Hospice Leaders to Lawmakers: Strengthen CMS Oversight of Accreditors

Individuals in several states have been securing hospice licenses only to turn them around in a quick sale. A number of these hospices are accredited, prompting calls for greater oversight of organizations with deeming authority.

A surge of newly licensed hospices has swelled in California, Arizona, Texas and Nevada. Many of these have been accused of gaming the Medicare system and delivering poor-quality care.

The resulting outcry from hospice organizations and lawmakers has led the U.S. Centers for Medicare & Medicaid Services (CMS) to make ownership data, as well as propose a number of regulations. These include a 36-month ownership rule, updated mandates for certifications and denials, as well as restrictions on the types of providers who can prescribe certain medications.

In addition to actions like these, the agency may want to consider tightening the reins on accreditors as well, according to Lynne Sexten, CEO of Agrace Hospice and Supportive Care.

“The accrediting bodies are contracted and have a certain set of guidelines that they have to abide by to remain accrediting agencies, but rigorous oversight from CMS isn’t part and parcel with it,” Sexten told Hospice News. “And so I hope for more rigorous CMS oversight of the accrediting organizations. I think that would be absolutely powerful.”

Strengthening accreditation oversight was a topic of discussion in recent meetings between hospice leaders and members of Congress.

I hope for more rigorous CMS oversight of the accrediting organizations. I think that would be absolutely powerful.”

— Lynne Sexten, CEO, Agrace Hospice and Supportive Care

Of principal concern are the organizations with deeming authority, meaning essentially that providers can obtain Medicare certification by complying with their accreditation standards. The three major hospice accreditors are The Joint Commission, Community Health Accreditation Partner (CHAP) and the Accreditation Commission for Health Care (ACHC).

According to multiple hospice executives, many of the hospices under suspicion in four western states have been accredited.

A proportion of these providers have reportedly been enrolling small numbers of patients, often 10 to 20, keeping them on service until they reached the cap, and then selling or leaving the business before CMS could recoup the overages.

Allegedly, some have also manipulated their care models and census to game the payment cap system and avoid repaying claims, among other violations.

These issues were first identified in California, where the state’s Department of Justice reported that poor oversight of hospice licensing created an environment that was conducive to fraud and abuse. Months later, it became apparent that similar problems existed in a handful of other states.

Accreditors: Oversight should be balanced

CHAP CEO Nathan J. DeGodt told Hospice News that any future government action should be implemented without impeding accreditors’ ability to work.

“As for increased government oversight, it’s important to strike a balance,” he said in an email. “While more collaboration between accreditation organizations and governmental bodies could (and should) potentially help identify bad actors, accrediting bodies need to maintain the ability to be agile, adaptable and encourage innovation and excellence in care.”

Accrediting bodies need to maintain the ability to be agile, adaptable, and encourage innovation and excellence in care.

— Nathan J. DeGodt, CEO, CHAP

CHAP, which conducted in-person surveys throughout the pandemic, indicated that it continuously monitors the health care space, self-assesses its processes and revises its standards based on changing conditions or emerging best practices, according to Jennifer Kennedy, the organization’s vice president of quality, in an email.

When it comes to program integrity, however, accreditors do have a role to play, according to Community Healthcare of Texas CEO Viki Jingle.

For example, they can sometimes survey and accredit a hospice faster than overburdened state agencies.

“There’s a lot of hospices in our territory that have no accreditation whatsoever, and our state is overwhelmed in trying to get out to survey hospices,” Jingle told Hospice News. “And when they do a survey, it’s based on whether you are following this policy or not really going out and talking to patients and families and hearing what was actually provided.”

Susan Mills, senior program director for ACHC, pointed out that accreditation standards are often more rigorous than CMS certification requirements.

“Most organizations that choose accreditation over state agency review when seeking CMS certification are not looking for an easier path. [Accreditation organization (AO)] standards incorporate all CMS requirements plus additional expectations,” Mills told Hospice News in an email. “An AO’s ability to make a timely on-site visit, whether for an initial, renewal, complaint, or random survey is key to evaluating hospice practices regarding patient safety and quality of care. AOs are not charged with reviewing billing practices, but instances of fraud can be (and have been) identified through review of medical records, personnel files, home visits and staff and patient interviews.”

The Joint Commission did not respond to Hospice News’ questions.