Hospices lack clarity around how regulators are using artificial intelligence (AI) to improve program integrity.
Hospices need to understand the technology trends that are quickly taking shape in regulation, according to Angelo Spinola, home health, home care and hospice chair at the law firm Polsinelli.
For instance, federal agencies like the FBI, U.S. Centers for Medicare & Medicaid Services (CMS) and the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) have employed AI-driven algorithms to identify fraudulent activity, Spinola said during the law firm’s webinar on Thursday.
“[When] asking the question about whether CMS and OIG are using AI for purposes of detecting fraud, that is absolutely the case,” Spinola told Hospice News in response to a question during the webinar. “Not only is the government using AI, but so are reporters [and] indirect investigators who are identifying things and then reporting those anomalies to be investigated.”
AI regulatory trends
CMS in February proposed the use of a new AI enforcement tool to identify potential instances of fraud, waste and abuse. The Comprehensive Regulations to Uncover Suspicious Healthcare (CRUSH) proposal included in a Request for Information (RFI). The initiative would consider the use of data analytics to track billing claims and enrollment in tandem with law enforcement, among other provisions.
The CRUSH initiative is one example of where regulators may be headed in terms of AI regulatory tools, Spinola said. Hospices need internal compliance mechanisms to stay ahead of the technology curves. Data are key to understanding where the greatest risks exist, such as long hospice stays or repeated recertifications, he stated.
“There’s something called the CRUSH initiative to uncover suspicious healthcare, which is an AI-driven program,” Spinola said. “It’s looking at utilization, any kind of outliers like unusually long stays or anomalies in certifications. Something that you can do as a provider [is] look for those anomalies before the government finds them. In this environment, I highly encourage providers to be looking at those issues.”
Technology is changing the scope of hospice and home health regulation, said Jennifer Sheets, CEO of the National Alliance for Care at Home. Compliance may become more complex as regulators not only use AI tools themselves, but also seek to safeguard utilization in healthcare delivery and operations.
State laws have varied when it comes to oversight of AI, which can impact how hospices use these technologies to improve access and operational efficiency, Sheets indicated. Providers need to consider the diverse local regulations across their geographic service regions alongside evolving federal policy considerations, she said.
“Regulators are trying to modernize oversight of a sector that is itself being transformed by technology and workforce economics,” Sheets said during the webinar. “You’re going to hear more about the evolving patchwork of state and federal AI requirements that now touch nearly every home-based care organization using or considering AI tools. Most states are moving far faster than Congress here. The compliance landscape looks very different depending on where you operate. Whether it’s Medicare or Medicaid program integrity, new regulations or requirements for AI governance, the common denominator is that oversight of this sector is intensifying on every front at once.”
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