Over the past few years, rising concerns about fraud and abuse in Hospice have gained attention across the country, leading to increased scrutiny in several states. As of July 13, 2023, California, Nevada, Arizona, and Texas have had enhanced oversight measures implemented by CMS for specific hospice providers. These measures specifically target newly certified hospices and those undergoing partial or full ownership changes after the effective date.  

As a consequence of implementing stringent oversight measures, the time frame for the review process can range from 30 days to a year, contingent on the findings from the preliminary reviews. Our current understanding is that these reviews will include procedures like post-payment assessments and will be relevant for service dates starting from either the certification date or the change in ownership date.    

As previously highlighted, there has been escalating concerns surrounding the integrity of documentation. CMS, in an effort to verify the legitimacy of Hospice organizations, has initiated onsite visits similar to reevaluation inspections. The intention here is primarily to authenticate whether the Hospices are operational. Consequently, a number of hospices have been deactivated due to inactivity or failure to update their address changes in PECOS.  

In addition to the oversight in the four states mentioned above, the Supplemental Medical Review Contractor (SMRC) has been tasked with a specific project to scrutinize Hospice documentation for the year 2021. This review will focus on a predetermined set of diagnosis codes that can be found here. It is anticipated that around 200 Hospices nationwide will undergo this scrutiny. As of now, the rationale behind the selection of these specific diagnosis codes remains unclear. However, we hope to provide further information on this matter in due course. 

The Supplemental Medical Review Contractors generally operate based on referrals from other entities within the CMS contractor domain, or in response to specific data analyses. In an unvarying fashion, CMS is incorporating this project into their workflow. 

Hospices face significant concerns and frustrations, particularly those striving to maintain the highest standards of care and compliance. They will need to navigate through heightened audit procedures, specifically in the four states under increased scrutiny. This will be necessary even if they undergo a change in ownership. The introduction of the SMRC project is bound to influence these agencies, including hospices currently operating without any issues, adding to their operational challenges. 

I appreciate everyone’s participation today. We have a webinar on the horizon in August, focused on ICD10 Coding Updates for Home Health and Hospice. I encourage you to register for this event, and stay updated with the latest coding changes from HPS. 

Should you have any further questions, please feel free to get in touch

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