NHPCO Focus on Program Integrity and Oversight

Introduction

Since our founding in 1978 – prior to the existence of the Medicare Hospice Benefit – NHPCO has always worked closely with lawmakers and regulators, and with the hospice community, to ensure the ideals at the heart of the hospice model are upheld in the practice of hospice care. Hospices put patients’ values, wishes, and goals first, creating an individualized plan of care to support each patient and family. For hospices to continue to deliver on this promise, we need policies and regulations in place to ensure:

- - Hospices across the country are empowered to deliver excellent care
  - Local, state, and federal agencies have the capacity to set and enforce licensure and certification requirements for hospices
  - Patients and their families understand the hospice benefit and have access to the quality care they deserve
  - Hospices strive to deliver above and beyond the requirements of the Medicare hospice benefit

This approach is core to NHPCO’s advocacy efforts. We know that for hospice to continue to exist, hospice care needs to stay true to its core values, so we protect those values, we work to weed out any bad actors, and we support the delivery of the highest quality of care. As hospice program integrity has received more attention lately from lawmakers, regulatory and oversight bodies, and the media, we created this page to help advance those conversations by sharing key highlights as well as some of our own work in this space from 2019 through today.

Our work

2019 to 2020 – OIG Reports and the HOSPICE Act

- - OIG: In July of 2019, the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) published two seminal reports that shed light on issues within some hospice programs. NHPCO responded immediately, saying in part “Any hospice provider who fails to be fully compliant with all regulations and standards of practice and is unable or unwilling to provide the highest level of quality care should not be in the business of caring for the dying and their loved ones” and reiterating our commitment to working with regulators for accountability and transparency.

- - HOSPICE Act: Within a few weeks, we developed, vetted, and published a detailed list of recommended program integrity reforms that CMS or Congress could implement, offering assistance in “helping to stop fraud and abuse before it occurs and … increasing hospice data transparency.” Since then, NHPCO has worked closely with our members, Congressional leaders, and the Center for Medicare and Medicaid Services (CMS) to support the development and implementation of an improved framework for hospice oversight to ensure patient get the best possible care. The HOSPICE Act, introduced in the House of Representatives in February of 2020, became the primary legislative vehicle for these efforts. Through our collaboration with the Ways and Means Committee and other Congressional leaders, many of our program integrity recommendations were incorporated into the bill. In part due to our continued advocacy, the measures in the HOSPICE Act were passed and signed into law as part of the Consolidated Appropriations Act, 2021 in December 2020.

2020 to 2022 – Concerns about hospice rapid growth in select markets

- - Growth in California: In 2020 and 2022, we started to have serious concerns about the proliferation of newly certified hospices in parts of California. The pace of growth was noticeably different from hospice growth in other parts of California and in other states, without a demonstration of increased patient need. Then-NHPCO President and CEO was quoted in the LA Times in December of 2020, saying: “‘There are too many providers in L.A. County, and too many providers who are in it for the wrong reasons,’ said Edo Banach, who heads the National Hospice and Palliative Care Organization, the largest U.S. trade group for hospices. ‘Folks who go into this for the wrong reason generally do not do a good job.’”

- - California State Auditor’s Report: In March of 2022, the California State Auditor released a report on California Hospice Licensure and Oversight, noting that weak state oversight “created opportunities for large-scale fraud and abuse” by California hospices and pointing to the alarming pace of growth of hospices in the state. The findings both confirm concerns previously raised by NHPCO and others in the hospice community and inform future program integrity efforts.

- - Partnering with CHAPCA: We partnered with the state hospice organization, the California Hospice and Palliative Care Association, to discuss the findings and hear more about how the California legislature and governmental agencies were responding to the auditor’s report, including the implementation of a California moratorium on new hospice licenses. Although the moratorium addressed hospice licensure in California, it did not address the rampant growth in Medicare certification. Federal action was needed.

- - Hospice Growth Concerns in Arizona, Nevada and Texas: In the fall of 2022, we began hearing reports that gave us reason to have similar concerns about Arizona, Nevada, and Texas. On November 9, 2022, we joined with three other national organizations to alert CMS Administrator Chiquita Brooks-LaSure about our concerns regarding “reports of rapid proliferation of certified hospice agencies in select States,” and request a meeting to discuss “increased federal oversight…to protect hospice patients and their families, as well as the vast majority of hospice providers that properly observe Medicare and Medicaid laws and regulations.” A few days later, the four organizations jointly shared the letter on our websites and with media in order to shine a brighter spotlight on the issues at hand.

2021 to 2023 – HOSPICE Act implementation; ongoing advocacy

- - HOSPICE Act implementation: Once the measures in the HOSPICE Act were passed into law as part of the Consolidated Appropriations Act, 2021, the focus turned to implementation through regulatory rulemaking. CMS issued two proposed rules implementing components of the HOSPICE Act. First, the FY 2022 Hospice Wage Index Final Rule increased the hospice rate penalty from 2% to 4% for non-participation in quality reporting in CY 2022 for the Annual Payment Update in FY 2024. Second, the CY 2022 Home Health Prospective Payment Rate Update…Survey and Enforcement Requirements for Hospice Programs included provisions for mandatory surveyor training, multi-discipline survey teams, surveyor conflict of interest, and implementation details on enforcement remedies for hospices. NHPCO issued detailed Regulatory Alerts on both the proposed (August 27, 2021) and final (November 8, 2021) rules, submitted a comment letter on the proposed rule, and provided extensive webinar and in-person education on the contents of the final rule to help hospice providers prepare for the changes in the survey process and the addition of enforcement remedies, including civil monetary penalties.While many of the regulations to implement the provisions of the HOSPICE Act were implemented on January 1, 2022, implementation continues in 2023. NHPCO has supported this process by offering detailed analysis and education for hospice providers, and at every step, NHPCO has continued to confer with our members and to advise CMS and Congress.

- - NHPCO’s ongoing advocacy for hospice program integrity: Today, we continue this important work, often partnering with other national organizations in that effort, including LeadingAge, the National Association for Home Care & Hospice (NAHC), and the National Partnership for Healthcare and Hospice Innovation (NPHI). In November of 2022, the four organizations reached out to CMS Administrator Chiquita Brooks-LaSure, noting that “increased federal oversight is needed to protect hospice patients and their families, as well as the vast majority of hospice providers that properly observe Medicare and Medicaid laws and regulations,” and asking to meet. The four organizations then worked together to develop and vet a detailed list of 34 program integrity recommendations, which would build on provisions of the HOSPICE Act that are already being implemented. In January 2023, we shared those recommendations with our members and provided the list to CMS and Congressional leaders. In February, we had the opportunity to discuss the recommendations in meetings with CMS Administrator Brooks-LaSure and with key Congressional Representatives.

Going forward

We will continue to support a comprehensive approach to hospice compliance because it’s what our members want, it is essential for protecting patients, and it helps ensure the future of the Medicare Hospice Benefit.

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