Usually I try to add some “light and levity” to my Wednesday features as the content on this site is pretty heavy health policy and economics, regulatory in nature, etc. In my work, my usual Wednesday messages internally are “fun” – a bit of Hump Day humor or whimsy. By title of this post, readers will see the deviation.
In June I wrote a piece on the likelihood of upcoming regulatory actions by CMS within the hospice industry. The issues focus on program integrity and payment integrity for certain hospice services from certain hospices. In other words, CMS has been wary that some hospices are operating on a phantom basis, not really having a distinct office location and then, on almost a predatory basis (marketing, etc.), enrolling patients and providing inadequate care, yet billing Medicare for the services. The June article is here: https://wp.me/ptUlY-Ci
Yesterday (Tuesday, August 22), CMS dropped a blog piece indicating that they were taking regulatory/administrative action against certain hospices, primarily in the states of Arizona, California, Nevada and Texas for inappropriately certifying non-terminal patients (likely to die within 6 months) and then, providing minimal to no care for them. Various media reports classified these hospice schemes as “churn and burn” whereby the hospice is fraudulently established, enrolls patients, receives payment, and then quickly moves on or goes out of business a the “phantotm” location. From the CMS blog post: “Recent media reporting, and research by CMS, have identified instances of hospices certifying patients for hospice care when they were not terminally ill and providing little to no services to patients. The media reports identified that these activities led to a rapid growth in potentially fraudulent hospices, particularly in Arizona, California, Nevada, and Texas. Some of the addresses listed for these hospices also appeared to be non-operational. This reporting also brought attention to a trend of “churn and burn” schemes where a new hospice opens and starts billing, but once that hospice is audited or reaches its statutory yearly payment limit, it shuts down, keeps the money, buys a new Medicare billing number, transfers its patients over to the new Medicare billing number, and starts billing again.”
Per CMS, a regulatory strategy was formed to conduct site visits of all Medicare participating hospices. By August of this year, 7,000 site visits had been conducted. From these visits, CMS has identified 400 hospices that have questionable or non-verifiable addresses. This can be because of relocation and paperwork notifications that have yet to be updated or other technical issues. For those that cannot be verified, CMS states it will take action to potentially, if the hospice cannot be properly verified, revoke accreditation and licensure (although licensure is a state issue as well). CMS also indicates that for new hospices, it will undertake claims reviews to assure that payments are verified for medically qualified, terminally ill patients: “With the same goal in mind, CMS is initiating a pilot project to review hospice claims following an individual’s first 90 days of hospice care.” This review will not be limited to Arizona, Florida, Texas and Nevada.
Other CMS regulatory initiative/changes corresponding to the integrity concerns (patient qualification, location accuracy, payment) that are being implemented are,
- 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;
- Clarify that the definition of “Managing Employee” on the Medicare enrollment application form includes the administrator and medical director of a hospice;
- Implement a hospice Special Focus Program (SFP), as required in the Consolidated Appropriations Act (CAA), 2021, that would increase oversight of poor-performing hospices that have repeated cycles of serious health and safety deficiencies; and
- Include criminal background checks for owners upon initial Medicare enrollment.
The full CMS Blog Post on this regulatory action, other changes, etc., is available here: https://www.cms.gov/blog/cms-taking-action-address-benefit-integrity-issues-related-hospice-care HAPPY HUMP DAY!