The forthcoming Hospice Care Accountability, Reform and Enforcement (Hospice CARE) Act from U.S. Rep. Earl Blumenaur (D-Oregon), if enacted, would implement a number of changes to medical review processes.

Blumenauer announced the bill in June at the Hospice News Elevate conference in Washington D.C. Though the bill language is still in development, it will likely contain proposed updates to payment mechanisms for high-acuity palliative services, changes to the per-diem payment process and actions to improve quality and combat fraud.

The bill would also implement a temporary, national moratorium on the enrollment of new hospices into Medicare, to help stem the tide of fraudulent activities among recently established providers concentrated primarily in California, Arizona, Texas and Nevada.

‘There’s evidence that people who take advantage of hospice care delivered properly, actually have a higher quality of life. Oftentimes, they live longer,” Blumenauer said at Elevate. “This is an opportunity to do something in this Congress that is concrete, specific, that will save money and improve the quality of care for some of our most vulnerable people.”

Among the anticipated provisions of the bill would be an item requiring the U.S. Centers for Medicare & Medicaid Services (CMS) to use documentation in a patient’s medical record as supporting material. The documentation would include the reasons that an attending physician certified a patient for hospice and establish a six-month terminal prognosis.

The legislation would also alter current rules for medical reviews that go beyond certain thresholds for patient length of stay.

Current regulations require CMS to conduct a medical review for hospice care provided to an individual for more than 180 days when the provider has a certain percentage of patients that have stays that exceed that length. If the bill is enacted as written, this review would occur for stays longer than 90 days or when the provider reached a certain percentage of patients who were discharged alive.

The bill would also establish prepayment reviews for care that is deemed unrelated to the patient’s terminal condition.

“[The legislation] requires the secretary [of Health and Human Services] to conduct prepayment reviews for any claims submitted by providers and suppliers (not the hospice) that indicate that such claim is for an item or service unrelated to the terminal condition with respect to which a diagnosis of terminal illness has been made,” a discussion draft of the bill indicated. “Hospice is a holistic, comprehensive benefit and it should be rare for an item or service to be unrelated to the patient’s terminal condition.”

In fiscal year 2023, over $1.2 billion was paid to providers and suppliers for items and services provided during a patient’s hospice election that were identified as unrelated, according to the discussion draft.

The bill’s provisions include additional funding for the U.S. Department of Health and Human Services (HHS) to conduct these reviews.

In addition, the legislation would require staff from Medicare Administrative Contractors (MACs) who perform medical review of hospice care to receive specialized training in the philosophy that underlies those services, as well as education about determining prognosis, beginning in 2027.

HHS would also be required to submit a report to Congress on all hospice medical review activities that take place between Jan. 1, 2019 and Dec. 31, 2024, including the total number of claims reviewed, the percentage of claims denied that were appealed, the percentage of appealed claims overturned on appeal and a list of hospice medical review projects undertaken by contractors.

This report would also list actions that HHS plans to take to reduce the audit burden on hospices and minimize the number of overturned claims denials.

In recent years Blumenauer has emerged as a champion for hospice policy and reform. The Portland, Oregon native was first elected to Congress 27 years ago and later gained a seat on the influential Ways and Means Committee in the U.S. House of Representatives. Since then, he has sponsored a number of bills designed to improve the quality of hospice care as well as combat fraud in the space.

He announced late last year that he will not seek re-election to Congress in 2024.

This week, the Congress member received an award from the end-of-life care advocacy group Compassion & Choices recognizing his work in the space during his 30-year tenure in hospice.

“Congressman Blumenauer has been at the forefront of ensuring that people from all walks of life receive improved access to high-quality patient-directed end-of-life care, ” said Compassion & Choices President and CEO Kim Callinan, in a statement. “On behalf of the 570,000 volunteers, supporters, donors, and staff of Compassionate & Choices, we express our sincerest gratitude for his leadership and work to improve end-of-life care in the United States.”