More targeted efforts are needed to combat hospice fraud and preserve program integrity, according to Denis Fleming, Jr., the newly installed chief government affairs officer for the National Alliance for Care at Home.
Fleming previously served in the halls of government at the state and federal levels, including time as a congressional staffer, general counsel to a government and a chief deputy state attorney general. He has represented hospices while working at private law firms.
The Alliance is the nation’s largest organization representing providers who offer care in the home.
Hospice News sat down with Fleming to discuss the Alliance’s top policy priorities, the 2027 final hospice rule and efforts to bolster hospice and home health program integrity.
What are your top priorities as you come into this new role?
There are three of them. One of them is program integrity. I think the other, which underlies all of the three of them, is ensuring better access to care – hospice care, home health and all of our service lines for patients and families.
Workforce is important. And workforce and access are a function of rate and payment rate. For example, in hospice this year, we were fortunate to get an increase. It was 2.3%. But there are some other aspects of that [U.S. Centers for Medicare and Medicaid Services’ (CMS) 2027 final hospice rule] that we’re focusing on and have various work streams to try to leverage our contacts in Congress and with CMS to try to improve some of the aspects of that rule.
One of them is the market basket at 2.3%. We don’t believe that’s keeping up with inflation. Now, everybody put a lot of data behind that to try to demonstrate that it was inadequate, and it was moderately changed. But we still think it’s below the inflation rate.
We’re concerned about the moratoria [on home health and hospice enrollment in Medicare]. That’s sort of a near-term priority that we’re trying to focus on, and some other aspects of the rule like the [Service & Spending Variation Index (SSVI)].
We were encouraged by the palliative care-embedded [Request for Information (RFI)]. We all responded vigorously to that, and that was also a part of the proposed home health rule. Palliative care has long been an area of interest and emphasis, an important part of the care continuum, and to the extent we could ever position ourselves with hospice and home health to have a separate benefit for palliative care, we think it would be very helpful to patients and families.
Speaking of the moratoria, we’re several months in. How is that affecting providers to date?
We’re concerned about it. It can put a chill on access for patients and families to hospice care. It can also stop business development, and it can restrict the ability to provide services all over the country.
There are two aspects of it. One, we think it’s a blunt instrument. It’s overly broad. It’s you know taking a hammer when maybe a scalpel could be more appropriate.
We favor more targeted efforts on program integrity. For example, that’s embedded in some of the legislation that we’re seeing out there that’s been proposed. [Rep. Beth Van Dyne’s (R-Texas)] bill, for example, has a much more targeted approach that we favor.
When you look back on the moratorium, the history of them for home health and hospice, there were several of them that began in 2013. I can recall they would be targeted geographic areas that would be subject to moratorium, and they’d be limited to six months. Now several times they were extended, but ultimately it was lifted. This is the first time we’ve ever seen a nationwide moratorium put on home health and hospice.
It chills access and business development, and that can be an even worse scenario potentially in rural areas of the country where there are fewer providers and patients are often harder to reach. We favor a much more targeted approach and more efforts perhaps on the front end in terms of enrollment.
Do you have any reason to believe at this point that the moratorium would be extended?
We have indicated our concern about that. A number of our members have expressed concern about it, and have raised it in their interactions with CMS. Historically, they’ve extended mortoria for six-month periods of time, but that was when they had targeted moratoria.
We don’t have any particular tea leaves at this point as to whether it will be extended or in what fashion, and we’re making every effort we can to highlight the concerns of an extension, which may only grow over time. The more that remains in place, the more access remains constrained, and there continue to be unmet needs.
You mentioned program integrity as a priority. What more needs to happen when it comes to combating hospice fraud?
The best prescription to combat fraud is to actually go after the bad actors, to go after those that are at extreme risk of committing fraud, or that are attempting to establish services already in geographic areas where fraud has been demonstrated to occur.
Fraud, remember, requires some intentional act. Folks that are bad actors, that don’t necessarily have the best interest of the patient in mind, and there are just extreme examples of bad actors that have been prosecuted. I think rather than go at it in a broad-based approach, which can capture and affect good providers that are often rendering services where there is unmet need, it needs to be more targeted.
Now, the Van Dyne legislation does that in large measure. It has some robust accreditation provisions, background checks and safeguards on enrollment procedures on the front end to make sure the providers are interested in patient care and end-of-life care. We favor that sort of targeted approach, and hope that legislation continues to get some consideration in the coming months. It was only recently filed, but we think that’s a good approach.
What should hospices be thinking about as they prepare to implement new requirements from the 2027 final rule?
One of them is SSVI. That is an area of great concern. We have a workstream where we’re trying to put some data behind that to highlight how that has the risk of portraying inaccurately quality and utilization.
One aspect of that is the consideration of the non-hospice-related spend, which is completely extraneous to the control of the hospice agencies. And 63% of those claims, as has been demonstrated, are related to skin substitutes and non-hospice-related matters that weigh down on the spend figure.
There’s also no adjustment to recognize the difference in census and the size of hospices, so that the larger the spend, it gets unfairly tainted as indicating overutilization when that isn’t necessarily the case. So we’re worried about that, and we’re worried about the absence of any due process or the opportunity to challenge the findings of the post under SSVI.
Historically, whenever you have an administrative action that portrays you perhaps in a way that you may not think is accurate on utilization and spend, you would have an opportunity to submit some additional data. We would like to see that addressed going forward, and, ultimately, see SSVI completely revisited.
Companies featured in this article:
