Home Health & Hospice Week

But look to forthcoming home health rule for Special Focus Program details.

Background: In recent years, everyone from federal watchdog agencies to members of Congress to mainstream news publications have taken the hospice industry and the Centers for Medicare & Medicaid Services to task for a host of fraud problems ranging from poor quality care to financial scams. CMS introduced a plethora of initiatives aimed at combatting the problem in last year’s rulemaking cycle, and continues the job in the latest calendar year 2024 proposed rule.

Case in point: The rule “proposes that physicians who order or certify hospice services for Medicare beneficiaries must be enrolled in Medicare or validly opted-out as a prerequisite for payment for the hospice period of care in question,” CMS explains in a fact sheet about the rule. “CMS is looking closely at the hospice industry, as we have increasing concerns about fraud, waste and abuse in this space. While this rule takes initial steps, this is part of a larger effort by CMS to address hospice fraud, waste and abuse that will continue this year,” CMS warns.

“Over the years we have issued various final rules pertaining to provider enrollment. These rules were intended not only to clarify or strengthen certain components of the enrollment process but also to enable us to take further action against providers and suppliers: (1) engaging (or potentially engaging) in fraudulent or abusive behavior; (2) presenting a risk of harm to Medicare beneficiaries or the Medicare Trust Funds; or (3) that are otherwise unqualified to furnish Medicare services or items,” CMS explains in the rule. Requiring ordering physicians to enroll in the Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) would facilitate that ability.

Plus: “Many hospice certifying physicians are already enrolled in Medicare or have validly opted-out, meaning that they need take no action should our proposal be finalized, thus further reducing the burden on the hospice physician community,” CMS adds.

“This requirement would apply for all hospice certifi­cations,” the National Association for Home Care & Hospice explains in its rule analysis. That means “the patient’s designated attending physician, if any, and the hospice medical director or physician member of the interdisciplinary group (IDG) completing the initial hospice certification as well as the hospice medical director or physician member of the IDG completing any recertifications would need to be enrolled or be validly opted-out.”

The change would cause a 1,087-hour burden at a cost of $241,966, CMS estimates.

The rule includes a laundry list of fraud cases featuring shady physicians to bolster its proposal.

For example: “Two certifying physicians from a California hospice were convicted of health care fraud for falsely certifying beneficiaries as terminally ill,” the rule recounts. “The scheme involved illegal payments to patient recruiters for bringing in beneficiaries, establishing fraudulent diagnoses, and altering medical records,” CMS indicates.

But “we seek comment on this proposal,” CMS offers.

“With hospices being in the spotlight of late, it is not a surprise that CMS would make this enrollment proposal,” NAHC observes. And CMS has said “this proposal is likely one of additional future actions on program integrity in the hospice benefit,” the trade group points out.

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