Both opportunities and challenges exist for hospice providers as regulators zero in on program integrity.
Hospices stand to grow their census by taking on patients left behind by “bad actors” in certain markets. However, some fear that regulators’ responses could put a drain on employee retention and margins.
Widespread reports of fraud and abuse in hospice have led to intensified regulatory oversight during 2023. One potential benefit of this scrutiny is patients’ ability to move from an unethical provider to an agency that provides quality care, according to Guaranteed CEO Jessica McGlory.
The California-based hospice startup began providing services to the greater Los Angeles area last year in November.
Gaining brand recognition among patients in the community has come with difficulties in a saturated and competitive market, McGlory stated. Though greater transparency in hospice program integrity has opened the door to more patients in need of end-of-life care, she said.
Hospice News / RoboToaster“We’re really for the idea of increased transparency as much as possible [and] having different bad actors get removed,” McGlory told Hospice News at the ELEVATE conference in Chicago. “As they get removed or have to be forced out, it gives us more of an opportunity to show what we can do and really give us a chance to be able to grow. So, we’re excited to see and be able to continue to be advocates for the patients.”
California is among the states that have become hotbeds for fraud, including a swath of providers that were starting hospices just to flip the licenses.
The U.S. Centers for Medicare & Medicaid Services (CMS) honed in on hospice program integrity through a number of new regulations, including some in the agency’s 2024 hospice final rule. The regulations focused on Medicare enrollment in an effort to stifle unethical or illegal activity in the space. Other provisions appeared in the 2024 home health final rule, which prohibits the sale of a new hospice within 36 months.
During the past two years, CMS has introduced a host of other new regulations, as well as updated survey processes, increased auditing activities and enhanced reviews of providers’ claims, patient eligibility and quality measures.
Tighter regulations are needed to curb maleficence and skilled hospice care delivery, but ramping up compliance processes can be burdensome for staff, according to NVNA and Hospice CEO Renee McInnes, a registered nurse.
Additional documentation processes can be a stressor on clinical staff retention in particular, she stated. The amount of time spent on clinical documentation is a large point of dissatisfaction among clinicians, McInnes added.
“In terms of the future state of increased regulations, we have to add more and more infrastructure to support compliance and to support all of the documentation checks and balances that we need to have in place,” McInnes told Hospice News. “That puts more stress on the clinicians who are having less and less job satisfaction because of it — amid nursing shortages. It’s very hard to recruit and retain staff and attract nurses to the hospice realm when they are being taken away from the bedside, documenting.”
A key to navigating shifting requirements is ensuring staff are aware and educated on rules that impact patient care delivery, according to Howard Young, partner at the law firm Morgan Lewis.
Though it may require additional resources in compliance, hospices that are not “readily available” with survey readiness and audit response teams could face operational and financial strains, he said. The challenge, however, is balancing regulatory risks that may ultimately impact patient access, Young stated.
“Hospices should enhance compliance program controls to meet the challenges of enhanced regulatory scrutiny and continue its work with CMS to advance regulatory and program integrity oversight that is appropriately targeted, but that does not negatively impact access to hospice care,” Young told Hospice News in an email. “The ultimate risk is CMS deciding, on account of program integrity concerns, to effectively shrink the hospice benefit. This can be done by ramping up audits where CMS contractors apply overly stringent denial rationales, resulting in tremendous cost to the system of claim denials, appeals and other inefficiencies.”
The ultimate risk is CMS deciding, on account of program integrity concerns, to effectively shrink the hospice benefit. This can be done by ramping up audits where CMS contractors apply overly stringent denial rationales, resulting in tremendous cost to the system of claim denials, appeals and other inefficiencies.
— Howard Young, partner, Morgan Lewis
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