I think we need to stop for a minute and talk about what “payment suspension” actually means, because this is not the same thing as a post-payment review where Medicare has already paid the hospice and is now demanding money back. CMS is withholding Medicare payments from hospice providers while the review and investigation process continues.
Meanwhile, those hospices are still taking care of patients. Nurses still have to be paid. Pharmacy and DME bills are still coming in. There is still rent, insurance, payroll taxes, utilities, and every other expense involved in operating a hospice. The care doesn’t stop simply because the Medicare payments do, and that is what makes this so concerning.
CMS has made it clear that Medicare fraud prevention is becoming increasingly data driven. The agency is using advanced analytics, artificial intelligence, and machine-learning models to identify unusual billing patterns and other indicators of potential fraud, waste, or abuse. Once something looks unusual, the government has the ability to start looking deeper.
I want to be careful about one distinction. CMS has not said that a specific AI model was responsible for identifying each of the hospice providers included in that $23 million figure. What CMS has made very clear, however, is that hospice is part of a much broader technology-driven fraud enforcement environment.
For hospice leaders, the takeaway should be pretty simple: you need to know what your own data is saying before somebody else starts asking questions about it.
Know Your Trends Before CMS Does
Hospice leaders should already be monitoring the same kinds of indicators CMS can see through claims and other data. That includes length of stay, live discharges, diagnoses, utilization, visit patterns, non-hospice spending, referral concentrations, admissions, and the other measures reflected in the Supplemental Security Value Index, or SSVI. The purpose is not to manipulate your numbers so your hospice looks “normal.” Every hospice is different. Patient populations are different. Referral sources are different. Markets are different. There can be perfectly legitimate reasons why one hospice looks different from another. The purpose is to know when something changes.
If your live discharge rate suddenly starts climbing, you should know it. If your length of stay begins moving significantly, you should know it. If one diagnosis suddenly represents a much larger percentage of your census, you should know it. If non-hospice spending changes, visit patterns shift, or another metric begins moving away from your historical baseline, leadership should be able to see that change and start asking why. Sometimes there will be a perfectly reasonable explanation. Sometimes the change will uncover a clinical, documentation, operational, or billing issue that needs attention. Either way, I would much rather have the hospice find it first.
The Problem With Finding Out After Payments Stop
We are working with organizations going through increased Medicare scrutiny, and one of the most difficult parts is the uncertainty. There is not always a clear roadmap telling the provider exactly what is happening, how long each step will take, or when the process will be resolved. That uncertainty becomes much more serious when reimbursement is interrupted.
A hospice can have adequate reserves and still find itself under tremendous financial pressure if Medicare payments stop for an extended period. Your expenses don’t disappear while everyone waits for records to be reviewed and decisions to be made. That is why I believe the best protection is prevention.
You cannot guarantee that CMS will never look at your organization. You can, however, build systems that allow leadership to identify unusual changes early, investigate them, document legitimate explanations, and correct problems before they become much larger.
We Have Been Monitoring This for Years
At The Amity Group, we developed an agency-level monitoring tool years ago because we believed chart auditing alone was not enough. We wanted our clients to be able to see what was happening across their entire organization over time. Today, that tool monitors the same types of metrics reflected in SSVI and other areas receiving increased government attention. More importantly, we don’t simply look at one month’s number. We look at the trend. That matters because a single number only tells you where you are today. A trend tells you where you’re going.
If we see something beginning to move, leadership has an opportunity to ask questions while the change is still small. We can then drill into the underlying records, determine whether there is a legitimate clinical or operational explanation, identify documentation weaknesses, and address problems before they become established patterns. That is a very different position from trying to explain an outlier after Medicare reimbursement has already been suspended.
Chart Auditing Still Matters
None of this replaces chart auditing. In fact, I believe it makes good chart auditing even more important.
The data may tell you where to look, but the medical record ultimately needs to explain what happened. If your numbers show something unusual, your documentation needs to support the clinical reality behind those numbers. That is why compliance today has to work in both directions. Leadership needs to understand what the organization looks like through its data, and experienced clinical reviewers need to make sure the medical records support the care being provided and billed.
One without the other leaves a significant blind spot.
Staying Off the Radar Is Easier Than Getting Off of It
The hospice compliance environment has changed significantly. CMS has more data, better technology, and increasingly sophisticated tools for identifying providers that look different from their peers or from their own historical patterns. Hospice leaders need equally good visibility into their own organizations.
Know your numbers. Know your trends. Investigate changes early. Audit the records behind them. Correct problems when you still have an opportunity to correct them. Because once Medicare payments stop, you may be trying to operate a hospice while simultaneously proving why they should start again.
At The Amity Group, our Audit Protection & Compliance Division combines ongoing clinical record review with agency-level trend monitoring so hospice leaders can identify risks before they become crises.
In this new world of Medicare oversight, I believe that is one of the most important protections a hospice can have.
AmityStaffing.com
