requirement mandating that hospice annually assess the skills and competence of all individuals furnishing care, and to provide in-service training and education programs where required, and permitted providers to narrow the scope of their required Quality Assurance and Performance Improvement (QAPI) programs to focus on infection control and adverse events.

The agency further indicated that it would allow clinicians to use telehealth to fulfill requirements that are typically done face-to-face, including recertifications by physicians.

“With the 1135 waivers we are operating with very different rules than we normally would. Under an audit my initial concern is that sometimes auditors are not always that flexible, and they may not understand the full dynamics of how our situation has changed,” Brunnick told Hospice News.

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