Today’s hospice landscape is reaching a pivotal point of evolutionary growth that has come with increased oversight as regulators seek to curb fraudulent activity in the space, according to Bill Dombi, senior counsel for the law firm Arnall Golden Gregory (AGG).

Dombi also recently joined New Day Healthcare LLC’s board of advisors. He previously served as president of the National Association for Home Care & Hospice (NAHC) prior to its affiliation with the National Hospice and Palliative Care Organization (NHPCO) in 2023 and was heavily involved in the establishment of the Medicare Hospice Benefit. He has supported leadership of the combined organization, the National Alliance for Care at Home, throughout its integration process. 

Navigating the scope of hospice-related regulatory challenges and legal concerns on the horizon will take a “back to basics” approach to compliance, Dombi told Hospice News.

What are some of your main goals in the new roles you’ve stepped into recently?

When I looked at what interested and excited me, it was a wide range of things within the community that I’ve been working in for many, many years — health care services at home. I looked at the kinds of things that would get me up in the morning and not really necessarily keep me up at night all the time.

I’ve been practicing law for about 47 years, and it was something I thought would be a part of what I wanted to do. But I also wanted to be involved in the home care community in a much larger sense.

I took on a primary role of advocacy throughout my career in multiple forms, be it in Congress or in courts or at the regulatory bodies. I wanted to try to stick with something along those lines. But I also honestly wanted to know more about what it takes to be successful in providing high quality care at home.

It was a combination of my roles at the AGG law firm, which gave me that opportunity to be on the advocacy side, and with New Day, which gave me the opportunity to to really learn more about the day-to-day operations of a health care provider. And then, of course, there’s that little sideline of staying involved with the Alliance and supporting it. So, I kind of ended up with a positive trifecta.

What are the leading legal concerns facing hospice providers right now?

Hospice has been a very vibrant part of the health care world for quite a while now, but I think its energy levels are at an all-time high right now. And that’s energy levels in terms of not just public awareness and utilization of the services, but also the gained respect of recognizing that hospice is not a cottage industry anymore. Some people might label it as growing pains. I call it more of an evolution that naturally seems to occur in any field and in any organization.

That evolution has raised questions about what we need to do to have a positive next generation in end-of-life health care. Looking around, you see the same kinds of forces in play in hospice that we’ve seen in other health care sectors in terms of massive amounts of growth and changes in the tax status of the providers of services, which does change the cultural makeup of the whole hospice community.

Those growing pains often have all sorts of positives, but whether you like it or not, some negatives always seem to surface that bring the attention of regulators and oversight bodies. So, I think a lot of what you see going on in hospice that’s on the positive side has a bit of a balance with some of those questions that are coming up on quality of care.

The Special Focus Program (SFP) has been among the reactions to the issues of outright fraud, not just abuse, of the hospice program by some providers who are recent to the world. It feels like deja vu, because in other areas like home health we saw the same things happen. In a cycle of growth comes these other kinds of things. When we’re looking at the near-term future for home health, the words I offer to anybody are increased oversight.

It’s a yin and yang of those things that keep hospices up at night and also wake them up in the morning. It’s seeing the promise of hospice care being realized, and seeing the greater focus on an expansion in the definition of palliative services as being exciting, positive things coming about.

You mentioned the hospice Special Focus Program, what are your thoughts on the SFP lawsuit filed by industry stakeholders, and the U.S. Centers for Medicare & Medicaid Services’ recent response to delay the program’s implementation? Why is this an important issue to bring up, and what are the goals of the SFP program?

It’s important to first set the table that the Special Focus Program is not unique to hospice. At the same time, the concept of bringing special, targeted focus on quality of care oversight into hospice actually was advocated for and by the hospice community. This was not thrust upon the community. It was what might have been considered as a first-line action that should occur to ensure quality of care. It’s devoting resources to going after bad performers. Nursing homes have had this, home health has had it as well, but maybe it didn’t all have the same name.

At the same time as the advancement, there was a big part of that focus that was a targeted kind of effort, because there are limited resources to do oversight. Perhaps it might come with unnecessary oversight of the greatest high performers in the field, which can take caregivers away from caregiving. What we saw happen in the implementation of the SFP concept is that the program started defining itself as sort of mis-targeting. This then created under those very delicate circumstances a waste of precious oversight resources.

Some contend that they’re just really trying to get rid of the SFP, which isn’t the case. It’s trying to use those oversight resources as efficiently and effectively as possible. These are fairly new experiences for hospice to be at this higher level of advocacy needs, because for years people on the oversight side of things just kind of let hospice move along. But it’s grown up as a $25 billion service, and there’s been some good steps taken to minimize the fraud that’s happening.

I think what we’ve got now with the Special Focus Program is trying to get that oversight back on the right track, but the proof will be in what we ultimately see coming out of the new administration as to how this program will work. This administration came in blind to the need to bring things back to a new discussion. The last administration started realizing that this program wasn’t going to work. So, it’s fortuitous that a new administration has come in, because that has created an increased opportunity to go back to the drawing board.

What are the main red flags that can land a hospice in “legal hot water,” and how can they avoid these risks?

It’s about going back to the basics. What we have found not just in hospice, but also in home health is that too many people don’t go back to the basics and read what the rules and the regulations are to understand that sometimes there’s issues in what gets passed down from one generation of staff to another.

It gets changed so much, and so they develop an understanding of what they think is a compliance standard when it isn’t necessarily a compliance standard. And that’s often because they are not reading from the rule book. I think people should start from those basics and understand the conditions of participation.

There’s also three things that really are necessary.

One of them is self-auditing efforts. Instead of waiting for a surveyor to knock on your door with a complaint, do your own internal analysis. That takes resources to do, but the return on investment is strong.

The second thing is as basic as can be: If you’re not documenting things correctly, it will be understood incorrectly. So, documentation has always been for purposes of coverage, for other compliance matters, but also an essential thing for quality of care.

The third thing is management. It’s about listening to what your staff is telling you and understanding the complications they’re trying to communicate. Some staff are not communicative at all, and that silence allows leaders to take a better look at things themselves. See what’s going on with the patients [and] stay connected with the team overall on that care. Those are the three basics that come to mind when looking at the issues confronting hospices.