HCP 517 Week 1 Compliance Program Elements for a Chosen Health Care Sector Example

Building a Hospice Compliance Program From the Sector's Own Risks: Eligibility, Long Stays, Levels of Care and Referral Relationships in a Six-County Nonprofit Hospice

[Student Name]

University of Phoenix

HCP/517: Communication and Reporting Mechanisms in Compliance

Week 1 Assignment

[Instructor Name]

[Date]

The hospice, its census, patients and program are composites written for a model paper; federal data, reports and research come from the sources listed.

A composite nonprofit hospice serving six counties hired its first dedicated compliance director last spring. The hospice cares for about 410 patients on an average day, most at home and some in nursing facilities and assisted living, with a small inpatient unit. In two years, its average length of stay rose from 71 to 94 days and live discharges, patients discharged alive because they were no longer terminally ill or chose to leave, doubled. The board asked the director to build a compliance program designed for hospice. This paper outlines it.

Why Hospice

Medicare's hospice benefit pays for palliative care once a physician judges that a patient would likely live six months or less if the disease followed its usual course, and the patient chooses comfort over cure for that illness. The benefit has grown rapidly. In 2024, about 6,706 hospices, 5,497 of them for-profit, cared for more than 1.8 million Medicare beneficiaries, including 52.9% of Medicare decedents, and Medicare spent $28.3 billion; the average lifetime length of stay for decedents was 99.6 days, while the median was 19 days (Medicare Payment Advisory Commission, 2026). Growth has come mostly from for-profit entrants.

Where Oversight Has Found Problems

A federal inspector general's portfolio of work on hospice described investigations that found hospices enrolling patients without their knowledge or under false pretenses, enrolling people who were not terminally ill, billing for services not provided, paying kickbacks and falsifying documentation, alongside quality problems such as care not provided as planned (Office of Inspector General, 2018). These findings point directly to the risks the program must address.

Why Length of Stay Draws Scrutiny

Research explains why long stays and certain diagnoses draw attention. A national study found that patients of for-profit hospices were less often cancer patients and more often people with dementia and other noncancer diagnoses, a longer median length of stay and more patients with stays longer than a year (Wachterman et al., 2011). Stays longer than six months are not improper in themselves, since prognosis is uncertain, but they require strong documentation that the patient remained terminally ill.

How Hospice Payment Creates Risk

Hospice payment is a per diem: the program pays for every day of enrollment, and the rate depends on which of four levels of care the patient receives that day: routine home care, continuous home care during crises, inpatient respite care and general inpatient care for symptoms that cannot be managed elsewhere. Physicians must certify terminal illness at admission and recertify at each benefit period, with a face-to-face encounter before the third benefit period and each one after. A per-patient aggregate cap limits total payments. Daily payment rewards longer stays; higher levels of care pay more; and certification depends on clinical judgment documented in narrative form. In hospice, the most important compliance fact on every claim is a prognosis, and prognosis is a judgment that must be written down honestly.

The Hospice's Own Signals

The director reviewed the hospice's own data. Patients with dementia had risen from 19% to 31% of admissions. Live discharges reached 17% of discharges, most of them patients with dementia or heart failure who had stabilized. Two nursing facilities referred a large share of admissions, and a marketing liaison had been paid a bonus tied to admissions. None of these facts proved a problem, but each matched a pattern the inspector general had described.

What Families and Patients Need From Compliance

Compliance in hospice also protects patients and families directly. A patient enrolled who is not terminally ill gives up curative treatment for the illness without need; a family told the hospice will provide more than it delivers may be left alone at the worst moment. The director framed the program for staff in those terms: accurate eligibility decisions and honest descriptions of services are part of good end-of-life care, not paperwork added to it.

The Survey Picture

Quality oversight adds another layer of risk. Hospices are surveyed by state agencies or accrediting organizations against federal conditions of participation, and recent federal rules created a special focus program for hospices with poor survey records. The hospice's last survey found two deficiencies in care planning, which the program will track alongside billing risks.

Element One: Policies for Hospice Risks

Policies will address eligibility determination and documentation, recertification and face-to-face encounters, levels of care with clear criteria for general inpatient and continuous home care, live discharge decisions, visit requirements, relationships with nursing facilities and referral sources and compensation of marketing staff.

Interpreting the Signals Fairly

The rise in length of stay and live discharges did not prove wrongdoing. More patients with dementia, whose decline is slower and harder to predict, would lengthen stays and increase stabilizations on their own. The director's first question was therefore whether each long-stay patient's record documented continued terminal decline, not whether the numbers were too high. Signals point to where to look; documentation shows what is true.

Element Two: Leadership and Oversight

The director's line runs to the chief executive, and each quarter she reports in person to the board committee for quality and compliance. An internal committee brings together the hospice's physician leader, the head of nursing and clinical care, finance and the manager of the inpatient unit.

Element Three: Training

Training will be role-specific: physicians on prognosis documentation, nurses on eligibility narratives and level-of-care criteria, marketing staff on kickback rules and all staff on reporting concerns.

Element Four: Reporting Channels

A hotline and direct access to the director will be promoted to field staff who work alone in homes and facilities, since they are often first to see problems.

Element Five: Consistent Standards

Discipline and incentives will be applied consistently, and the admissions bonus for marketing staff will be replaced with a salary and quality-based measures.

Element Six: Risk Assessment, Auditing and Monitoring

Monitoring will track length of stay, live discharges, admissions by referral source, diagnosis mix and level-of-care use. Audits will review eligibility for long-stay patients, general inpatient care and patients discharged alive, using clinicians independent of the patients' care teams.

Element Seven: Response and Correction

Findings will lead to root cause analysis, corrective action and prompt repayment wherever claims were not supported by the record.

First-Year Priorities

The director set three priorities: an eligibility audit of patients with stays over 180 days, a review of every referral relationship and marketing compensation and training for physicians and nurses on documenting prognosis.

Conclusion

Hospice has grown quickly and been found to carry specific risks: enrolling patients who are not terminally ill, long stays without documented eligibility, misuse of higher levels of care and kickbacks. Federal data, inspector general findings and research on stays and diagnoses show where to look. Tailoring each program element to those risks gives the hospice a program built for its sector.

References

Medicare Payment Advisory Commission. (2026). Hospice services. In Report to the Congress: Medicare payment policy (pp. 293-324). https://www.medpac.gov/wp-content/uploads/2026/03/Mar26_Ch10_MedPAC_Report_To_Congress_SEC.pdf

Office of Inspector General. (2018). Vulnerabilities in the Medicare hospice program affect quality care and program integrity: An OIG portfolio (OEI-02-16-00570). U.S. Department of Health and Human Services. https://oig.hhs.gov/oei/reports/oei-02-16-00570.pdf

Wachterman, M. W., Marcantonio, E. R., Davis, R. B., & McCarthy, E. P. (2011). Association of hospice agency profit status with patient diagnosis, location of care, and length of stay. JAMA, 305(5), 472-479. https://doi.org/10.1001/jama.2011.70