NPHI Calls for Revisions to Proposed Hospice SFP, Home Health Rule Provisions

The U.S. Centers for Medicare & Medicaid Services (CMS) should clarify timeframes associated with a proposed informal dispute resolution process for hospice providers and retool aspects of the agency’s forthcoming Special Focus Program, according to an industry group representing nonprofits.

The National Partnership for Hospice and Healthcare Innovation (NPHI) has issued public comments on CMS’ 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.

The rule, if made final as written, would also implement an informal dispute resolution process to resolve questions about condition-level deficiencies.


“NPHI supports the proposed process to allow a hospice with a Condition-Level Survey finding to resolve disputes related to the findings informally and allow for continued participation in the Medicare program. This will save time and financial resources for all parties involved as noted by CMS,” the organization indicated in a letter to CMS. “However, NPHI requests that there be a defined timeframe implemented for CMS, the Survey Agency (SA), or the Accrediting Organization (AO) to review the IDR and render a decision.”

The hospice advocacy group recommended a 14-day timeframe so that any enforcement actions by CMS, state governments or accreditation organizations can be halted if the deficiency is determined to be unfounded. 

NPHI further noted that regulators’ responses to immediate jeopardy situations should not be delayed due to this proposed timeframe. 


The group is a collaborative of more than 100 nonprofit, community-based hospice and palliative care providers from 37 states and the District of Columbia.

NPHI also raised questions about the algorithm that CMS would use to select hospices for its new SFP, which is set for a 2024 implementation.

The SFP was among the requirements established by the Consolidated Appropriations Act of 2021. Congress included the language in response to July 2019 reports on hospice quality from the Office of the Inspector General (OIG) at the U.S. Department of Health and Human Services (HHS). CMS expects that implementation of these proposals would cost an estimated $5.5 million annually.

The agency initially pitched the idea in 2022, but instead convened a Technical Expert Panel (TEP) to further guide the development process. The agency wants to move ahead with it in 2024.

One major concern is that Consumer Assessment of Healthcare Providers and Systems (CAHPS) survey results can be skewed for organizations that serve a relatively small patient population.

“Our primary apprehension with the proposed hospice SFP concerns the factors included in the algorithm used to identify and select hospices for eligibility,” NPHI wrote in the letter. “CMS proposes to use survey data, both standard and complaint, along with CAHPS and Hospice Care Index (HCI) data to determine eligible hospices for the SFP. We have concerns that many hospices will not be included in the calculation and that hospices that have large average daily censuses (ADC) will be disproportionately and unfairly categorized as poor performers merely due to their size.”

These data are also used to determine star ratings on the CMS Care Compare website, which is increasingly used by families, payers and referral partners when they are choosing a hospice. When a hospice has a small patient census, mathematically, one “bad review” can significantly affect the results that get reported.

Providers with a patient census lower than 50 can request an exemption from the CAHPS survey requirement. While they are not officially penalized for this by CMS, the end result is that they have no star rating. Within the SFP, small providers could face a similar situation, NPHI contends.

“Given the ongoing program integrity and quality challenges facing the hospice community and the preponderance of those concerns among hospices that disproportionately do not report CAHPS data, it is especially alarming that the algorithm weights said data so heavily,” NHPI indicated in its letter to CMS.

The organization also weighed in on the proposed “36-month rule.” This 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.

NPHI expressed support for the rule as a concept, as well as proposed exceptions, but recommended some tweaks to its structure.

CMS has posited four possible exceptions:

  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.

“This rule will carry more weight if the new hospice is concurrently required to maintain an active census during that time period allowing for the ongoing monitoring of hospice care provided,” NPHI wrote. “We also support the inclusion of hospice in the existing exceptions allowed for home health providers.”

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