Hospices’ Compliance Outlook a ‘Balancing Act’

The future outlook of hospice compliance is a mixed bag of uncertainty as program integrity oversight heats up alongside evolutions in telehealth regulation.

Hospices today are facing one of the most challenging regulatory environments that the industry has seen, according to Pamela Duncan Owens, chief compliance officer of Agape Care. A portfolio company of Ridgemont Equity, the South Carolina-based hospice and palliative provider offers care across nine states.

From an influx of technology being leveraged in care delivery to a wide swath of regulatory changes to curb malfeasance in the space, adaptability will be a hospice’s strong suit in compliance in coming years, Duncan stated.


“It’s a balancing act, because we want to be very firm in our grasp on program integrity and all of the processes, policies and systems that support doing the right thing and doing things right,” Duncan told Hospice News at the Elevate conference in Washington D.C. “At the same time, we want to have a hospice that is nimble, flexible, agile and able to adapt to these changes without breaking something. It’s a balancing act of that firm handle on what program integrity is and how that looks at the front line.”

Pamela Duncan Owens Hospice News / Merz Photography
Pamela Duncan Owens, chief compliance officer, Agape Care

Telehealth unknowns

Among the significant changes coming down the hospice regulatory pipeline this year is the expiration of telehealth waivers temporarily implemented during pandemic, which are set to expire by Dec. 31. These flexibilities have allowed hospices to recertify patients via telehealth services.

Hospices need to prepare for the possibility of discontinued telehealth flexibilities and what that could mean for their operational efficiencies, clinical capacity and care delivery approaches, according to Duncan.


“We hope that we’ll be able to continue with these [telehealth] efficiencies that will have better access,” Duncan said. “But we also have to accept that we may not and be prepared for not allowing the discontinuation of these flexibilities to impact care. We have to get ready either way.”

Legislators have recently introduced a bill, the Preserving Telehealth, Hospital and Ambulance Access Act, which proposes to extend the flexibilities through 2026. If enacted, the legislation could allow hospices more time to assess the impacts of telehealth utilization and steer their future care delivery approaches.

Lawmakers for the last several years have brought legislation forward that would make the temporary telehealth waivers permanent. The Creating Opportunities Now for Necessary and Effective Care Technologies (CONNECT) for Health Act was reintroduced last year after making its debut in 2016. The bill has yet to pass.

Navigating the unknowns of telehealth will take careful strategizing, according to Lisa Griffee, vice president of quality and customer experience at Hospice of the Chesapeake. The nonprofit organization provides hospice and palliative/supportive care in four Maryland counties.

Part of preparing for a telehealth sunset involves hospices reallocating their workforce resources to provide in-person recertification visits, which could add further strain to prolific staffing shortages in health care nationwide, Griffee indicated.

“We’ve been ramping up to figure out how to get to that 100% covering recertification visits in person,” Griffee said at the conference. “It’s been a struggle [and] a challenge. From a quality perspective, we’re having lots of conversations about who should get in-person visits [to] come up with our own algorithm.”

Lisa Griffee Hospice News / Merz Photography
Lisa Griffee, vice president of quality and customer experience, Hospice of the Chesapeake

Program integrity, quality, access risks

A large key to the telehealth equation has also been assessing when it’s an appropriate method of care delivery versus not, Griffee added.

Many patients have short lengths of stays and often do not reap the full benefits of hospice care, she stated. This can make telehealth a difficult avenue to assess a patient’s needs, Griffee said.

“I think that with telemedicine, it swung the pendulum way too far, and it got really easy to just do everything from home,” Griffee told Hospice News. “There’s got to be some value to in-person re-evaluation. … We’ve got to figure out what the right balance is. A short length of stay makes that a challenge as well.”

Telehealth has become a large part of increasing access among underserved patient populations, particularly those in rural regions. But the uptick in utilization may be having unintended impacts around quality outcomes.

Concern has mounted as to whether the temporary telehealth waivers have widened doors for fraudulent activity in the hospice space.

A 2022 report from the Office of Inspector General (OIG) identified an estimated $127.7 million of “high risk” telehealth Medicare fee-for-service billing claims during the first year of the pandemic alone. Though a small portion of overall providers who billed for these services, the findings indicate that “targeted and strengthened” oversight measures are needed to curb maleficence in the telehealth realm, the OIG indicated in the report.

A large concern is that telehealth services were billed, but not received by patients and their families.

Hospice advocacy organizations have urged regulators to consider ways to safeguard against telehealth fraud and make these services a more permanent fixture in health care delivery.

Doing away with telehealth flexibilities could pose serious access issues, said Patrick Harrison, senior director of regulatory and compliance at the National Hospice and Palliative Care Organization (NHPCO).

“Absent legislation, that [telehealth] flexibility will end, and we are seriously concerned that it will cause some problems,” Harrison said at the conference. “With hope, if we can’t conduct visits via telehealth looking at rural and highly urban communities, that’s also going to cause problems there. We’ve been very active in [Capitol] Hill addressing that and active with the [U.S. Centers for Medicare & Medicaid Services (CMS)] providing some feedback. We continue to advocate and look forward to continuing that discussion further.”

Patrick Harrison Hospice News / Merz Photography
Patrick Harrison, senior director of regulatory and compliance, NHPCO

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