Good evening,
As you likely know, NAHC, our members, and the other national hospice associations have been working for some time now to advance targeted hospice program integrity solutions to address concerning cases of fraud and abuse in parts of the program. This afternoon, the four hospice associations (NAHC, NHPCO, NPHI & LeadingAge), as well as Congressman Earl Blumenauer (D-OR), who has been a key hospice champion and supporter of rooting out fraud, met with leadership and staff from CMS' Center for Program Integrity (CPI) and Center for Clinical Standards & Quality (CCSQ) to discuss the agency's efforts on hospice program integrity (PI). We wanted to provide our membership with a high-level readout of the meeting, given that they shared some significant updates on their PI activity (NAHC will be doing a deeper analysis on these and providing more updates via NAHC report soon):
New hospices in CA, TX, AZ, & NV will be placed under a period of enhanced oversight starting tomorrow (7/13)
- Late yesterday, CMS released an MLN article about their intent to institute a period of enhanced oversight for new hospices in Arizona, California, Nevada, & Texas starting July 13, 2023 (PDF is also attached)
- For purposes of this policy, "new" hospices include those:
- Newly enrolling in the Medicare Program (starting July 13, 2023)
- Submitting a change of ownership (CHOW) that meets all the regulatory requirements under 42 CFR 489.18
- Undergoing a 100% ownership change that doesn't fall under 42 CFR 489.18
- The period of enhanced oversight can last anywhere btw 30 days – 1 year, and it can include "medical review such as prepayment review"
- CMS does not have the authority to apply it retroactively to already-enrolled hospices.
New Supplemental Medical Review Contractor (SMRC) effort on hospice stays longer than 90 days
- CMS shared that Noridian, CMS' Supplemental Medical Review Contractor (SMRC) recently launched a new "Hospice 90 Day Stay project, in which they will do post-payment review on select hospice claims from January 1, 2021, through December 31, 2021 that are for patients with stays 91 days or longer with specified diagnoses. The codes can be found on Noridian's webpage HERE. The webpage for this review states that "CMS internal data has identified a potential area of vulnerability beginning with the second benefit period, or 91st day in hospice."
- During the meeting, a CMS CPI official stated that request letters to hospices related to this project started to go out about 2 weeks ago. He also stated that they are starting small at this time, aiming to do a "couple hundred reviews" across the country.
- On the call with them, NAHC, the other hospice associations, and Rep. Blumenauer all expressed concern with this new review project, stressing that hospices are already under an intense regulatory burden focused on second-guessing eligibility, and that adding a new layer to that burden without simultaneously taking steps to reduce the current scrutiny (which entangles mostly high-quality compliant providers) could be problematic.
- We will be following up directly with CMS to learn more about this project and continue to discuss our concerns. We will be gathering samples of how similar efforts in the past have placed undue burden on good providers, and showcased how many SMRC reviewers lack requisite understanding of hospice program and payment requirements and norms.
Nationwide site visits of all hospices to check if they are operational
- As we have mentioned to you before, in the last few months, CMS began doing site visits (note : these are not re-validation survey visits) to every hospice in the country. They indicated today that they have nearly completed all of these, and that a number of hospices have been deactivated that were clearly fraudulent or non-operational. CMS will provide a more substantive update when the full review of every hospice is complete.
Overall, the CMS team has been very appreciative of the hospice community for its partnership on PI issues. It is clear this is an effort that spans different departments within CMS, and is a high priority for them. While we are supportive of some of the targeted steps they are taking, we are concerned that they have initiated yet another medical review effort that may only add burden to good providers. They expressed a willingness to have open dialogue about any issues the industry has, and we'll continue to work with them to educate on why they should be focused on the most egregious fraud and exploitation in the program, and move away from approaches that are overly broad.
Please let us know if you have questions at this time
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Davis Baird
Director of Government Affairs, Hospice
National Association for Home Care & Hospice
Washington DC
(202) 547-7424
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