Concerns regarding individuals entering hospice without hospice care eligibility has lead CMS to pilot a new 90-day post-claim medical review process focused on trying to identify targets retroactively (given the data lag) and looking specifically for outliers — particularly around long length of stay. CMS will pilot looking at individuals earlier on in the hospice stay to try identifying potential issues with eligibility sooner and provide education.

Notifications started going out for document requests in July, and for those selected CMS contractors will be looking at claims after a beneficiary has completed their first 90 days in hospice. Depending on what CMS finds in their initial test of this new system, they may extend it, expand it, and tighten it up.

LeadingAge raised a number of concerns about this component of the strategy. We asked how the approach was going to be targeted—there are diagnosis codes available on the SMRC website detailing this new medical review. We also raised that there are many current audit initiatives ongoing for hospice providers and asked if CMS had a plan to streamline their reviews. Adding another form of review without thinking about a holistic strategy for oversight was going to continue to burden providers in a way that is simply not sustainable.

The fact that hospice is a six-month benefit and a review at 90 days should not undercut care for appropriate patients who were on a longer trajectory toward death is also a point to be emphasized. CMS underscored that this new review was supposed to help find inappropriate patients and trends much earlier in the process, and they were using this opportunity to look at hospice oversight comprehensively and with a fresh perspective—they are open to taking things off the table that are not working. CMS is also open to continuing the dialogue with LeadingAge.

Nationwide Site Visits

In addition to the implementation of a 90-day review, CMS is nearing the end of a nationwide site visit project (93.5% of all locations are complete) to determine whether hospices are operational at the address listed in the Provider Enrollment, Chain, and Ownership System (PECOS). CMS will provide results on the number of providers visited and the enforcement actions taken. In this process, CMS has identified several hospices that appear to be non-operational or failed to update their new location in PECOS and are further reviewing those hospices for potential administrative action.

LeadingAge members have asked about visitors to their offices; those visits have been part of this process. LeadingAge has followed up and asked CMS for more details on these visits.