Hospice Medical Directors: How Many Is Too Many?

According to recent guidance from the Centers for Medicare & Medicaid Services (CMS) Region V, having more than one Medical Director for each hospice provider number could lead to sanctions, including termination. On January 12, 2018, CMS Region V sent out clarification to their state agencies on the roles of the hospice Medical Director and other hospice physicians engaged by a hospice. The clarification was issued after numerous hospices in CMS Region V were cited in 2017 for conditional level survey deficiencies in connection with the role and numbers of their Medical Directors. In particular, initially surveyors in Region V asserted that a hospice can have only one Medical Director, and that the single Medical Director must certify and recertify a patient’s terminal illness. Hospice agencies who were cited either had multiple physicians designated as “Medical Directors,” or allowed other hospice physicians not designated as the Medical Director to certify or recertify a patient’s terminal illness.

Some relief from this unworkable model was provided in the January clarification from CMS Region V. It provides that, for each hospice agency (i.e., for each hospice provider number, including satellite, branch, or multiple site locations), there can be only one Medical Director. However, Region V’s clarification now provides that either the Medical Director or a physician from the interdisciplinary team (IDT) may certify or recertify a patient’s terminal illness or eligibility for the hospice benefit.

While this clarification came from CMS’s Region V Office in Chicago, it was issued after lengthy dialogue with and input from the CMS Central Office in Baltimore. Moreover, the clarification cites hospice conditions of participation at 42 C.F.R. § 418.12 as authority for its position. Whether this survey scrutiny on the number of Medical Directors and their roles will spread to other regions is not entirely clear. However, it would be prudent for hospices to review their Medical Director rosters and take steps to align with Region V’s clarification. These steps should include:

• Review employment contracts to ensure that there is only one contract with the job title of hospice Medical Director per hospice provider number and that job titles for any other hospice physicians are labeled appropriately. An appropriate title would be “hospice physician.” The latter contracts should not simply be duplicative of the Medical Director contract, but should specify that hospice physicians are supervised by the Medical Director.
• Review and update policies and procedures and other relevant documents to ensure that they clearly delineate that there is only one hospice Medical Director per hospice provider number.
• Since federal law requires that the hospice Medical Director be responsible for the medical component of the hospice’s patient care program, including overseeing the implementation of the hospice’s physician, nursing, social work, therapy, and counseling areas to ensure the areas meet patient and family needs, hospices should review their contracts, policies and procedures to ensure that these job responsibilities are clearly delineated as obligations of the Medical Director. These obligations extend to all hospice multiple, satellite, or branch locations.
• In the absence of the hospice Medical Director, the hospice should have a “physician designee” to serve in the Medical Director’s absence, and the Medical Director contract should provide for this measure.
• Organizational charts and policy and procedure documents should clearly delineate that all other hospice physicians report to the Medical Director.
• During surveys, hospice staff and personnel should be able to answer questions regarding their understanding of the roles of the physicians that are engaged by the hospice, including that there is only one hospice Medical Director. Staff and personnel should be able to identify the Medical Director and communicate an understanding of the Medical Director’s role for the hospice.