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Home Health & Hospice Week

Program Integrity:

Keep Up With The Many PI Actions CMS Has Taken Lately

Published on Fri Aug 25, 2023

Still no payment suspension, civil money penalty powers.

It’s no wonder hospice providers are feeling the burden of increased scrutiny, with the lengthy lineup of fraud- and abuse-fighting actions Medicare has implemented in recent months.

In a new blog post (see related story, p. 230), the Centers for Medicare & Medicaid Services rattles off its laundry list of program integrity initiatives, including:

1. Site visits of every hospice location nationwide. “Our goal was to protect patients and their families from engaging with fraudulent actors by making sure that each hospice is operational at the address listed on their enrollment form,” Medicare officials say in the post.

“The site visits are sometimes just a drive-by, meaning the person conducting the site visit may not even enter the premises — although they can,” explains attorney Emily Solum with law firm Husch Blackwell in Jefferson City, Mo. “These should really be of no concern to legitimate hospices, unless they’ve forgotten to submit an address/location change,” Solum tells AAPC.

“From CMS’ point of view, having correct addresses for all certified hospices that provide services to Medicare patients seems like ‘Provider Enrollment and Program Integrity 101,’” notes Washington, D.C.-based healthcare attorney Elizabeth Hogue. “CMS should not have to hunt for providers,” she admonishes.

That means hospices that haven’t notified CMS about changes in their addresses “are vulnerable,” Hogue warns.

2. Posting survey info on Care Compare. “We … intend to publicly post survey information on Care Compare to offer patients and their families even more information and transparency into the quality of care provided by hospices in their area,” CMS says.

The impact of this change is debatable. “CMS has activity underway to move survey information from the QCOR (Quality, Certification and Oversight Reports) site to iQies, and anticipate that the data on iQies will be much easier to access and more up to date,” reports the National Association for Home Care & Hospice’s Theresa Forster. “That appears to be taking a fair amount of time but is a necessary step before CMS can create public access via Compare,” Forster explains.

“It is our hope that CMS will make every effort to ensure that the survey data that is accessible via Compare is shared in a way that is meaningful to patients, families, and referral sources as access to survey reports alone will not serve the public well,” Forster adds.

“It is likely that this data won’t make much difference to beneficiaries, but referral sources may certainly rely on it when making referrals,” Hogue expects.

3. Provisional period of enhanced oversight for hospices in Arizona, California, Nevada, and Texas. That includes pre-pay medical review for newly enrolling hospices. (See more details in HHHW by AAPC, Vol. XXXII, No. 27.)

4. Supplemental Medical Review Contractor review of claims for hospice stays of 90 days or more. “This pilot will not be limited to Arizona, California, Nevada, and Texas,” CMS specifies in the blog post. (See more details, including diagnosis codes that could trigger review, in HHHW by AAPC, Vol. XXXII, No. 27.)

5. The 36-month rule. This provision proposed in the 2024 home health rule will “prohibit the transfer of the provider agreement and Medicare billing privileges of a new hospice for 36 months — like the existing rules for home health agencies,” CMS says in the blog. (See more details in HHHW by AAPC, Vol. XXXII, No. 24-25.)

“If a hospice violates the 36-month rule, its Medicare provider agreement and billing privileges would not convey to the new owner and a new Medicare enrollment and certification would be required,” explains law firm McGuireWoods in online analysis of the rule. That would “necessitat[e] an initial survey, which would cause a significant delay in operations and billing,” McGuireWoods notes.

6. Enrollment changes. The home health proposed rule also contains provisions to implement stricter criminal background checks and “clarify that the definition of ‘Managing Employee’ on the Medicare enrollment application form includes the administrator and medical director of a hospice,” according to the blog. (See more details in HHHW by AAPC, Vol. XXXII, No. 24-25.)

7. Screening of hospice physicians. The hospice final rule for 2024 tasks CMS with screening “hospice certifying physicians to ensure they are qualified to treat Medicare beneficiaries, including making sure they have active licenses and do not have felony conviction records,” the blog notes. (See more details in HHHW by AAPC, Vol. XXXII, No. 28.)

8. Updated and enhanced survey procedures. They include Consolidated Appropriations Act (CAA), 2021 provisions requiring “multidisciplinary survey teams, prohibiting surveyor conflicts of interest … and requiring surveyors from accrediting organizations (AOs) to complete comprehensive training and testing,” the blog notes. CMS doesn’t mention that it has yet to implement the CAA requirements for enforcement remedies including payment suspension and civil money penalties. (See more details in HHHW by AAPC, Vol. XXXII, No. 6.)

9. Special Focus Program. The SFP, included in the home health proposed rule, aims to “increase oversight of poor-performing hospices that have repeated cycles of serious health and safety deficiencies,” CMS notes.

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