Hospice Advocacy Groups Call on CMS, Congress to Strengthen Program Integrity Oversight

Four national hospice and senior care industry groups have called on Congress and the U.S. Centers for Medicare & Medicaid Services (CMS) to make regulatory and legislative changes to instill stronger program integrity safeguards.

The organizations penned a joint letter to CMS in November urging for increased oversight to help curb hospice frauds, including the National Association for Home Care & Hospice (NAHC), National Hospice and Palliative Care Organization (NHPCO), National Partnership for Healthcare and Hospice Innovation (NPHI) and LeadingAge.

Now the organizations have laid the foundation of the proposed regulatory and legislative changes, submitting recommendations to CMS and Congress today. The proposed list of measures outlined in Hospice Program Integrity aimed to create more effective oversight.

“A lot of eyes are looking at hospice at this point in time. The thing to watch for particularly in the hospice realm is oversight on claims, quality and performance — even to the point of dealing with fraud and abuse in the hospice benefit,” said NAHC President Bill Dombi during its recent 2023 Industry Outlook webinar. “We have recently joined forces with other voices in hospice to present a list of program integrity measures that can be considered.”

The Hospice Program Integrity plan lists 34 recommendations that center around five key areas. These areas include stronger oversight of hospice Medicare enrollment and billing practices, developing Medicare certification “red flag” criteria, expanded surveyors’ ability to confirm all four levels of hospice care, and adding education and experience qualifications in Conditions of Participation (CoPs) for hospice administrators and patient care managers.

Hospice organizations have come under increasing legal and regulatory scrutiny related to medical necessity complaints under the False Claims Act and the closely related anti-kickback statute. These cases generally involve allegations that hospices billed Medicare for services for which patients were not eligible.

“There has been incredibly stepped up oversight [and] media attention where quality, fraud and abuse issues have been the centerpiece. We want to have high levels of compliance and the quality side of it is job number one,” Dombi said. “But the signs are out there that hospice is in for a new generation and hospices need to prepare for that. There are many good things about hospice that remain out there and there’s still room for more.”

Also on regulator’s radar is the rising number of new hospices cropping up in some states. The proliferation of new hospices in California, Texas, Arizona and Nevada has stoked concerns around potential fraud and other abuses.

These same industry organizations in November 2022 called for greater federal oversight of hospice licensing practices in response to the issue.

The issue of fraud has garnered national attention following a recent article from the NewYorker and ProPublica that dug into instances of potential illegal and unethical behavior in the industry. Hospice News published an editorial response to the piece that detailed some of the nuances of eligibility, payment and regulation around end-of-life care.

Developing regulatory benchmarks for hospice program integrity is a stab at “meaningful change,” NPHI CEO Tom Koutsoumpas indicated in a combined statement from the industry groups.

“End-of-life care providers have an obligation to support and care for patients and their loved ones with dignity and respect at this most vulnerable time in their lives. Providers who manipulate the Medicare benefit solely to profit at the expense of their patients have no place in the hospice program,” Koutsoumpas said. “To curb the entry of bad actors into hospice, NPHI is pleased to put forth, in conjunction with our national partners, robust program integrity reform recommendations. We look forward to working with our partner organizations, Congress, and CMS to advance meaningful change that will better protect those receiving hospice care at the end-of-life.”

The industry groups proposed that CMS exercise its authority to establish a targeted moratorium that would limit the enrollment of new hospice providers in regions with “troubling rates of explosive licensure and Medicare certification growth.”

California recently tightened up hospice licensure oversight by placing a moratorium on new provider licenses. The California Depart of Justice (CDOJ) issued a report in March detailing the lax hospice oversight. In the report, the CJOG indicated that the state has “weak controls [that] have created the opportunity for large-scale fraud and abuse,” and that it had identified “numerous indicators of such fraud and abuse by hospice agencies” statewide.

“Ensuring program integrity is essential to enabling good hospice care. These recommendations are the latest such effort and are especially topical given the alarming recent growth of Medicare certified hospices in California, Arizona, Nevada, and Texas which are fraudulent actors,” NHPCO COO and Interim CEO Ben Marcantonio said in the statement. “[We] must be proactive in our response and intolerance toward deceptive hospice care that does not live up to the standards of high-quality care we expect from members of our community.”

The hospice groups proposed that regulators expel non-operational hospices from Medicare and increase site visits from surveyors. This revocation would prevent these hospices from being sold to inexperienced providers for a profit, according to the industry groups. Recommendations also advised that CMS investigate Medicare provider numbers to detect any gaps in billing.

The integrity program also included a set criteria aimed at helping CMS to identify red flags on hospice Medicare certification applications. These application triggers included the co-location of multiple hospices at single address, a single hospice administrator overseeing multiple hospices, a patient care manager or other hospice leadership staff serving multiple hospices, and a hospice company that “appears to be hidden behind a shell company,” according to the group statement.

The agencies’ recommendations included adding educational and professional qualifications to the hospice CoPs for leaders and patient care managers. Provisions include minimum years of experience or a combination of education and experience and required background checks for hospice owners and administrators.

They also recommended that CMS provide strengthened survey oversight to ensure hospices have the ability to provide all four levels of care, citing that a large number of providers currently lack routine home care and after-hours services. The groups also proposed specifications around the forthcoming Hospice Special Focus Program that would clearly identify how it will inform future rulemaking decisions and include a provision for new hospices with condition level deficiencies.

The hospice organizations called on Congress and CMS to “act expeditiously” to ensure that only well-qualified providers are permitted to care and support Medicare beneficiaries at the end of life.

“It’s time to take action. America’s population is aging, and high-quality services are needed now more than ever before,” LeadingAge President and CEO Katie Smith Sloan said. “Reform must promote high-quality care, including the right services in the right quantity, and eliminate opportunities for misdeeds. Our goal in collaborating with other hospice provider groups, with Congress, and with CMS, is to ensure necessary change. Yet it is only part of the solution; our work will not be complete until we address the desperate need for a system of long-term services and supports that is responsive to how older adults live and die now.”