Proposed CMS rules around hospice care will address high noncompliance with transparency requirements in Utah, says expert


Boram Kim


Last month, CMS issued a proposed update to the hospice wage index that would impose base pay reductions on hospice care providers who fail to meet Medicare reporting requirements intended to increase transparency.

Under the proposed rule, CMS would analyze hospice care utilization, including Medicare spending, services outside of the hospice benefit, and claims data, to ensure compliance and prevent fraud. 

Speaking to State of Reform, Matt Hansen, executive director of the Home and Hospice Association of Utah (HHAU), outlined how the increased scrutiny could impact the state. 

“Utah is on the [federal] radar simply because we are always the top one or two highest utilizing states of hospice services,” Hansen said. “I attribute that more than anything because of our public outreach and education. I think we’ve done a great job about sharing the hospice message and about the value that it provides to people for palliative and end-of-life care …

Documentation is the other area. One thing that we are hearing a lot more of now, across the country is some targeted auditing for documentation. And usually, it’s because physicians from what we’re hearing may not be documenting medical decline or medical necessity for hospice, and the appropriateness.”

CMS reports the number of Medicare beneficiaries utilizing hospice care grew from 715,349 in federal FY 2003 to over 1.7 million in federal FY 2022, and the expenditures for this care rose from $5 billion in FY 2003 to approximately $23 billion in FY 2022. 

The proposed rule would affect the Hospice Conditions of Participation and Hospice Quality Reporting Program (HQRP) by implementing new reporting measures around hospice aide competency evaluation and quality of care. The rule also aims to improve race/ethnicity data collection on services and outcomes for minority populations.

While the rule proposes an annual payment update of a 2.8% increase to the hospice wage index and aggregate cap, providers who fail to comply with HQRP would see a higher 4% payment reduction. 

CMS is collecting more data to improve accountability and transparency for hospice care providers after reports of fraud and abuse across the country continue to emerge, according to Hansen.

He said federal data collection under the proposed rule will focus on minority and vulnerable populations, trying to gain insight into underlying health status, non-medical factors, and the disparities that emerge from service utilization. This goal is to increase access and value within the Medicare hospice benefit for minority populations. 

Earlier this month, CMS also issued its final rule to revise Medicare Advantage (Part C), Medicare Prescription Drug Benefit (Part D), the Medicare cost plan, and Programs of All-Inclusive Care for the Elderly (PACE). The federal government said the new rule will implement a key provision of the Inflation Reduction Act meant to improve access to affordable prescription drug coverage for an estimated 300,000 low-income individuals.

The final rule aims to strengthen health affordability, access, and equity for seniors by cracking down on “misleading marketing schemes” by Medicare Advantage and Part D plans and their associated entities, removing barriers to care created by complex coverage criteria and utilization management, and expanding access to behavioral healthcare.

Hansen said the final rule fails to clarify whether hospice providers can prescribe medications and controlled substances through telehealth, a provision that will expire with the end of the Public Health Emergency on May 11th. 

“[Telehealth] has an impact obviously on hospice,” Hansen said. “If it’s morphine or [another controlled substance]—if that can’t be prescribed through telehealth and that person can’t get into the physician’s office, where does that leave us? What does that mean?”

HHAU will be working on building relationships with state and federal officials and helping those in government understand the work being done in hospice and palliative care. Hansen said the organization would also continue to educate and engage the public about the value of hospice to clear up misconceptions that have emerged about what care is. 

“Hospice is so much more than a death benefit—it’s an end-of-life benefit,” Hansen said. “It’s really about the quality of life. It’s about honoring choices. It’s about helping people to live their last days how and where they would like to. And with the average length of stay in the country still being somewhere around 14 days, we hear a lot about the long stays.

Unfairly, a lot of attention is put on that, but if somebody has cancer and they elect hospice, they’re probably going to be on longer than someone else who may be end-of-life because of [chronic obstructive pulmonary disease], and/or has had an acute infection recently and is just not doing well.

And so we need to recognize that and still provide that opportunity and look at not how long they’re on hospice, but what that person wants and [their] quality of life.”