Home Health & Hospice Week

It’s yet another year where hospices need to pay close attention to the proposed home health payment rule.

Why? The Centers for Medicare & Medicaid Services includes significant hospice provisions regarding the Special Focus Program targeting poor-performing hospices with additional survey scrutiny; Informal Dispute Resolution for condition-level deficiencies on surveys; and a host of tougher enrollment policies (see story, p. 194).

When CMS released its hospice proposed rule back in March, it warned that it was “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.”

“These items in the home health rule are further evidence of steps CMS is taking to address the fraud, waste and abuse concerns that they are seeing in this sector,” stresses consultant Angela Huff with FORVIS in Springfield, Mo.

Hospices have been waiting for SFP details with both eagerness and anxiety for months, since the hospice 2024 proposed payment rule didn’t include the program specifics. The home health rule scheduled for publication in the July 10 Federal Register includes these SFP proposals:

• Targeting criteria. CMS plans to use data from hospice surveys (recertification and complaint); the claims data-based Hospice Care Index Overall Score; and four CAHPS Survey measures “that are most aligned with caregiver experience,” according to the rule fact sheet. The complaint data must be “substantiated” and from the most recent three years, CMS indicates in the rule. The survey data are condition-level deficiencies related to 11 Conditions of Participation identified by CMS as “quality of care”-focused.
• Selection methodology. CMS proposes to rank hospices by aggregated score, with the 10 percent of hospices with the highest scores “considered for participation in the SFP” annually, the agency explains. CMS plans “no stratifi­cation by state or otherwise” and “hospices with [Accreditation Organization] deemed status … placed in the SFP would not retain deemed status and would be placed under CMS or, as needed, [Survey Agency] oversight jurisdiction until completion of the SFP or termination.” Hospices must be “an active provider that has billed at least one claim to Medicare FFS in the last 12 months as captured in iQIES and has data for at least one algorithm indicator” to be included in the ranking.
• Public reporting. CMS plans to report that 10 percent, SFP selections, and current and past SFP status on the CMS SFP webpage at www.cms.gov/medicare/quality-safety-oversight-certification-compliance/hospice-special-focus-program by the end of the first quarter of each calendar year.
• Survey frequency. “While enrolled in the SFP, a hospice should be surveyed ‘not less than once every six months’ over 18 months,” as mandated by law, CMS says in the fact sheet.
• Completion criteria. To graduate from the SFP, hospices must have no condition-level deficiencies for two standard surveys (conducted every six months), and no pending complaint investigations triaged at immediate jeopardy or condition-level, “or have returned to substantial compliance with all requirements, during the 18-month timeframe,” CMS spells out. Hospices that fail those criteria “would be considered for termination from the Medicare program,” CMS indicates. Requiring no CLDs for any two surveys in the 18-month period, rather than just the first two surveys, makes CMS’ proposal more stringent than the recommendation from the Technical Expert Panel CMS convened on the topic, the rule notes.

CMS also proposes an Informal Dispute Resolution process that “would allow hospice providers an opportunity to refute one or more condition-level deficiencies cited in the Statement of Deficiencies survey report, which would align with the established IDR for Home Health Agencies,” according to the fact sheet.

Don’t Underestimate SFP Impact

“The hospice focus program is going to be a very significant issue,” warns attorney Robert Markette Jr. with Hall Render in Indianapolis. “If you talk to anyone in the nursing home industry, the focus program is a major issue,” Markette tells AAPC.

But take note that “although the proposed methodology for the hospice SFP is similar in certain facets to that of nursing homes, the proposed SFP methodology is tailored specifically to the hospice setting and to the data that is available to evaluate hospice performance,” the National Association for Home Care & Hospice points out in its rule analysis.

This rule “should have hospice providers sitting up and taking notice with the Special Focus Program, high-risk screening shift, and flipping prevention approaches lined out here,” Huff cautions.

“Hospices should definitely be paying attention,” reinforces M. Aaron Little, also with FORVIS.

While the SFP program may make hospice providers nervous, one industry representative is welcoming it with open arms.

The National Hospice and Palliative Care Organization “is pleased to see many hospice program integrity issues addressed in the proposed CY 2024 Home Health rule,” NHPCO says in a statement shared with AAPC. “In January, NHPCO and three other national hospice stakeholder organizations provided CMS with 34 recommendations that would address hospice program integrity, fraud and abuse concerns. Many of these recommendations have been incorporated into this proposed rule,” the trade group cheers.

“We believe that, if these proposals become final, we will address many of the concerns identified in California and other states with significant increases in Medicare-certified hospices and rapid changes in ownership,” NHPCO notes.