On March 20, Department of Health and Human Services (HHS) Secretary Xavier Becerra testified in front of the House Committee on Ways and Means on the President’s Fiscal Year 2025 Budget Request to Congress. Reps. Beth Van Duyne (R-TX) and Michelle Steel (R-CA) focused their questions on issues related to hospice program integrity. They asked Sec. Becerra about ongoing hospice certifications in California and other hot spots.

LeadingAge has been engaging with both Congress and CMS on issues of hospice fraud over the past year and half and we were pleased to see Reps. Steel and Van Duyne continue to pressure HHS to ensure access to quality hospice care.

As we work to ensure hospice program integrity, LeadingAge’s advocacy with the Centers for Medicare and Medicaid Services (CMS) and members of Congress continues. Following January 2024 meetings with CMS and members of Congress, LeadingAge, in collaboration with 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), on March 12 released findings of a hospice provider survey. Those findings underscore the need for CMS and Congress to act to improve the auditing and adjudication process of Medicare hospice benefit claims, and give policymakers important on-the-ground examples of shortcomings in the audit process.

Katie Smith Sloan, president and CEO of LeadingAge, said in a press release: “We’re moving in the right direction. Not only have nearly half of the 34 recommendations presented in early 2023 to improve oversight of the benefit been implemented, CMS, in our recent conversations, has demonstrated a willingness to consider, holistically, which pieces of oversight need to be strengthened and which need to be redirected. These survey findings, which underscore what’s not working currently, are the next step in that work. To ensure hospice beneficiaries are served by high-quality providers, the current oversight system must be reformed and enforcement focused to uncover genuine instances of fraud, waste, and abuse. We look forward to continuing our work with CMS and Congress to ensure an equitable and effective enforcement system that preserves access to nonprofit, mission-driven hospice care.”

As the Centers for Medicare and Medicaid Services (CMS) and the Center for Medicare and Medicaid Innovation (CMMI) explore the  hospice Value-Based Insurance Design Model (VBID), LeadingAge has taken advocacy action on two fronts.

In our February 14 response to CMMI’s Request for Information (RFI) for the VBID, LeadingAge strongly advised CMMI to exert extreme caution regarding closed networks for hospice providers and strongly opposed any change to current prior authorization restrictions for the VBID Hospice Benefit Component.

Read more details in the full LeadingAge article.

LeadingAge and our partner national hospice associations conducted a survey to assess the burden of audits across our memberships and to gather data to share with the Centers for Medicare & Medicaid Services (CMS). See the key findings and access the full report in the LeadingAge article here.

After LeadingAge and our industry partners went through tremendous efforts to educate CMS on the reality of implementing the proposed Special Focus Program (SFP) as proposed in the CY2024 Home Health Rule, CMS has decided to move forward with what was initially proposed.

• CMS is finalizing the inclusion of CAHPS Hospice Survey data in the SFP algorithm as proposed, which includes using four CAHPS Hospice Survey measures to create the Hospice CAHPS Index, standardizing the CAHPS Index, double weighting the CAHPS Index in the algorithm, and using two versions of the algorithm to address missing CAHPS Hospice Survey data.
• CMS is finalizing without modification the inclusion of the HCI score, the standardization of the HCI score, and how missing HCI scores are handled in the SFP algorithm, specifically by replacing a hospice’s missing score with zero after standardization which is equivalent to replacing it with the average value.
• CMS is finalizing the inclusion of unscaled Condition Level Deficiencies and unscaled substantiated complaints from three consecutive years of data, the standardization of both inputs, and replacing a hospice’s missing CLDs or substantiated complaints with zero after standardization which is equivalent to replacing it with the average value in the SFP algorithm as proposed.

Additionally, CMS plans to select the poorest performing hospices, from the 10% selectee list based on the finalized SFP algorithm score, in sequential value. This selection process will not include hospices already in the SFP or on a correction track. The industry had asked for a preview period in advance of implementing the SFP algorithm, however CMS believes further delay would likely impact patient and family health and safety. CMS added, hospices are aware of their status for each element used in the algorithm and had opportunities to preview these elements prior to the use in the algorithm. Read a joint statement from the hospice industry associations.

The Centers for Medicare and Medicaid Services (CMS) released the 2023 Hospice Information Gathering Report from Abt Associates, which supports further hospice quality development efforts by reviewing available resources each year. This is the fifth report since 2019.

Literature from 2023 suggests that hospice quality still has room for improvement, specifically in the areas of symptom management, medication deprescribing, and hospice patients with dementia. Of interest to non-profit providers, hospice services provided by non-profit hospices, or hospices in states where hospice growth is regulated, were associated with better quality outcomes. Reviewers found few studies on novel quality measures or treatment approaches. The only studies identified in the report were for the Healthy Days at Home measure study and studies associating physical activity with improved symptoms.

The Center for Medicare and Medicaid Innovation (CMMI) released its yearly evaluation of the Value Based Insurance Design (VBID) demonstration including an at-a-glance review of the hospice benefit component. More than 1,168 hospices provided care to at least one hospice-eligible VBID beneficiary, a substantial increase from 596 hospices in 2021. Of those hospices, only 22% were in network hospices—but that’s a 6% increase since 2021. In 2022, almost half of VBID beneficiaries receiving hospice care chose in-network hospices, up from 37% in 2021. Additional key findings on the hospice benefit include:

• Indications that participation in hospice benefit is growing, but uptake of palliative care, transitional care coordination, and hospice supplemental benefits continued to be low in 2022.
• Hospices and new insurers reported substantial implementation challenges, but insurers with more than one year of experience with VBID reported fewer challenges, suggesting that implementation is becoming easier over time.
• The proportion of beneficiaries receiving care from in-network hospices grew from 2021 to 2022.
• Participation in the Hospice Benefit component was not associated with changes in hospice enrollment in 2021.
• Participation in the Hospice Benefit component was associated with reductions in combined MAPD bids in 2021 and 2022 and reductions in combined MAPD premiums in 2021.

LeadingAge staff met with the Government Accountability Office (GAO) on October 19 to discuss the implementation of the hospice survey changes authorized by the Consolidated Appropriations Act, 2021. This is the second conversation LeadingAge had with GAO regarding changes to survey expectations for state and accrediting organization surveyors, a new hospice Special Focus Program, and general information on barriers to hospices serving Medicare beneficiaries.

In this follow up from the May 2023 meeting, LeadingAge staff shared concerns with the proposed algorithm for the hospice Special Focus Program published in the CY2024 Home Health Proposed Rule. LeadingAge staff reiterated support for the HOSPICE Act and its provisions, but noted that the implementation is critical for success as excessive regulations and oversight can lead hospices to close or consolidate, hurting general access to services. LeadingAge asked to stay in touch with GAO as they move forward and the final proposal for the Special Focus Program is released in the final Home Health Rule.

In an October 4, 2023 letter, four members of Congress echoed LeadingAge’s concerns about the implementation of Special Focus Program (SFP) proposed by CMS. Writing to CMS Administrator Chiquita Brooks-LaSure and White House Office of Management and Budget Director Shalanda Young, the House members wrote that the SFP would not adequately identify poor performing hospices who are “truly struggling with performance” if implemented with the current algorithm. LeadingAge supported the HOSPICE Act, which resulted in creation of the SFP, and notes that it was implemented specifically to identify poor hospice performers, not as a fraud prevention program.

LeadingAge, along with our national association partners, met with the White House Domestic Policy Council (DPC) on September 18 to discuss our concerns with the proposed implementation of the hospice special focus program. We discussed our support for the program but discussed flaws in the Centers for Medicare & Medicaid (CMS) proposed algorithm that we had outlined in our comment letter. DPC staff asked a number of good questions that showed understanding of the issues we were raising and asked to see our comments in follow up.

Following up on LeadingAge’s August 11 letter on hospice audits to the Centers for Medicare and Medicaid Services’ (CMS) Center for Program Integrity, and the need to more effectively target hospice oversight, LeadingAge and other national organizations met with the Centers for Medicare and Medicaid Services (CMS) on September 8 to further discuss these important issues.

In a blog posted on August 22, Dara Corrigan, the Centers for Medicare & Medicaid Services (CMS) deputy administrator and director of the Center for Program Integrity, and Dora Hughes, CMS chief medical officer, Innovation Center, summarized benefit integrity issues that have come up related to Medicare hospice services and the actions CMS has and will take. As of mid-August, they identified 400 hospices that are being considered for potential administrative action, suggesting some will be able to demonstrate compliance by submitting a valid provider address, while those unable to do so “may be deactivated or revoked.”

Continuing its advocacy efforts aiming to improve targeting of hospice program initiatives, LeadingAge, the association of nonprofit providers of aging services including providers of hospice care, joins four other hospice-focused trade organizations in applauding the Centers for Medicare and Medicaid Services’ (CMS) reform work and urging additional action to ensure the success of the agency’s audit focus by appropriately targeting oversight efforts. In a letter to CMS’ Center for Program Integrity (CPI), the organizations described fundamental, long-standing problems that must be addressed including audit focus areas, the overpayment recovery and recoveries adjudication processes, and auditor consistency and education.

The Centers for Medicare & Medicaid Services (CMS) is nearing the end of a nationwide site visit project to determine whether hospices are operational at the address listed in the Provider Enrollment, Chain, and Ownership System (PECOS), as 93.5% of all locations are complete. Upon the completion of the project, CMS will provide results on the number of providers visited and the enforcement actions taken.

In response to the concerns regarding individuals entering hospice not being eligible for hospice care, the Centers for Medicare & Medicaid Services (CMS) is piloting a 90-day post-claim medical review process. Learn more in this LeadingAge article.

LeadingAge, three other hospice organizations, and Congressman Earl Blumenauer (D-OR) met with the Centers for Medicare & Medicaid Services (CMS) in a follow-up to our 34 hospice program integrity recommendations. The meeting was with leading officials from the Center for Program Integrity and the Center for Clinical Standards and Quality.

As required in the Consolidated Appropriations Act of 2021 (CAA 2021), the CY2024 Home Health Proposed Rule would implement a Special Focus Program (SFP) for poor performing hospices as well as an Informal Dispute Resolution process.

The CY2024 Home Health Proposed Rule included a number of actions related to hospice, including an outline of expectations for the Special Focus Program. In addition to the introduction of the Special Focus Program for hospices, the Centers for Medicare and Medicaid Services (CMS) include a number of other integrity actions. This article reviews those actions in more detail and how they will impact hospice providers.

Representatives Van Duyne (R-TX) and Blumenauer (D-OR) led a bipartisan letter to Department of Health and Human Inspector General Christi Grimm. The letter asked for a briefing on the OIG’s current and planned response to the proliferation of fraudulent hospices in the western United States. LeadingAge is supportive of the Congress’ continued pursuit of answers regarding these hospices and continue to advocate that Centers for Medicare & Medicaid Services implement our 34 recommendations.

The Consolidated Appropriations Act 2021 requires surveys and statements of deficiencies by state agencies and accrediting organizations, as well as enforcement actions taken as a result of these surveys, to be publicly reported prominently on the Centers for Medicare & Medicaid Services (CMS) website. Reports must be posted in a manner that is easily accessible, searchable, and presented in a readily understandable format. The surveys and deficiency reports can be found here, and the hospice data is complete through September 2022.

As part of the Consolidated Appropriations Act of 2021, the Department of Health and Human Services was authorized to develop a Special Focus Program (SFP) for hospice agencies which aims to address issues that place hospice beneficiaries at risk. Last fall, CMS convened a Technical Expert Panel (TEP) to provide feedback to inform the development of the SFP. CMS stated in the FY2024 Hospice Wage Index proposed rule, that regulatory proposals to implement the SFP would be in the CY2024 Home Health Proposed Rule. A new report summarizes the TEP conversations and feedback.

On March 28, HHS Secretary Xavier Becerra appeared before the House Ways and Means Committee to discuss the President’s FY24 budget proposal. Top aging services issues were discussed, such as the 3-Day Hospital Stay Requirement, Nursing Home Mandatory Staffing Ratios, and Home and Community Based Services (HCBS). Both Rep. Earl Blumenauer (D-OR) and Rep. Beth Van Duyne (R-TX) brought up hospice program integrity and pressed the Secretary to crack down on “shadow” or “ghost” hospices, and pledged bipartisan Congressional support to do so. This aligns with LeadingAge’s work on hospice program integrity.

Statement from Katie Smith Sloan, president and CEO, LeadingAge, the association of nonprofit providers of aging services, including hospice, on hospice benefit reform proposals submitted to Congressional leadership: LeadingAge Submits Hospice Benefit Reform Proposals.

In response to a request from a member of Congress, LeadingAge submitted ideas in a memo around reforms and improvements to the hospice benefit.

The four national hospice provider organizations: LeadingAge, 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), provided the Centers for Medicare and Medicaid Services (CMS) and key Congressional stakeholders with recommended legislative and regulatory changes to strengthen hospice program integrity.

LeadingAge President and CEO Katie Smith Sloan responds to The New Yorker article, “How Hospice Became a For-Profit Hustle.”

On December 8th, 2020, the Helping Our Senior Population in Comfort Environments Act or HOSPICE Act (H.R. 5821) passed out of the House as part of the Beneficiary Enrollment Notification and Eligibility Simplification (BENES) Act (H.R. 2477). We continue to work with the Senate to advocate for some key changes.