Quality Data, Transparency Becoming More Critical to Hospice Compliance Under New Rules

Quality is a paramount concern as hospice regulation and payment continue to evolve. Quality and transparency will be critical not only to curbing regulatory scrutiny, but also to a hospice’s bottom line.

New quality measures were among the major provisions included in the final rule for hospice payments in Fiscal Year 2022. The rule implemented the Hospice Care Index (HCI), a new collection of measures in the Hospice Quality Reporting Program (HQRP). The index contains 10 quality indicators that are calculated using claims data. The data represent different aspects of hospice care designed to illustrate care processes that occur between the patient’s admission and discharge.

Hospices can expect the U.S Centers for Medicare & Medicaid (CMS) to roll out more claims-based measures as the agency takes a heightened focus on quality of care, according to Katie Wehri, director of home care and hospice regulatory affairs at the National Association for Home Care & Hospice (NAHC).


The 10 HCI measures include:

  1. Continuous Home Care (CHC) or General Inpatient (GIP) Provided 
  2. Gaps in Skilled Nursing Visits 
  3. Early Live Discharges 
  4. Late Live Discharges 
  5. Burdensome Transitions (Type 1) – Live Discharges from Hospice Followed by Hospitalization and Subsequent Hospice Readmission 
  6. Burdensome Transitions (Type 2) – Live Discharges from Hospice Followed by Hospitalization with the Patient Dying in the Hospital 
  7. Per-beneficiary Medicare Spending 
  8. Skilled Nursing Care Minutes per Routine Home Care (RHC) Day 
  9. Skilled Nursing Minutes on Weekends 
  10. Visits Near Death 

“The future of the Hospice Quality Reporting Program is one that we really expect to change significantly over the next couple of years,” said Wehri during NAHC’s Fall Forum. “We’re expecting a lot more measures to be added once the [Hospice Outcomes & Patient Evaluation (HOPE)] is implemented.”

The forthcoming HOPE Tool, currently is in the first stage of pilot testing. When complete, the HOPE tool will replace the current Hospice Item Set (HIS) quality reporting system. CMS indicated the tool’s dual objectives are to provide data for the HQRP through standardized data collection and provide clinical data that could inform potential future changes to Medicare hospice payments.


CMS is working to develop measures for the HOPE reporting program that are compliant with the agency’s Meaningful Measures Initiative. In contrast to the HIS system, which extracts item set data from a patient’s medical record using a standardized mechanism, the HOPE tool will measure aspects of hospice care at different points in the patient’s experience.

The tool is designed to use outcome measures in addition to some of the process measures used in the HIS system. Outcome measures reflect the impact of the health care service or intervention on the health status of patients, according to the U.S. Agency for Healthcare Research & Quality, whereas process measures indicate what a provider does in caring for the patient.

“The HOPE instrument will gather data as care is being delivered to patients and will allow CMS to have significantly more measures in the Hospice Quality Reporting Program such as things that are clinical measures as well as other types of process measures potentially that could be out there,” Wehri said. “We really don’t anticipate HOPE being implemented for a couple more years yet. We might see in the spring of 2023 in our proposed rule, and some more information about HOPE and possibly hospices having to utilize it in fiscal year 2024.”

Hospices who fail to comply with the quality reporting requirements could incur a 2% point reduction to their annual payment update percentage increase for that year. Additionally, they risk drawing regulators to their doorstep. Claims-based measures will be important considerations in compliance as the industry looks ahead to implementation of the hospice Special Focus Program (SFP).

The SFP appeared in the CMS proposed rule for home health payment for 2022 but was removed from the final version. CMS delayed the program, establishing a Technical Expert Panel (TEP) to ensure that SFP is designed effectively for hospices. Through SFP, CMS will have the power to impose enforcement remedies against hospices with poor performance on regulatory or accreditation surveys.

Hospices flagged by the program would be surveyed every six months rather than the current three-year cycle. The SFP will have the authority to impose fines, suspend reimbursement, appoint temporary management to bring the hospice into compliance, or revoke a provider’s Medicare certification altogether.

Some of the new quality reporting measures could cross over into a hospice’s Special Focus Program eligibility criteria, according to Wehri. CMS may examine integrating survey information with quality information.

“CMS may take a look at combining survey information with quality information, depending on what happens with this [program]. It’s not for sure that they will, but there’s a strong possibility” said Wehri. “A hospice that falls outside of the door in their performance in these areas of vulnerability has a greater chance of receiving an audit request, so [quality] is an area that you want to monitor.”

Suspended during the pandemic, CMS in September resumed Targeted Probe and Educate (TPE)audits. The TPE program is designed to identify providers that have frequent errors on their Medicare claims or billing practices that CMS considers to be unusual. TPEs, typically conducted by Medicare Administrative Contractors (MACs), also focus on services that have high national error rates and represent a financial risk to Medicare, according to CMS.

These are just the beginning of what to expect of ongoing provisions in the pipeline, Forster recently stated.

The hospice survey revisions in the home health rule take effect. Jan 1, 2022. Among the changes is a requirement allowing CMS to publicly report survey findings from accreditation bodies that have deeming authority. Three accreditors currently have this authority: the Accreditation Commission for Health Care (ACHC), Community Health Accreditation Partner (CHAP), and The Joint Commission.

Transparency will become a higher priority for compliance, according to Theresa Forster, NAHC’s vice president for hospice policy and programs. Stakeholders have voiced concerns about the accreditation reports, which tend to use more technical language that may seem arcane to a lay person, saying that the agency must find a way to present the information in a manner that is easier for the general public to understand.

“Public display, CMS has indicated, is really going to be only the first step relative to this new transparency that they are seeking relative to survey findings,” said Forster. “It is important that survey findings be translated somewhat so that they can be more easily digestible by the public. CMS has every intention of developing some type of framework that will better convey [the information] to the public.”

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