[UPDATED] Nearly 53% of Hospices Undergo Multiple Audits Simultaneously

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Program integrity and an onslaught of audits are top of mind for many hospice providers in 2024.

The nation’s four largest hospice industry 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) — in late 2023 conducted a 133-respondent provider survey focused on regulation.

The organizations earlier this year presented their findings, published today, to members of Congress and the U.S. Centers for Medicare & Medicaid Services (CMS). Regulatory issues topped providers’ list of concerns, the survey found.

“To ensure hospice beneficiaries are served by high quality hospice providers, the current oversight system must be reformed and enforcement focused to uncover genuine instances of fraud, waste, and abuse,” said Katie Smith Sloan, president and CEO of LeadingAge, in a statement. “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.” 

One central issue was the matter of provider audits, which have been increasing steadily for several years running.

A majority of providers who responded to the survey indicated that they have undergone more than one audit simultaneously. Most commonly, this was a Targeted Probe and Educate (TPE) in conjunction with a Supplemental Medical Review Contractor (SMRC).

About 52.9% reported having multiple audits, each of a different type, within six months of one another, and 31% said they were required to submit the same charts for each of these audits.

About 77% of respondents said that they have been subject to a TPE during the past five years, and 32% said those audits lasted between 18 months and two years. Close to 80% were related to General Inpatient Care utilization (GIP).

“The findings from our collaborative survey offer valuable insights into the auditing and adjudication processes of Medicare hospice benefit claims,” NPHI CEO Tom Koutsoumpas told Hospice News in an email. “Moving forward, we are eager to continue our close engagement with CMS and Congress to ensure the integrity and effectiveness of hospice audits.”

Hospices have increasingly come under a regulatory microscope around GIP in particular during the past few years, particularly when it comes to stays longer than five days.

In addition to those my Medicare Contractors, last year the U.S. Department of Health & Human Services Office of the Inspector General(OIG) launched a national audit of GIP utilization. The impetus for the audit was primarily related to billing errors.

An OIG study of hospice billing claims submitted during 2012 found that 31% of the GIP claims that providers submitted to CMS were inappropriately billed — to the tune of an estimated $268 million that year alone.

Survey respondents also indicated that audit contractor activities are “opaque, inconsistent and uneven,” resulting in severe inefficiencies for hospices. They also noted that these auditors often lack a clear and complete understanding of hospice care and do not follow correct policies and procedures, resulting in inaccurate reports.

Moreover, when errors occur, providers must undergo a time-consuming appeals process.

“Of significant concern was that many of these providers did not have patterns of billing performance outside the norm yet they were targeted for audits, and in some cases, simultaneous or continuing audits from multiple audit contractors,” Katie Wehri, NAHC’s director of home care and hospice regulatory affairs, told Hospice News in an email. “Of further concern was the inconsistency by auditors of the Medicare hospice requirements. There needs to be greater transparency on why hospices are targeted for audits, a coordinated approach by the audit contractors with consistent and correct application of the requirements.”

The organizations made several recommendations to policymakers in response to the survey. These included improving transparency of the audit process and the contractors carrying them out and development of a less cumbersome process for disputing audit findings. They also recommended that personnel conducting these audits have knowledge equivalent to a hospice medical director.

“It is critical that oversight efforts are appropriately tailored to address actual instances of fraud and improper spending,” Patrick Harrison, NHPCO’s Senior Director of Regulatory and Compliance, told Hospice News in an email. “Otherwise, wide audit nets inevitably catch high performing providers, which can impair continued access to appropriate end-of-life care. We look forward to continued engagement to ensure that oversight activities are conducted appropriately and effectively to protect the hospice benefit.”