In recent years, unscrupulous hospice providers have cropped up in California and other states. In response, the Centers for Medicare & Medicaid Services has prepared a slew of tools to curtail the fraud. States continue to feel the effects.

As an example, a California hospice operator last week was convicted in a Medicare fraud scheme for billing nearly $3 million for services that patients did not need, according to the Department of Justice. The investigation was a joint effort of the Department of Health and Human Services’ Office of the Inspector General and the Federal Bureau of Investigation.

This case is another sign of CMS ramping up its efforts to shut down hospice fraud, according to Katie Wehri, director of home care and hospice regulatory affairs at the National Association for Home Care & Hospice.

“It’s definitely a product of the extra scrutiny that’s coming from CMS and then getting the DOJ OIG involved,” Wehri said in an interview with McKnight’s Home Care Daily Pulse on Wednesday. “I think that we will see more reports in 2024.”

Stay in tune

CMS has promised enhanced oversight for hospices in Arizona, California, Nevada and Texas to address growing reports of fraud, waste and abuse. And while compliant operators may not be CMS’ intended target for extra scrutiny, the new year may be a good time for all providers to make sure things are ship-shape. 

“I think those providers who are focusing on delivering the Medicare hospice benefit as it was intended and providing high-quality care can expect more inquiries, a little more scrutiny,” Wehri said. “But as long as they’re focused on meeting those conditions of participation, and delivering care as intended under those conditions of participation, I really think they will be OK.”

Sheila Clark, president and chief executive officer of the California Hospice and Palliative Care Association, asserted that CMS and other regulating bodies are likely to widen their surveillance in states subject to enhanced oversight.

“We can and should expect to see continuing scrutiny by the FBI, OIG and Department of Justice for Medicare fraud cases in California and in other states,” Clark said in a statement to McKnight’s Home Care Daily Pulse.”

New enforcement activities

Still, CMS has continued to put pressure on hospice providers. The 2024 Hospice Payment Rate Update Rule included updates to the Hospice Outcomes and Patient Evaluation (HOPE) assessment tool that could provide another way for CMS to catch providers with poor quality of care, according to Wehri.

And on deck is the recently finalized Special Focus Program, which has promised to identify poor-performing hospices and get them back on track with remedies including civil money penalties, directed trainings, suspensions or even termination from the Medicare program. Though the program had been slated to go into effect at the beginning of this year, CMS has since pushed back the start date. The SFP will most likely begin in the fourth quarter 2024, according to Wehri.

The ultimate goal of the SFP, enhanced oversight, HOPE and greater collaboration with other regulating agencies is to catch poor performers and fraudsters — who have no intention of providing high-quality hospice care to people that need it, Wehri noted. However, the question still remains: Will CMS’ actions be enough to stop those bad actors?

“They’re moving to other states,” Wehri said of the hospice criminals. “They’re continuing to migrate and CMS needs to follow that migration and ensure that they’re identifying those providers quickly and terminating them.”

So to prevent hospice fraud from festering and growing in other states, Wehri said regulators must be more diligent in identifying bad actors and nipping them in the bud. 

“CMS needs to refine its oversight activities to be able to better identify the type of provider that presents the greatest concern,” she said.

Editor’s Note: This story was updated to include comment from Sheila Clark, president and chief executive officer of the California Hospice and Palliative Care Association, and to better reflect the amount of money billed in a Medicare fraud scheme.