The U.S. Centers for Medicare & Medicaid Services (CMS) is considering administrative action against 400 hospices, which could include revocation of their Medicare certification.
The agency has been mobilizing against hospice fraud this year. In addition to new regulations and updated survey processes, CMS has been conducting unannounced onsite visits. To date, CMS personnel have appeared at 7,000 locations, with plans to visit every hospice site in the country.
Two CMS officials outlined the effort in a blog post emailed to Hospice News — Dara Corrigan, CMS deputy administrator and director of the Center for Program Integrity, and Dr. Dora Hughes, acting director of the agency’s Center for Clinical Standards and Quality (CCSQ) and acting CMS chief medical officer.
“CMS revisited and revitalized our hospice program integrity strategy, focusing on identifying bad actors and addressing fraudulent activity to minimize impacts to beneficiaries in the Medicare program,” Corrigan and Hughes wrote. “As part of this strategy, CMS embarked on a nationwide hospice site visit project, making unannounced site visits to every Medicare-enrolled hospice. Our goal was to protect patients and their families from engaging with fraudulent actors by making sure that each hospice is operational at the address listed on their enrollment form.”
The agency is working to curb the impact of a rash of new providers that have emerged so far in four states: California, Arizona, Texas and Nevada.
A large contingent of these companies were established with the purpose of selling the license at a profit, with little concern for patient care. In some instances, multiple hospices have been operating out of the same address without a corresponding increase in the population of eligible patients.
When CMS finds providers that have not been operating from the address on its Medicare enrollment form, the agency has been revoking their billing privileges.
Also on the agency’s radar are hospices that allegedly enrolled patients in the Medicare Hospice Benefit who were not genuinely eligible, according to Corrigan and Hughes.
“We take our role as stewards of the Medicare Trust Funds seriously, and we work to ensure that taxpayer dollars are spent on high-quality, necessary care for each beneficiary,” they indicated in the blog post. “Part of this includes preventing fraud, waste, and abuse from taking place in the first place. CMS has adopted new policies and safeguards to quickly identify and take action against hospices engaged in such practices.”
Among these new policies is a rule prohibiting changes of ownership within 36 months of Medicare enrollment, designed to curb quick license sales in an effort to avoid regulatory attention.
Additionally, CMS is conducting a small pilot program to test the waters on post-payment reviews of hospice stays that exceed 90 days. The agency has contracted with Noridian Healthcare Solutions, LLC as its Supplemental Medical Review Contractor (SMRC). Noridian will perform the reviews and submit findings to CMS.
Coupled with this, CMS is developing an “enhanced oversight” program for providers in California, Nevada, Arizona and Texas. A key component of this includes a medical review of claims before a Medicare Administrative Contractor (MAC) will pay them.
The enhanced oversight period applies to hospices in those four states that are newly enrolled in the Medicare program as of July 13, as well as those who are submitting or undergoing a change in ownership.
The agency is also implementing a screening requirement for hospice-certifying physicians to ensure they are qualified to treat Medicare beneficiaries, including verification that they have active licenses and do not have any felony convictions on their records.
These efforts follow a survey redesign first proposed in 2021. CMS now requires surveyors from state agencies or accreditation organizations to use a multidisciplinary survey team and prohibits surveyor conflicts of interest.
Surveyors from accrediting organizations must now complete comprehensive training and testing. Accreditors are now also required to collect standardized survey deficiency information in the same manner and format used by state survey agencies, which is disclosed publicly on CMS’ Quality, Certification, and Oversight Reports (QCOR) website.
“CMS has been hard at work implementing new survey and enforcement requirements, with a goal of making sure that hospices enrolled in Medicare are fully able to provide high-quality care,” Corrigan and Hughes wrote. “State agencies and national accrediting organizations are required to conduct surveys of hospices to make sure they provide all required services and meet all hospice conditions of participation.”
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