Home Health & Hospice Week

Many new PI efforts are homing in on the wrong providers, attorney argues.

“One of the most frustrating aspects of recent negative reports around hospice is that they fail to acknowledge the amazing work that most hospices do on a day-to-day basis, as well as the significant efforts that have been undertaken by representatives of hospices over recent years to press for reforms,” Forster relates. That includes “the work the trade associations did with CMS and Congress in development of the HOSPICE Act and more recently to strengthen program integrity efforts,” she highlights.

Some of the measures CMS has implemented are not going to help prevent much fraud, but will cause big headaches for providers, Markette argues. For example, “the 36-month rule has been in place for home health for many years now,” he illustrates. “I don’t know that I have seen any data showing it decreased fraud. It has caused some headaches for legitimate transactions amongst honest providers,” however, he points out.

As far as the medical review pilot project, “I have always been skeptical of pre-claim review as an effective anti-fraud tool, because fraudulent providers always have good documentation,” Markette tells AAPC. “It’s easy to comply with the rules when you just prepare it all and don’t have to worry about physicians, staff, etc.,” he explains.

“Don’t get me wrong, I agree that criminals are coming into hospice and causing all sorts or problems,” Markette avers. “These people need to be prosecuted and thrown into jail,” he stresses.

“I just get tired of CMS acting like the whole industry is bad and penalizing everyone, when the vast majority of hospices are operated by compassionate caring individuals who want nothing more than to provide care to the dying and their families,” Markette continues. “These folks spend countless hours jumping over all of the hurdles CMS puts in their way, because of their relentless commitment to their patients.”

Bottom line: “We need to find ways to prosecute the law breakers to the fullest extent of the law, without adding additional compliance burdens onto providers who are already dealing with numerous regulatory burdens” ranging from certifications of terminal illness to notices of election to surveys, Markette asserts.

Infighting Muddies The Waters

Hospices may feel like they are bowing low under the additional compliance pressure they are under, but one expert says they need to take some responsibility for the fraud and abuse problems that have led to high-profile mainstream press headlines critical of the industry.

In an opinion letter published on Aug. 22 by the Boston Globe-affiliated STAT news outlet, Ira Byock, a past president of the American Academy of Hospice and Palliative Medicine, criticizes “national groups, including [AAHPM] and the National Hospice and Palliative Care Organization (NHPCO),” who “at first complained about being unfairly treated by the press” when critical stories came out. “They notably avoided admitting any responsibility for this long-brewing crisis,” Byock accuses.

“By the early 2000s, clinicians and administrators in the field all knew that the quest for margins over mission was taking a toll on the quality of hospice care,” Byock recalls in the letter. “Worrisome trends were evident in Medicare utilization and program survey data, coinciding with the rise in publicly traded, investor-owned hospice companies. Most of us didn’t need data to know that things were amiss.”

Although Byock refers to himself as a “reluctant public critic,” he claims that “as the field succeeded, [national associations] became shackled by the investor-owned hospice companies that hold seats on their boards of directors and sponsor projects and conferences. Corporate influences have led to tepid responses to scathing federal and state government reports. Consistently missing are any expressions of respon­sibility or commitments to set standards and monitor the quality of hospice programs.”

Byock lists a number of ways to rectify the problem, including “national hospice associations and their for-profit provider members acknowledg[ing] their part in tolerating shoddy business and clinical practices.”

NHPCO and NAHC didn’t respond to requests for comments on Byock’s letter by HHHW’s press time. But they have addressed the larger program integrity issue in other statements.

“Hospice has come under increasing fire over recent years, initially from reports about hospices that perform poorly on health and safety standards and endanger vulnerable patients, and more recently with respect to dramatic growth in the number of hospice providers in some western states that have raised program integrity concerns,” NAHC President William Dombi says in an Aug. 23 member newsletter article about the CMS blog post. “All concerned have a part to play in addressing these concerns. In response to health and safety concerns, the national hospice associations played a significant role in development and passage of the HOSPICE Act, which contained numerous reforms to the hospice survey process that are currently being implemented,” Dombi offers.

“Earlier this year the same associations concluded a year-long effort to develop a series of program integrity recommendations that were submitted to [CMS] and to key members of Congress for their consideration,” Dombi continues. “We believe unified efforts of this kind are rare if not unique, and demonstrate a deep commitment to protecting hospice patients and families and the mission and integrity of the hospice program.”

In a July release outlining which of the trade group PI recommendations CMS had acted on thus far, NHPCO noted that “for high-quality hospice to continue to exist, hospice care needs to stay true to its core value. In protecting those values, the hospice national stakeholder groups must work together to weed out any bad actors and support the delivery of the highest quality of care.”