Hospice providers are navigating a minefield in today’s regulatory environment to avoid getting caught up in the mix of fraudulent activity in the space.

The current state of hospice regulations has providers walking compliance tightropes, according to Patrick Harrison, senior director of regulatory and compliance at the National Hospice and Palliative Care Organization (NHPCO).

Fraud, waste and abuse exist in several different industries and health care is no exception. But the majority of hospices are striving to provide quality end-of-life experiences to terminally ill patients and their families, Harrison said at the Hospice News Elevate conference in Washington D.C. Regulators must keep this notion in mind when shaping hospice regulations to avoid limiting and restricting providers’ ability to grow and be innovative in end-of-life care delivery, he stated.

“Program integrity continues to be tragically a problem with hospice,” Harrison told Hospice News. “It’s a concern that continues to tarnish hospice. The fear here is that this may impair, this may challenge beneficiaries and their families’ decision to elect hospice services out of fears of that fraud transpiring. We certainly want to get rid of that. In fact, we want to move away from that fraud so it no longer tarnishes the great work that providers are doing and continue to do serving your patients, serving families and serving your communities.”

Fighting for program integrity

Hospice program integrity concerns have been on the rise as instances of fraud, waste and abuse have cropped up in the industry.

Fraudsters have bilked Medicare for millions, with some cases resulting in criminal charges and even imprisonment. The fraudulent activity has involved the enrollment of ineligible patients, often without their knowledge or consent. In other instances hospice patients did not receive care for billed services, among other violations.

Hospice scams have proliferated in certain states such as Arizona, California, Nevada and Texas. The malfeasance has included a proliferation of new providers without a corresponding increase in the population of eligible patients. In some cases, multiple hospices are operating out of the same address.

The quality of care provided (or complete lack thereof) has been so egregiously poor that patients have suffered at the end of their lives, leaving a wake of complicated grief experiences among their families.

Though increased regulatory oversight in response to the fraudulent activity has been warranted, it has posed some unintended negative consequences for providers and patients alike, according to Pamela Duncan Owens, chief compliance officer at Agape Care, a South Carolina-headquartered hospice and palliative care provider.

Bad actors have made the road to compliance a complicated journey even among legitimate hospice providers, Duncan indicated. One poor quality provider can raise concerns and potentially deter access to much needed increased end-of-life support among terminally ill populations, she said.

“There are a few that would waste resources, that would commit fraud, that would abuse government and payer services and resources,” Duncan told Hospice News at the conference. “There are a few that bill for services not rendered or bill for services that should not have been rendered. That one kernel, right or wrong, [creates] the environment we have. And we [who] clearly aren’t those, we get to the scrutiny in front of that, fair or not.”

Navigating compliance

Calls are growing louder for increased hospice program integrity oversight. Rep. Earl Blumenauer (D-Oregon) is in the process of drafting the Hospice Care, Accountability, Reform and Enforcement (Hospice CARE) Act. The bill will include provisions designed to improve quality and curb fraud in the space, Blumenauer said at Elevate.

Regulators are taking action, including through increased and more diverse auditing activity in recent years. More than half of providers nationwide reported undergoing multiple types of audits annually in a recent nationwide survey of hospice organizations from the NHPCO, LeadingAge, the National Association for Home Care & Hospice (NAHC) and the National Partnership for Healthcare and Hospice Innovation (NPHI).

Additionally, the U.S. Centers for Medicare & Medicaid Services (CMS) in its finalized 2024 hospice rule implemented increased penalties for hospices that fail to comply with quality reporting requirements. Beginning this year, hospices that do not report their performance on quality measures received a 4% payment reduction, a rise from 2% previously.

To improve compliance, hospices need to steer their staff education efforts around the lasting impacts of these regulatory changes on patients and their families, according to Lisa Griffee, vice president of quality and customer experience for Hospice of the Chesapeake. The Maryland-based nonprofit provides hospice and supportive care services across four counties in the state.

Operational and implementation challenges can come alongside changes in quality measures, Griffee said. Ensuring that staff are well-informed and educated on the evolving regulatory changes that impact their roles and quality outcomes is a significant part of both staff satisfaction and compliance,

Accurate documentation is a well-known key to compliance, but instilling awareness of the risks and implementing best practices to avoid them can be a challenging process as quality measures evolve, Griffee

“The argument to make to the front end staff around documentation is not documentation for compliance’s sake,” Griffee told Hospice News. “It’s got to be framed around what’s in it for a patient, what’s in it for the family. What is the big picture? Because a lot of these ideas are birthed for the right reason. [It’s] just that something happens along the way that they get distorted. I find that we get more pick up, that we’re able to connect the dots a little bit better to the frontline users who keep it focused on why it is important.”