How Hospice Labor Pressures Can Impact Regulatory Compliance

Industry-wide staffing woes are bleeding into hospices’ compliance programs.

Many hospices are struggling not only operationally, but also financially to comply with regulations, according to Norbert Hudak, partner at in90Group, a Los Angeles-based business marketing and strategy development company.

The company recently polled 100 home health and hospice executives on their biggest quality and compliance challenges. About 90% indicated that they would prefer to manage compliance internally but lack the time and staff to do so, according to survey results that in90group shared with Hospice News.

These respondents said that they often experienced “difficulty prioritizing compliance over patient care.”

“An average hospice or home health leader is spending $30,000 to $40,000 a year and dedicating six to 10 people just to manage their quality and compliance programs,” Hudak told Hospice News. “About two-thirds are having difficulty collecting the data they need and tracking performance improvement plans, both of which are at the core of maintaining a good quality program. We found that there’s a lot of pain out there around their ability to manage workflows and maximize their compliance effectiveness with limited staffing resources.”

Additionally, around 40% said they were “not properly staffed” to be successful in compliance.

Workforce shortages and compliance issues are coinciding at a time when government scrutiny is reportedly heating up.

Regulators have been keeping a keen eye on length of stay and eligibility, for example. These data points can raise red flags for the Centers for Medicare & Medicaid Services (CMS) and its contractors and frequently lead to audits.

Unified Program Integrity Contractor (UPIC) and Targeted Probe and Educate (TPE) audits are designed to ensure hospice program integrity. CMS contracts UPIC auditors to investigate instances of suspected fraud, waste and abuse. These contractors initiated activities in 39 states during 2020, with hospice among the most common areas of focus, CMS reported.

Meanwhile, the U.S. Department of Health & Human Services Office of the Inspector General (OIG) is rolling out a nationwide audit of hospice eligibility this year. The audit will focus on patients who did not have a hospitalization or emergency department visit prior to electing hospice. OIG will audit hospices’ Medicare claims and associated documentation during the calendar year of 2023.

Hospice providers need strong compliance teams to avoid getting into regulatory hot water, according to Howard Young, partner at the law firm Morgan Lewis. This can be particularly essential when it comes to issues related to the anti-kickback statute and False Claims Act complaints, he said.

Those two areas pose the greatest regulatory risk when it comes to drawing “a whiff of criminal inquiry or investigation,” from regulators, Young said in a recent episode of Hospice News’ ELEVATE podcast. 

“Adopting a compliance program doesn’t give you immunity, but it gives the organization and its staff the ability to raise concerns,” Young told Hospice News. “As far as what could get you into [regulatory] hot water and turn something from the civil enforcement area to criminal, one of the risk areas is if there’s a complaint lodged internally and the individuals face retaliation for raising concerns. The other area we often see with criminal enforcement is the anti-kickback law area. Hospices, just like other health care providers, can’t knowingly pay for referrals. The government is always interested in enforcing that statute.”

This means hospices must weave compliance into the fabric of employee training efforts and interactions with referral partners, as well as their approaches to intake and clinical documentation, Young added.

Hospices doing more with less

Due to the labor pressures, hospice providers are being called upon to do more with less when it comes to compliance and care delivery, according to John Gochnour, COO at The Pennant Group (NASDAQ: PNTG).

“The reality is, we are facing a very unique and difficult environment, and it’s going to demand more from us as operators than it ever has before,” Gochnour said during a recent Hospice News webinar. “When you think about that and kind of lump that into the reimbursement rates, the challenges force us to deliver care more efficiently.”

The reality is, we are facing a very unique and difficult environment, and it’s going to demand more from us as operators than it ever has before.

— The Pennant Group COO John Gochnour

Technology has played a larger role in how understaffed hospices are addressing compliance challenges.

Having an electronic health record system that streamlines workflows is an important part of efficient compliance practices when operating under slim staffing parameters, according to Trisha Crissman, vice president and COO of CommonSpirit Health at Home.

The hospice and home health provider has put a lot of focus on shoring up its technology systems and compliance processes to ensure that staff can collect patient data efficiently in real-time, Crissman said. Having tighter control over care delivery processes and patient admissions is a “vital component” of being successful in today’s regulatory climate, she added.

“A key combination is having an EMR like this that allows us system controls,” Crissman said during the webinar. “And the only way that we can be successful with that is if we ensure that processes are followed and all layers of our organization, including the back office, frontline staff, and revenue cycle functions, [are] agile and responsive enough to keep all ships afloat.”

Hospices have to keep tabs on a wide variety of quality measures, including the Hospice Item Set (HIS). The agency requires hospices to submit HIS data for each patient served. Those that do not risk a 2% payment cut across the board.

With the rich mix of hospice quality regulations and requirements in motion, keeping staff up to speed on regulations and standards is vital, according to Jennifer Kennedy, vice president of quality and standards at Community Health Accreditation Program (CHAP).

This involves taking a vigilant, “all-hands-on-deck” approach to compliance that includes both clinical and back-office staff, she said.

Each of these employees must have a firm understanding of how their individual roles affect compliance, Kennedy said.

Training is particularly important when human resources are lean and employees are wearing multiple hats, she added.

“All areas of hospice operations, not just clinical but also billing and referrals, among others — any place in operations needs to have compliance hardwired into it,” Kennedy told Hospice News. “Taking the high road of compliance means that the organization takes regulatory requirements very seriously and ensures everyone knows what their role is in compliance. Compliant organizations are going to be the ones in business five years from now.”

“All areas of hospice operations, not just clinical but also billing and referrals, among others — any place in operations needs to have compliance hardwired into it,” Kennedy told Hospice News. “Taking the high road of compliance means that the organization takes regulatory requirements very seriously and ensures everyone knows what their role is in compliance. Compliant organizations are going to be the ones in business five years from now.”