Jim’s Notebook: CMS Moratorium Takes Big Swing at Fraudsters But Threatens Access
After spending a couple of days pondering the various viewpoints, I have to come out and say that I think it’s a bad idea for the U.S. Centers for Medicare & Medicaid Services (CMS) to implement a moratorium on new hospice and home health provider enrollments.
We can pick our metaphors. CMS has been accused by stakeholders in the space of using a “sledgehammer” or a “chainsaw” to excise fraudulent operators, rather than a “scalpel,” which many consider to be a better metaphorical tool.
Most of the documented fraud in the space has occurred in a handful of states, and I think actions targeted to those regions would have been a better option. A temporary moratorium might provide regulators with critical time to tighten oversight, investigate suspected misconduct and stop organizations already under scrutiny from continuing to grow. Yet a nationwide freeze is a broad response to what remains a relatively concentrated issue.
It’s true that there would be some risks with a geographically targeted moratorium, such as fraudsters simply shifting their operations across state lines. But it’s an open question whether the nationwide six-month moratorium meaningfully limits that ability.
And this raises the questions about whether the six-month moratoria will be extended. Is this intended to buy CMS time to prepare for further actions? The value of the moratorium could be determined by what the agency does next.
But the possibility exists that this was a big, bold move that risks doing little to solve one of the industry’s major problems – rampant fraud in certain areas – while exacerbating another of the sector’s top challenges: lack of care access.
In certain rural and underserved areas, a legitimate need persists for additional high-quality hospice providers. After all, only about half (53%) of the Medicare decedents who could potentially benefit from hospice actually receive it. Though some of that number may have died suddenly, certainly a large number could also have benefited from hospice, and some may live in regions in which capacity has not caught up with demand.
Questions also circulate around providers’ ability to use telehealth during the moratorium period, particularly hospice recertifications. Federal law states that if a moratorium were implemented, telehealth hospice recertifications would no longer be allowed.
CMS, however, has said in a statement that existing telehealth flexibilities will remain in effect during the moratorium. The apparent contradiction between the CMS statement and the statutes puts providers in a gray area, with some uncertainty about what they are able to do. This perpetuates a maddening cycle of ambiguity around telehealth policy that has limited this technology from achieving its full promise, as providers and tech innovators alike are hesitant to make meaningful long-term investments without a solid regulatory framework.
Hospice News has sought clarification from CMS on what the actual policy is related to recertifications during the moratorium, but as of today we haven’t gotten an answer. We’ll keep you posted.
Another problem on our radar is the barrage of payment suspensions that many providers nationwide are facing. CMS has suspended payments for more than 700 hospice and home health agencies, due to suspicions of fraud. However, some legitimate providers are being caught in the dragnet and may not be able to survive, further diminishing access to quality care. Check out our Hospice News coverage on this issue here.
What do you think about the moratorium? I’d love to hear your thoughts in a comment or message. To explore this more deeply, my colleagues at Home Health Care News and HME Business are planning a webinar to discuss the issue on June 23. Save the date!
I have to acknowledge that my perspective on the moratorium is coming in its earliest days, and developments to come could change my mind. I’ll have my eye on a few things to solidify my point of view on it, including clarity around telehealth, further CMS action during the freeze, how the agency communicates its progress and intentions and its longer-term impact on the hospice community.
Interesting perspective, and I can definitely understand the concern about unintended consequences for rural and underserved communities.
As a newer hospice RN case manager who recently interviewed with multiple agencies before entering the field, I’ve honestly found myself with mixed feelings about the moratorium. While I absolutely worry about access issues long term, I also saw firsthand some newer agencies that seemed far more focused on rapid growth and reimbursement than on strong clinical support, training, and patient-centered care.
I actually wrote about this today from the perspective of a hospice nurse entering the field and trying to make sense of the changes, the fraud concerns, and what this may realistically mean for patients, families, nurses, and existing agencies.
“The Shift at the End — Week Three: Hospice, Fraud Crackdowns, and Why We’re All About to Document Like the FBI Is Watching.”
I’d genuinely be interested in your thoughts on it as someone covering the industry closely.
In Certificate of Need states, such as Florida, we already have rules that we abide by to ensure compliance and limiting entry of bad actors. These rules require proof of need, showing unserved deaths and a population of consumers that will benefit from adding hospice services and also require hospices to prove beyond any question that they are legitimate. To apply the moratorium to a CON state is ridiculous. Our state healthcare organization, AHCA, and our state trade organization FHPCA, work closely together and communicate on a routine basis. By implementing the moratorium now, it prohibits forward movement and freezes the process of adding one additional hospice to serve approximately 400 unserved deaths in Palm Beach county. We are currently in the middle of a batching cycle for consideration of this additional license. Our leaders at the federal level do not understand all of the nuances and unintended consequences.