Data on the recent entry of large numbers of newly created hospice organizations in several states and the subsequent ProPublica/New Yorker article heightened long-standing LeadingAge concerns (as shared with CMS in November 2022) about the adequacy of Medicare oversight of hospice organizations. We hear from members regularly about the lack of targeting of oversight so we wanted to create recommendations that would balance these concerns with the distressing trends in hospice care. The recommendations focused on issues particularly related to certification, accreditation, and enforcement processes.

LeadingAge joined the National Association for Home Care & Hospice (NAHC), the National Hospice and Palliative Care Organization (NHPCO), and the National Partnership for Healthcare and Hospice Innovation (NPHI), in providing the Centers for Medicare and Medicaid Services (CMS) and key Congressional stakeholders with 34 recommendations grouped into 11 core issue areas.

Those issue areas are:

• Limiting Enrollment of New Providers
• Enforcement Against Non-Operational Hospices
• Medicare Certification
• Recommendations for New Providers
• Aggressive or Inappropriate Marketing or Solicitation
• Hospice Quality
• Medicare Regulations and Surveys
• Other Survey Considerations
• Personnel Requirements
• Accrediting Organizations and Deemed Status
• Role of Medicare Administrative Contractors (MACs)

Some highlights from the recommendations are:

• Limit enrollment of new providers with a targeted moratorium on new hospices: Use existing CMS moratorium authority to limit enrollment of new hospice providers in counties with troubling rates of explosive licensure and Medicare certification growth.
• Enforce against non-operational hospices by revoking Medicare enrollment and increasing site visits: Investigate Medicare provider numbers that show aberrant gaps in Medicare billing. Revoking enrollment of non-operational hospices prevents them from being sold to inexperienced providers for a profit.
• Develop hospice “red flag” criteria: Identify Medicare certification application “triggers” related to specific areas of concern that would prompt CMS to investigate an applicant before certification could be approved. Red flags should include:

1. 1. Co-location of multiple hospices at single address;
   2. A single hospice administrator overseeing multiple hospices;
   3. A patient care manager or other hospice leadership staff serving multiple hospices; and
   4. A hospice company that appears to be hidden behind a shell company.

• Require surveyors to confirm ability of hospices to provide all four levels of care:  Surveyors must ensure hospices have the ability to provide all four levels of care, including General Inpatient Care (GIP) and respite contracts, as well as provision for continuous home care (CHC) and afterhours care.
• Add hospice administrator and patient care manager qualifications to Medicare hospice Conditions of Participation (CoPs): Add education and/or qualifications to the hospice CoPs for these key personnel, including minimum years of experience or a combination of education and experience.

LeadingAge will continue to advocate for reform on behalf of our nonprofit and similarly mission driven members to both stop the growth of fraudulent hospices and to promote high-quality hospice care that beneficiaries and their families need and deserve at the end of life. Please contact Katy Barnett at kbarnett@leadingage.org or Mollie Gurian at mgurian@leadingage.org with any additional questions.