Home Health & Hospice Week

Aggressive audits naturally reduce care, experts point out.

In its proposed hospice payment rule for 2024, Medicare singles out hospices that don’t furnish upper-level care as potentially shady. But officials may not be considering the whole picture.

Recap: In the rule published in the April 4 Federal Register, the Centers for Medicare & Medicaid Services highlights some historical statistics for provision of Continuous Home Care, Inpatient Respite Care, and General Inpatient Care, noting that the percentage of Routine Home Care days is going up while the utilization of CHC and GIP is falling (see HHHW by AAPC, Vol. XXXII, No. 15). In fiscal year 2022, 98.8 percent of hospice days were for RHC, 0.1 percent for CHC, 0.3 percent for IRC, and 0.9 percent for GIP. That compares to 97.5 percent, 0.4 percent, 0.3 percent, and 1.8 percent, respectively, in FY 2013.

And “despite rebasing payment rates for the higher levels of care [in 2020], there still remains a high percentage of hospices that provide little to no CHC, IRC, or GIP,” CMS says.

“Hospices that are unable, or unwilling, to provide higher levels of care such as CHC and GIP may not adequately be able to care for patients who are in crisis or have symptoms that cannot be managed in the home, resulting in a worse outcome for the patient,” CMS charges in the rule. “Furthermore, not providing those levels of care, and also not providing IRC, places a greater burden on caregivers which may worsen the quality of care at the end of life.”

As usual, CMS levels some charges at for-profit hospices. “We find that for-profit hospices make up 71.6 percent of hospices from FY 2019 through FY 2022, and that for-profit hospices make up 82.9 percent of the hospices that do not provide GIP in a given FY and 84.3 percent of the hospices that do not provide IRC in a given FY,” the rule says. “Conversely, for-profit hospices make up 68.5 percent of the hospices that provide CHC in a given FY, indicating for-profit hospices are more likely to provide CHC compared to other ownership types.”

Don’t Underestimate Pandemic’s Impact, Expert Says

While CMS implies hospices providing small or no amounts of higher levels of care are furnishing poor quality services, that broad implication is unfounded, experts maintain.

“CMS’s analysis seems to assume that hospices should be providing hospice at higher levels of care … but never explains the basis for that assumption,” contends attorney Matt Wolfe with Baker Donelson in Raleigh, North Carolina. “The hospice population is not homogeneous. The way in which hospice is accessed and utilized is also highly variable,” Wolfe stresses.

And “the data with IRC and GIP may fail to account for the pandemic,” suspects attorney Robert Markette Jr. with Hall Render in Indianapolis. “It became very hard to admit hospice patients into facilities during the pandemic,” Markette points out.

“I also know that a number of SNFs will refuse to enter into open-ended IRC/GIP inpatient agreements,” Markette adds. “This forces hospices to negotiate these agreements as needed.” While “CMS has expressed that a patient-by-patient approach is improper, [it] does not put any pressure on the SNFs to change,” he criticizes.

Result: “When a hospice is forced to enter into an agreement each time a patient needs the GIP or IRC service, it can result in the issue resolving before the agreement is signed,” Markette explains. “Remember, GIP and IRC are both short-term benefits.”

Workforce woes affecting all of healthcare may be contributing to the data as well, Markette adds. “It would interesting to assess if staffing shortages are impacting the use of CHC, because hospices cannot provide the staffing during the period,” he tells AAPC.

CMS also seems to ignore more financially driven reasons that it often creates or exacerbates itself, the experts agree.

“No one should be surprised to see declining inpatient and continuous care,” believes attorney Brian Daucher with law firm Sheppard Mullin in Costa Mesa, California. “Auditors are shameless in downcoding these services,” Daucher blasts. “So a hospice will be stuck paying for these services … with no upside,” he says.

“There have been significant regulatory efforts to shift hospice away from the higher levels of care, so the utilization patterns are not surprising,” Wolfe agrees.

“No one wants to be on the radar,” Markette says. “In the past, the [HHS Office of Inspector General] and CMS have expressed concerns CHC has been abused,” he notes.

CHC in particular has exacting rules, Markette notes. “CHC has specific requirements, including amount of service provided during the period,” he explains.

“Also, inpatient care eats away at the hospice cap,” Daucher points out. “If Medicare wanted to promote more utilization, it should rein in its auditors and exclude all dollars above routine payment levels from cap calculations,” he exhorts.

Bottom line: “The volume numbers, without data on staffing and patient conditions, is hard to interpret,” Markette argues. “This is a trend, but the trend cannot tell us why it occurred. That requires looking into some of the issues.”

In general, “for us to draw any conclusions on whether there are issues or changes that need to be made, the analysis needs to be more granular,” Wolfe maintains. v

Note: The 36-page proposed rule is at www.govinfo.gov/content/pkg/FR-2023-04-04/pdf/2023-06769.pdf. Comments are due May 30.