Hospices in a Regulatory ‘Fight’ for Quality

Fraud, waste and abuse issues that have percolated in the hospice space have put providers up against some regulatory walls.

Heightened scrutiny around hospice from regulatory agencies is not without warrant, but increased oversight can have adverse effects on the ability to provide quality care, according to Bill Dombi, president, National Association for Home Care & Hospice (NAHC).

Bad actors in the hospice space can cost the nation’s health care system millions in fraudulent billing practices and also hinder access to care among terminally ill patients. Though these are substantial issues to address, regulators need to strike a balance, Dombi indicated.

“We have a lot of harm that hits us as much as it hits [payers] from fraud, waste and abuse,” Dombi said during the NAHC Financial Management Conference in New Orleans. “An important area to address is quality of care and hospice services. We do not want just a regulation pass that crosses everybody and creates a lot of paperwork for everybody but doesn’t do anything about the bad that is going on there. We need to be a step ahead of the bad people, because many of them aren’t even delivering any care.”

Program integrity has been in the spotlight recently as agencies crack down on health care fraud. In some cases, hospice providers have allegedly received millions through kickback schemes and fraudulent billing practices, with some providers facing criminal charges and prison sentences for their involvement.

Additionally, multiple reports of unethical or illegal practices among hundreds of newly licensed hospices have cropped up in states such as Arizona, California, Nevada and Texas.

Fraudulent or inaccurate Medicare claims cost the federal government an estimated $60 billion annually, according to a 2018 CNBC report. Medicare hospice claims represent a solid chunk, according to regulators.

These driving forces coupled with rising demand are bringing hospices to a period of substantial change in the industry, according to Kenneth Albert, president and CEO of Androscoggin Home Healthcare + Hospice.

“Never before have we needed to fight more than we do right now in this very moment,” Albert said. “We are undergoing a really revolutionary transformation in the American health care industry. Our patients are why we have to be there and we have to fight.”

Never before have we needed to fight more than we do right now in this very moment. We are undergoing a really revolutionary transformation in the American health care industry. Our patients are why we have to be there and we have to fight.

— Kenneth Albert, president and CEO, Androscoggin Home Healthcare + Hospice

Hospices’ best “weapon” in that fight is ensuring that they have airtight documentation, according to Katie Wehri, NAHC’s director of home care and hospice regulatory affairs.

Ensuring that clinical staff are well-versed in compliance through training is crucial, she indicated.

“There’s a lot you can approach this from what hospices can do with their staff and what they can do from the standpoint of protecting themselves and insulating themselves from regulatory oversight,” Wehri told Hospice News at the conference. “You hear it all the time about documentation, documentation, documentation. We know that good care is being delivered but we aren’t taking credit for that, especially when we’re thinking about some of those higher levels of care. That’s really what it is, it’s making sure that your documentation reflects that you are delivering exactly what you’re supposed to be delivering every single day.”

Medicare billing claims need to have clinical documentation that makes the case for more costly health care at the end of life, such as general inpatient care, Wehri said. This means consistently documenting patients’ needs for this level of care on a daily basis, since “each day stands on its own” in the eyes of auditors keeping watch for fraud and abuse.

The U.S. Department of Health & Human Services Office of the Inspector General (OIG) has zeroed in on this level of care, mainly due to reportedly inaccurate billing claims that cost the health care system millions each year, the agency indicated.

As regulators work to address fraud in the hospice space, providers can anticipate more changes on the horizon to come, Dombi indiciated. This means placing compliance at the forefront, he indicated.

“We’ve got to make sure that we are redoubling our efforts on quality of care in hospice,” Dombi said. “We have to recognize that there’s been an evolution in other parts of health care and home programs — there will be an evolution in hospice.”