What’s next for integrity of home health and hospice?

Jennifer Sheets

Submitted photo/InsideSources

The evidence that CMS has cited shows fraud concentrated in specific geographies and among specific actors, not spread evenly nationwide. When the risk is concentrated, the response should be, too. A nationwide freeze treats every market the same, regardless of whether that market has ever shown a pattern of abuse. You wouldn’t take a sledgehammer to pound a nail, yet that is precisely what is happening here.”

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OPINION — Fraud in home health and hospice care is real, and it hurts everyone who touches this industry — patients, who deserve care they can trust, taxpayers, who fund the Medicare program, and the honest providers, whose reputations are dragged down every time a bad actor makes headlines.

We have spent years pushing for more effective oversight, and we will continue to do so.

On May 13, Centers for Medicare & Medicaid Services imposed a six-month nationwide freeze on new Medicare enrollment for home-health agencies and hospice providers. The action sends an unmistakable signal: Washington is watching, and it is acting. Urgency has its place, but urgency without precision has consequences, and those consequences have landed on providers who did nothing wrong, and the individuals and families they serve. 

Now, as we approach that six-month mark, our industry is anxiously awaiting what comes next. 

The overwhelming majority of home-health and hospice-care providers deliver exactly the kind of compliant, person-centered care CMS says it wants to protect. A nationwide moratorium does not distinguish between the operator running a fraud scheme and the agency serving a rural community.

More importantly, it does nothing to stop bad actors already taking advantage of the Medicare program.

This national moratorium is a blanket instrument applied to a targeted geographic problem, and that mismatch reduces competition, slows innovation and freezes out new providers, who could otherwise be improving care in their communities and reaching underserved populations.  

The access implications are more worrying. In many regions, patient demand for home-health and hospice services is rising while capacity is already stretched thin. That is especially true in rural and underserved communities, where a single new agency can be the difference between an individual receiving care at home or going without. 

The evidence that CMS has cited shows fraud concentrated in specific geographies and among specific actors, not spread evenly nationwide. When the risk is concentrated, the response should be, too. A nationwide freeze treats every market the same, regardless of whether that market has ever shown a pattern of abuse. You wouldn’t take a sledgehammer to pound a nail, yet that is precisely what is happening here.  

And for legitimate operators, the moratorium removes one of the clearest paths to growth: opening new Medicare-certified locations. That pathway is now off the table for everyone, not just the bad actors CMS is trying to stop. Many states condition Medicaid participation on a provider’s Medicare enrollment. This means Medicaid beneficiaries are affected. At a moment when demand for home-based care is climbing, an entire industry’s ability to expand and meet that demand is on hold.  

The provider community has long recommended a different approach, and we have continued to share those with CMS. Program integrity works best when it is data-driven and risk-based, aimed at known bad actors and high-risk geographies rather than the entire provider community.  

We do not want to be bystanders in this effort. We want to be partners. Providers see the patterns on the ground before regulators do. We are prepared to bring that knowledge to the table, to help CMS build tools that find bad actors faster and with less collateral damage to the providers doing this work honestly. 

As we approach six months of the home-health and hospice moratorium, we urge CMS not to extend this broad measure. Instead, we ask the agency to use targeted, risk-based enforcement strategies that allow legitimate providers to better meet community needs while focusing efforts to stop fraudsters in high-risk areas.  

CMS is right to act. We are asking the agency to act with precision instead of a blanket freeze. We stand ready to help build that approach. 

Jennifer Sheets is CEO of the National Alliance for Care at Home. She wrote this for InsideSources.com. Please submit comments at yourvalley.net/letters or email them to AzOpinions@iniusa.org. We are committed to publishing a wide variety of reader opinions, as long as they meet our Civility Guidelines.