Navigating the Latest Hospice Regulatory Reviews: Key Updates from HCRA Consulting Group
At HCRA Consulting Group, we are committed to keeping our clients informed of critical regulatory developments. We recently participated in a deep-dive session on hospice regulatory reviews led by ACHC and its partnering industry experts. Here’s what you need to know:
Who’s Reviewing Hospices?
Several key organizations are actively involved in hospice audits and oversight, including:
MACs (Medicare Administrative Contractors) – e.g. Palmetto, CGS, and NGS
CERT Auditors (Comprehensive Error Rate Testing)
SMRC (Supplemental Medical Review Contractors)
UPIC (Unified Program Integrity Contractors) – e.g. Qlarant Integrity Solutions
OIG (Office of Inspector General)
RACs (Recovery Audit Contractors)
Each has a different role, but all aim to ensure compliance, prevent fraud, and improve hospice service quality. If your agency has recently been evaluated or is in the process of being reviewed by any of these organizations, it is crucial to grasp the primary roles of each reviewing body to facilitate a smooth clearance process.
Key Regulatory Programs Impacting Hospices:
Special Focus Program (SFP):
Although currently on hold, this program targets underperforming hospices. Facilities flagged under SFP face frequent inspections and must correct deficiencies quickly or risk certification termination. Remedies could include civil penalties, payment suspension, or appointment of temporary management.
Provisional Period of Enhanced Oversight (PPEO):
New hospices in high-growth states like Texas, California, Nevada, and Arizona will undergo a year-long prepayment review. This process will delay payments and increases administrative tasks. Poor performance during PPEO could lead to Medicare enrollment revocation.
Targeted Probe and Educate (TPE):
This initiative focuses on high-risk billing practices. Providers with elevated claim errors will be reviewed, educated, and given opportunities to improve before further action is taken. Common issues include incomplete physician certifications and lack of supporting documentation for patient eligibility.
Other Audit and Review Programs:
CERT Reviews focus on random sampling to detect improper payments.
SMRC Audits target known areas of improper billing, such as GIP level of care and certification errors.
UPIC Investigations (Qlarant) operate under the assumption of potential fraud, often leading to law enforcement referrals.
OIG Oversight continues to focus on documentation deficiencies and inappropriate billing, with serious financial implications for providers.
What Does This Mean for Your Hospice?
Hospice providers must ensure thorough, accurate documentation and compliance with Medicare regulations.
Newly established hospices must fully understand the new PPEO process and be prepared for an automatic review. It is crucial to ensure adherence to all Medicare requirements and full compliance with hospice program documentation requirements from day one. Maintaining meticulous documentation and adherence to these standards will be key to your organization's success during the automatic review process.
Key focus areas include proper patient eligibility documentation, accurate physician certifications, and detailed encounter notes.
At HCRA Consulting Group, we stand ready to support you through this increasingly complex regulatory environment. Whether you are preparing for a MAC audit, facing PPEO challenges, or responding to TPE findings, our team can help you navigate the process and strengthen your compliance program.
Need Help?
Contact HCRA Consulting Group today to schedule a consultation and prepare your hospice for success in 2025 and beyond.
