‘Work to Be Done’ in Shaping Hospice Quality, Program Integrity

While many in the hospice space agree that evolution is needed to help ensure quality end-of-life care outcomes, conflicting views swirl around how regulatory requirements and associated processes could get us there.

Regulators and hospice providers share a common goal of ensuring quality end-of-life care experiences. But points diverge when it comes to molding the regulatory path toward hospice program integrity.

Changes in hospice regulation have been long overdue, but the ways providers and regulators try to strike a balance between quality and oversight have room for improvement, according to Mollie Gurian, vice president of home-based and HCBS policy at LeadingAge, a senior advocacy group.


“It’s come more to the national forefront from a combination of bad actors coming to light,” Gurian told Hospice News at the ELEVATE conference in Chicago. “It’s using that to draw attention to how policy needs to be nuanced. [The U.S. Centers for Medicare & Medicaid Services (CMS)] has taken a number of actions, ranging from additional audits to cracking down on providers in certain states, especially newly enrolled providers. But there’s more work to be done around how we differentiate between program integrity efforts going after those truly bad actors versus trying to improve the quality of the industry as a whole.”

Mollie Gurian Hospice News / RoboToaster
Mollie Gurian, vice president of home-based and HCBS policy at LeadingAge. (Hospice News photo)

Regulators have heated up program integrity efforts in the hospice space in recent years as concerns around quality, safety risks, fraud and profiteering have come to the forefront.

Program integrity issues have pointed toward a proliferation of new hospices in certain states such as Arizona, California, Nevada and Texas. A large portion of these companies were set up with the purpose of selling the license at a profit. Some instances have also included hundreds of hospices operating out of the same address without a corresponding rise in eligible patient volumes.


Other program integrity concerns have included those related to fraud, waste and abuse, including anti-kickback schemes in which providers collect hospice reimbursement dollars without providing patients with end-of-life care.

Hospice program integrity changes have included heightened oversight aimed at addressing these concerns. 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.

Hospices hold valuable pieces when it comes to helping regulators weed out maleficent operators, according to Marian Grant, senior regulatory advisor at the Coalition to Transform Advanced Care (C-TAC).

The significant changes needed in hospice regulation will take time and effort to formulate, she stated.

“We’re all trying to figure out how we fix what is the battleship at a time of great scrutiny,” Grant told Hospice News at the conference. “But [it’s] part of an enormous bureaucracy, and it is not easy to quickly change anything. [Regulators] have to be very circumspect in the unintended consequences. They are very aware, the question is, can we help them make good decisions going forward? It’s helping them to clarify things. We don’t want to go after the people who are providing good care to folks who are ultimately going to die. We want to be able to figure out how we get the right patients into hospice and help them for as long as we can.”

Marian Grant Hospice News / RoboToaster
Marian Grant, senior regulatory advisor at the Coalition to Transform Advanced Care. (Hospice News photo)

In addition to program integrity oversight shifts, CMS has also increased auditing activity, revamped survey processes and made changes to auditing efforts and quality reporting requirements in recent years.

One significant change in the 2024 final rule was the CMS’ decision to increase penalties for hospices that do not report data to the Hospice Quality Reporting Program (HQRP). Going forward, those providers will face a 4% payment reduction, up from 2%, the agency stipulated in the rule.

Quality concerns bubbling up in the space have included findings of a 2019 report from the U.S. Department of Health & Human Services (HHS) Office of the Inspector General (OIG) that showed 20% of hospices nationwide had condition-level deficiencies that posed serious risks to patient life and safety.

The other side of that proverbial coin is that the large bulk of hospice, 80%, did not have serious safety deficiencies.

Some hospices may be getting lost in the mix as the regulatory environment shifts around quality requirements and program integrity oversight, according to Gurian.

A key need in regulatory changes is finding tools that balance appropriate repercussions while allowing ways to grow toward improved quality, she stated.

“The regulatory environment that has come to a head this year has really been a long-time coming,” Gurian said. “The goal is great care for beneficiaries [but] we want to get to a place where all the oars are rowing in the same direction. It’s using this opportunity when there’s a lot of lenses on hospice to say, ‘How can we get to a place where all the oversight tools are working together and working to get us a program that’s really promoting high quality and pushing those that aren’t interested in that goal out of the game?’”

Hospice providers have employed a slew of tactics, including ramped up internal reviews, expanded documentation processes and increasing staff training, among others. These efforts can take both financial and operational resources as hospices invest in additional staffing, technologies and processes.

Thriving in an evolving regulatory environment has required hospices to take a deeper look into how they operate and what areas may require additional attention, Agape Care CEO Troy Yarborough stated.

“We have to be mindful of what’s going on and less reactive, more proactive in how you look at your business, how you structure your investments in terms of your compliance team and what you challenge them to go inspect,” Yarborough said at ELEVATE. “You have to be the look-in-the-mirror type personality that says, ‘We’re good at this, but we’re not good at that.’ And this is definitely something that we need to improve upon, lest we run into an issue with an audit.”

Hospice News / RoboToaster
Troy Yarborough, CEO, Agape Care. (Hospice News photo)

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