Telehealth policies and program integrity concerns represent two of the leading regulatory issues on hospices’ radar this year.

Regulatory changes and increasing oversight were the second-most cited concerns among nearly a quarter (21%) of 112 hospice professionals who participated in this year’s Outlook Survey by Hospice News and Homecare Homebase. Challenges around staffing and improved public awareness also topped the list of providers’ concerns.

This is the third piece of this three-part Hospice News series that explores the significant regulatory challenges facing hospice providers in 2025. Hospices are navigating a sea of obstacles related to new quality measures and potentially fallible regulatory oversight efforts aimed at curbing fraudulent activity, according to Robert Love, executive director of Butte Home Health & Hospice.

“It’s hard to understand why the obvious frauds aren’t being treated more harshly while the quality providers are caught up in unnecessary scrutiny,” Love told Hospice News in an email. “I can appreciate scrutiny, given the bad actors that have entered the industry. The industry is riddled with inferior and profit-motivated hospice owners, and it’s very disturbing.”

Photo by Hospice News

Regulators’ flawed hunts for fraud

Fraudulent operators in the hospice space have misspent millions of Medicare dollars in recent years. The malfeasant activity has included patients being enrolled who are not eligible for hospice, often without their knowledge. Additionally, the fraudulent practice of “license flipping” has also escalated, which has involved hospice operators selling their licenses quickly after obtaining them to avoid regulatory detection.

The severity of these fraud issues has led to significant concerns about the impacts to future payment, access, sustainability and utilization. But identifying quality hospices and illegitimate operators is complex.

Ramped up auditing activities have some hospices contending with operational and financial strains. More than half (52.9%) of hospice providers have reported undergoing multiple audits simultaneously in recent years.

A large issue with the current hospice auditing climate is the lack of consistent enforcement activity, according to Megan Turby Weaver, vice president of compliance, quality and health information management at Gulfside Healthcare Services. The Florida-based nonprofit provides hospice, home health and palliative care. Gulfside has expanded its auditing response team, adding two full-time employees to navigate increased activity.

“We’re seeing audits from all different angles and the auditors are interpreting things very differently across these different audits,” Turby Weaver told Hospice News. “This puts providers in a ‘Catch-22 event’ of not knowing what to expect. Inconsistent interpretation is really what that comes to in the audits as a huge regulatory concern. It’s really putting a lot of strain on providers, even the ones who are doing everything right to be under intense scrutiny.”

An issue that goes “hand in hand” with the auditing concerns is the way in which regulators are addressing hospice program integrity concerns, Turby Weaver said. Legitimate providers have faced rising risks of being looped in with fraudulent actors through a number of ways, including new quality reporting measures as the the Special Focus Program (SFP).

Several stakeholders and providers have expressed concerns related to the SFP program that the U.S. Centers for Medicare & Medicaid Services’ (CMS) finalized in the 2024 home health payment rule. The SFP program is designed to root out poor performing hospices and mandate quality improvement measures. In some cases, the SFP can impose enforcement remedies and additional penalties. Hospices who fail to meet quality requirements can potentially face expulsion from the Medicare program, or increased survey oversight of every six months versus the current three-month cycle.

The Trump Administration suspended the program earlier this year pending a review.

Many in the hospice space see the SFP’s methodology for selecting hospices as deeply flawed, eventually voicing these concerns through legal action. A group of hospice providers and state associations filed a lawsuit in January against the U.S. Department of Health and Human Services (HHS) urging a halt to the SFP’s implementation in 2025.

The SFP’s current design may inadvertently target legitimate hospices trying to improve their outcomes, according to a spokesperson at home health and hospice provider Enhabit Inc. (NYSE: EHAB). CMS’ initial cohort of hospices flagged by the SFP program, released in December 2024, demonstrated the depth of its potential methodology issues, the Enhabit spokesperson said.

Many of the providers the agency identified had good quality scores on the hospice care index and were in compliance with current regulations. With the program suspended, the list of SFP hospices has since been removed from the U.S. Centers for Medicare & Medicaid Services’ (CMS) website.

“We are very disappointed in the current design and implementation of the hospice Special Focus Program,” the Enhabit spokesperson told Hospice News in email. “We have serious concerns about how consumers in these markets will interpret the list and the program. We believe the program needs a reset. We still strongly believe that CMS must be diligent and committed to identifying and exposing fraud and ongoing quality issues from hospice agencies to mitigate harm to patients and families.”

Unknown telehealth impacts

The future shape of telehealth is also an important regulatory topic impacting the outlook of end-of-life care delivery.

Temporary telehealth waivers implemented during the pandemic have had lasting impacts on the ability for hospices to reach patients in rural and remote settings with limited resources. The flexibilities included the ability to conduct face-to-face recertification virtually. Telehealth utilization has since become a key lever in adding more supportive services for patients and their caregivers while also aiding in clinical capacity during a time of prolific staffing shortages.

“It’s seeing how telehealth folds or unfolds for hospice in two ways,” Turby Weaver said. “I see potential impacts on patient care if there’s too much telehealth in hospice, because we do need to be with the patient and see them. But from an access perspective, there can be such a great benefit to telehealth. It’s something we’re all very interested in watching and seeing how far the regulations will go to allow telehealth in hospice.”

The expiration of the telehealth waivers has been adjusted several times. Most recently, a new law extended these waivers to expire September 30, six months after the previously set date. Providers, stakeholders and legislators alike have called for more permanent telehealth implementation.

Hospices are facing a challenging time of uncertainty when it comes to technology utilization in care delivery. Some providers have predicted potentially detrimental and disastrous impacts on patient access with the sunset of the telehealth flexibilities.

“We urge Congress to permanently grant telehealth flexibilities in an effort to modernize the benefit and eliminate regulatory uncertainty,” said the Enhabit spokesperson. “Additionally, we ask CMS and Congress to focus on simple, common-sense updates such as reconsidering certain timeframes related to establishing eligibility. This would allow agencies to better understand a patient’s needs and develop a more appropriate plan of care to support patients and families.”