Home Health & Hospice Week

CIMO application aims to prevent new hospice ‘flipping.’

The hospice Special Focus Program isn’t the only home health proposed rule provision aiming to boost hospice fraud-fighting.

The Centers for Medicare & Medicaid Services “is also proposing several provider enrollment regulatory changes to prevent and address hospice fraud, waste, and abuse in the future,” it says in its fact sheet about the 2024 rule. “These provider enrollment provisions related to hospice ownership and management will strengthen protections against hospice fraud schemes and improve transparency,” the agency believes.

The proposed hospice enrollment-related regulatory changes include:

• Subjecting hospices to the highest level of provider enrollment application screening, which includes fingerprinting all 5 percent or greater owners of hospices. Initially enrolling hospices would fall into the “high” level of categorical screening and revalidating hospices would be “moderate,” notes consulting firm The Health Group in Morgantown, W.Va.
• Clarifying that the definition of “Managing Employee” in 42 CFR § 424.502 includes the administrator and medical director of a hospice.

CMS also proposes “to expand the scope of § 424.550(b) (1) to include hospice [changes in majority ownership] within its purview.” That regulation “states if an HHA undergoes a change in majority ownership (occasionally referenced as a ‘CIMO’) by sale within 36 months after the effective date of the HHA’s initial enrollment in Medicare or within 36 months after the HHA’s most recent CIMO, the provider agreement and Medicare billing privileges do not convey to the HHA’s new owner,” the rule explains.

That in turn requires the prospective provider/owner of the agency to: “(1) enroll in Medicare as a new (initial) HHA; and (2) obtain a state survey or an accreditation from an approved accreditation organization,” CMS describes.

“We believe that our … concerns about hospices, such as fraud schemes, patient abuse, and improper billing, require the level of scrutiny that a survey can furnish,” CMS says in the home health rule. “Although surveys cannot by themselves entirely halt all of these issues, we are confident that a survey’s thoroughness can greatly assist the vetting of the new owner to help ensure the latter’s commitment to quality care,” the agency says in its CIMO expansion proposal.

CMS includes a long list of hospice fraud cases in the rule, as well as HHS Office of Inspector General fraud findings. Given all of those, “we believe that certain provider enrollment measures are necessary to help address these issues,” CMS insists. “Although not every case of hospice fraud involves or can be attributable to the hospice’s owner, we believe the owner can set the tone for the hospice’s operations as a whole. If, accordingly, an owner has a criminal background involving fraud or patient abuse, this could lead to similar activity within the hospice,” the agency says.

“We believe that the increasing number of fraud cases warrants a revisiting of our original assignment of hospices to the moderate risk category,” CMS concludes. “With our obligation to protect the Trust Funds and vulnerable Medicare beneficiaries, we believe more thorough scrutiny of hospice owners is required,” the rule says.

Watch out: “Changes in ownership will require enhanced planning and meeting increased reporting requirements because of any implementation of the 36-month rule as well as other proposed hospice integrity changes,” The Health Group cautions in its electronic newsletter.