NHPCO Voices Support for CMS’ 36-Month Rule, Program Integrity Actions

The U.S. Centers for Medicare & Medicaid Services (CMS) is on the right track with several new rules designed to improve hospice program integrity, but some could use some fine-tuning, according to the National Hospice and Palliative Care Organization (NHPCO).

The hospice advocacy group today issued public comments on CMS’s proposed home health rule for 2024. The proposal included some hospice-related provisions, including a 36-month change of ownership rule and the implementation of a Special Focus Program (SFP), among others.

“NHPCO supports the expansion of [the rule] to require hospices who undergo a change in majority ownership (CIMO) within 36 months after initial enrollment or following the hospice’s most recent CIMO to enroll in Medicare as a new hospice and obtain a state survey or accreditation from an approved accreditation organization,” NHPCO indicated in its comments. “By implementing the 36-month rule in hospice, CMS will be able to stop the bad actors from the initial enrollment of new hospices or quickly setting up and selling hospice [CMS certification numbers] to new owners without consequences.”


The “36-month rule” mirrors a regulation that has existed for several years for home health agencies. The rule forbids any change in majority ownership during the 36 months after initial Medicare enrollment, including acquisitions, stock transactions or mergers.

NHPCO also agreed with the four exceptions that CMS included for the 36-month requirement:

  1. The hospice submitted two consecutive years of full cost reports since initial enrollment or the last CIMO, whichever is later;
  2. The hospice’s parent company is undergoing an internal corporate restructuring, such as a merger or consolidation;
  3. The owner of an existing hospice are changing the hospice’s existing business structure (for example, from a corporation to a partnership (general or limited), and the owners remain the same;  
  4. An individual owner of a hospice dies.

A related clause in the rule would deactivate the Medicare certification of providers that do not bill Medicare after six months of providing services.


“Good faith providers have minimal, if any, reasons to go six months without billing Medicare, so this adjustment will have little impact on these providers,” NHPCO noted in its comments. “In contrast, bad actors who hold hospice [CMS certification numbers] whose only goal of selling the hospice will be brought to light through this proposal.”

However, NHPCO recommended that CMS clarify the timeframes for hospice providers that participate in an informal dispute resolution process to resolve questions about condition-level deficiencies.

The industry organization also called on CMS to continue data migration to the agency’s Quality and Certification Oversight Reports (QCOR) website, citing a need to address overdue provider surveys as well as for timely data on deficiencies.

Currently, QCOR reports show that 35.1% of the nation’s 7,152 active Medicare-certified hospices are overdue for a recertification survey. The CMS website shows that “hospice provider and survey information will only be accurate and complete through September 29. 2022,” NHPCO indicated in its comments.

The organization also raised concerns about apparent shortages of personnel qualified to conduct a hospice survey and how this might affect the forthcoming SFP.

Hospices providers and state hospice organizations report that there are multiple surveyor openings in [state agencies], causing delays both in standard surveys and complaint surveys,” NHPCO commented. “The implementation of the hospice SFP will also require additional surveys for those enrolled. We are concerned that there may be a backlog in surveys for SFP, in addition to the ones that already exist for recertification and complaint surveys.”

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