The Centers for Medicare & Medicaid Services is placing new hospices in Arizona, California, Nevada and Texas under enhanced oversight due to growing reports of fraud and abuse.
The enhanced oversight applies to any new hospice, a hospice submitting a change of ownership (CHOW), or a hospice undergoing a 100% ownership change that doesn’t fall under a CHOW, as described in a Medicare Learning Network (MLN) article released Thursday. Enhanced oversight will last anywhere from 30 days to one year and can include prepayment reviews, additional visits for providers not billing, and possible deactivation of the hospice’s provider number, according to the National Hospice and Palliative Care Organization.
The number of Medicare-enrolled hospices — as well as hospice fraud lawsuits — has seen a marked increase in Arizona, California, Nevada and Texas in recent years, which raises concerns of market oversaturation, according to the MLN document.
Meeting with CMS
Separately, NHPCO revealed Thursday it met with CMS this week regarding the ongoing fraud in those four states. Representatives from the National Association of Home Care & Hospice, LeadingAge and National Partnership for Healthcare and Hospice Innovation, as well as Rep. Earl Blumenauer (D-OR) joined the discussion.
CMS disclosed that it is finishing a project to visit all 7,000 hospices across the country to deactivate nonfunctioning or shell hospices, NHPCO shared. It also is conducting a small pilot project with post-payment review of beneficiaries with a stay longer than 90 days. The goal of the review is to target patients who should not have been admitted to hospice at all, covering billing between Jan. 1 and Dec. 31, 2021.
The enhanced oversight in four states is the latest move to crack down on rampant hospice fraud in certain areas of the country. In the recent proposed home health rule for calendar year 2024, CMS outlined a Special Focus Program (SFP) in an attempt to identify “poor performing” hospice providers. It is part of CMS’ 2021 Consolidated Appropriations — or No Surprises — Act, NAHC hospice experts Theresa M. Forster, VP for Hospice Policy & Programs, and Katie Wehri, director of home health & hospice regulatory affairs, explained in a NAHC webinar Thursday.
Quality indicators that CMS will look at include an agency’s Hospice Care Index, its ability to alleviate patients’ pain and symptoms, and its efficiency in providing care. Any complaints against the agency, and patients’ reported willingness to recommend the hospice, will also be taken into account.
When a hospice provider is placed into the SFP, CMS can impose remedies to get them “back on track.” SFP surveys occur every six months, and the process can last up to 18 months in total. Providers have two possible options: graduation or termination, the experts said .
To graduate, a provider must be in full compliance with any two SFP surveys and have no active immediate-jeopardy complaints or CMS citations. If an agency fails any two SFP surveys, or have any pending investigations regarding patient care, they will be terminated from the Medicare program.
For providers placed under SFP, there will be an informal appeal process whereby one can dispute the findings of a survey. However, placement under SFP cannot be disputed, and CMS recommendations must still be followed.