New Hospice Investigations, Audits Forthcoming from OIG

More than a year after two major hospice reports, the U.S. Department of Health & Human Services Office of the Inspector General (OIG) continues to look hard at the industry to address concerns ranging from billing and claims to patient safety. 

Reports are forthcoming from OIG that address the ways that the hospice inpatient aggregate payment cap is calculated, as well as payments that are made outside of the Medicare Hospice Benefit. The office is also looking at specific providers’ compliance with law and regulation and Medicare payments for chronic disease management. 

“Hospice issues are really important; they are very important to the OIG. It is a priority for the OIG, and we will continue to follow up on these issues and try to protect this vulnerable population,” Regional Inspector General Jodi Nudelman told Hospice News. Nudelman co-authored the 2019 reports.

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OIG is also investigating potential problems throughout the health care continuum that have arisen during the COVID-19 pandemic, but those efforts have not slowed the office’s work in the hospice sphere.  

“During COVID. I think these [hospice] issues are even more pressing,” Deputy Regional Inspector General Nancy Harrison said. “While our [2019 hospice report] was prior to COVID, these issues continue to play out and are even more pressing,”

Harrison was also a co-author on the 2019 reports. 

Last year’s reports shook many in the hospice community and received widespread media coverage. The first OIG report indicated that about 20% of hospices surveyed by regulators or accreditors between 2012 and 2016 had a condition-level deficiency that posed a serious safety risk.

A second report discussed 12 examples of those deficiencies in-depth. OIG examined state agency and accreditor survey findings as well as complaint data from 2012 through 2016. Regulators and accreditors surveyed nearly all hospice providers in the nation during those years.

Since OIG issued those reports, the office has continued to eye progress on its recommendations to the U.S. Centers for Medicare & Medicaid Services (CMS) for strengthening hospice oversight and revamping processes for evaluating compliance.

“We are absolutely monitoring the progress on the issues that we raised, because for us it’s so important to protect this vulnerable population. We want to see beneficiaries get the care they need. We want beneficiaries to get the information they need,” Nudelman said. “Hospices provide quality care, and we want to make sure that hospices that don’t do their jobs are held accountable. We work with CMS on an ongoing basis, and we have a back and forth with them as they implement these recommendations. They have made some progress on several of them. More work needs to be done, but we have seen some movement.” 

For example, CMS has been in the process of enhancing the information made available to health care consumers via the Hospice Compare website, which the agency recently rolled into a new Care Compare site. Hospice complaint survey data is now included on the site, though the information posted on Hospice Compare is still less comprehensive than the Compare sites for other health care settings, according to Harrison.

CMS is also analyzing claims and deficiency data to drive improvement in its survey process, including the ways the agency handles Immediate Jeopardy citations — which represent an urgent threat to a patients’ health and safety.

“We think that a data-driven approach is key to using CMS resources efficiently and effectively. CMS has stated that it’s going to conduct data analysis on Immediate Jeopardy citations and analyze those trends over time, and also look at whether citations were appropriately cited at the standard or condition levels,” Harrison said. “CMS has also said they’re going to look into making the complaint process easier for beneficiaries and their families, and we think that is really important. That’s how quality of care will improve —  if families are able to make complaints and things can be addressed.” 

OIG has also asked CMS to require hospices to report all instances of abuse or neglect that they uncover, regardless of whether hospice staff were involved or responsible.

While many in the hospice space acknowledged the importance of the safety issues raised in the 2019 reports, some balked at the idea of CMS taking a more stringent approach for the entire industry. These stakeholders argued instead that heightened oversight should be concentrated on providers that have a history of serious deficiencies or patient safety events.

While indicating that system-wide change was needed for some areas, Nudelman and Harrison raised no objections to focusing stepped-up enforcement on demonstrated bad actors.

“Oversight does not necessarily have to be a one size fits all. There should be a baseline level of scrutiny for all providers, but there are some providers that warrant extra scrutiny, especially those that have had deficiencies that can lead to patient harm. We think there can be a multi-faceted approach,” said Harrison. “You’ve got to increase transparency. You’ve got to increase education. It’s important that hospices are well informed about common deficiencies in key areas that put patients at risk. We feel that can really inspire poor performers to provide better quality care.”