NAHC President Dombi: Hospices Face Stricter Oversight in 2023

Regulators have been keeping an increasingly close watch on hospice providers, and this may intensify in 2023.

Moving into next year, hospices have a spectrum of crucial issues on their plates. The U.S. Centers for Medicare & Medicaid Services (CMS) will be implementing a revised compliance survey process and has convened a Technical Expert Panel to develop a hospice Special Focus Program.

Meanwhile, the U.S. Department of Health & Human Services Office of Inspector General (OIG) will conduct a national audit for patient eligibility. Questions as to whether enrolled patients are legitimately appropriate for hospice are a common factor in Medicare claims denials and has also driven a rise in False Claims Act cases.


Hospice News sat down with Bill Dombi, president of the National Association for Home Care & Hospice (NAHC), at the organization’s annual conference and expo in St. Louis, Missouri, to discuss the key regulatory trends that providers should be watching.

NAHC President Bill Dombi

Hospice will have a lot going on in the regulatory space next year. What are your expectations going into 2023?  What do hospices need to be focused on and ready for?

Sooner rather than later, they need to be preparing for, if not dealing with, hospice oversight expansion. 


We’ve got the national survey underway from the OIG, looking at claims compliance. And it’s not the survey itself that is the concern, it’s what comes after the survey. 

Because if we can project that, as usual, the OIG finds something wrong and says we’ve got billions of dollars of non-covered care being paid for, you’re going to see a reaction to that coming by way of CMS, having [Medicare Administrative Contractors (MACs)] step up auditing, the other program integrity contractors perhaps as well.

Some of these things take modification of contracts, but there have been too many signs of increased oversight.

What are some of the ways the more routine types of audit activity may impact providers, outside of the OIG’s eligibility inquiry?

We’ve seen a bunch of OIG audits. These are not audits that are saying “covered/non-covered,” extrapolated to millions of dollars. 

That sequence of action is not unusual. We saw it in home health, triggering reactions relative to increased audit activity on the claim side of it. So I would absolutely put that into the mix for 2023.

It’s not that sexy legislative issue kind of thing, but it’s real bread-and-butter and important. The generation of hospices today is beckoning for oversight. You’re familiar, I suspect, with California, and the large number of hospices that have been licensed and certified. What does that generate in the end?

We hope it doesn’t generate the state and federal government trying to point the finger at hospices. They should be pointing at themselves, but too often what we see from circumstances of that nature and this is pre-judging it that all those new hospices raise red flags. Too often, what we then see is some across-the-board kind of reaction to it.

Again, this would be oversight. That could be claims; it could be quality. 

Can you comment on the revised survey process?

We haven’t seen as much yet on [the survey process], but years ago, one of the problems, particularly in California, was that a home health or provider would get certified by Medicare license in a state, and they wouldn’t see a surveyor for years. 

Surveyors are important even on the claims audit side because there are requirements to do visits to homes for the patients. If you go to somebody’s home, and they’re not there on home health, does that mean they’re homebound; or if they knock on a hospice patient’s door, and the the family says, “Oh, you mean the people who deliver us like cupcakes every week, but never see otherwise?”

So those home visits by surveyors can be important as an adjunct to paper reviews on the claims side, as well as on the side of the quality of care. 

The Medicare Payment Advisory Commission (MedPAC) again called for reductions to the hospice payment cap. They’ve done this in the past, but to date, Congress hasn’t followed through. Should providers still be concerned about the recommendation? 

If you look at the [Medicare Payment Advisory Commission (MedPAC)] recommendations, and you look at the trust fund, they kicked that down the road a bit that the trust fund is not going to go bankrupt. But if you’re going bankrupt, you don’t usually try to take action the day before bankruptcy hits, right? MedPAC recommendations can then be given more attention than they might otherwise have been given during that non-trust-fund-going-bankrupt era.

We’re especially concerned about the recommendation on reducing the cap. That’s why we commissioned a study almost two years ago now to prep for that. We think we’re pretty well prepared for it, but can’t say at the moment that we will have an army in Congress, including professional staff of the Congress, jumping all over anybody who proposes a reduction of the cap, which adds to why do we keep it on our radar.

Obviously, we can’t do much other than react to the risk of it at this point, because for some sort of pre-emptive legislation that bans a change in the cap, they may say they’ve got better things to do than trying to prevent something which may never happen. I put those definitely on the radar for 2023.

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