Literature Review

Medicare spending, insurance claim denials top concerns: KFF poll Modern Healthcare; by Hayley Desilva; 1/17/25 A majority of individuals, regardless of their political leanings, say the federal government needs to spend more on healthcare programs, according to a KFF Health Tracking Poll released Friday. The survey of 1,310 people earlier this month highlights several areas in healthcare where the public would like to see things done differently. The results were published three days before a new administration is set to take over in Washington, D.C. 

CMS Health Equity Data Book U.S. Centers for Medicare and Medicaid Services - Office of Minority Health; by CMS Office of Minority Health; published December 2024, email notifications 1/15/25 One of the six pillars of the Centers for Medicare & Medicaid Services (CMS) 2023 Strategic Plan is to, “Advance health equity by addressing the health disparities that underlie our health system.” The CMS Office of Minority Health (OMH) aims to advance health equity by providing broader access to data about the state of health equity across CMS’ programs. This Data Book presents summary information on disparities within CMS programs as demonstrated by data related to prevalence. ... This Data Book is intended for use as a readily-available information source on health disparities within the Medicare, Medicaid, and the Health Insurance Marketplace populations. This Data Book is organized into five key sections – CMS at a Glance, Demographics, Chronic Conditions, Behavioral Health, and Social Determinants of Health – so that Data Book users can jump to the section most relevant to their data needs. Within each section, data are presented by each population type.

Concurrent/simultaneous services from Hospice and a Home and Community Based Services waiver- UPDATED Information about claims submissionAlabama Media Portal - media.alabama.gov; by the State of Alabama Press Release - Medicaid; 1/14/25The Alabama Medicaid Agency (Medicaid) updated the policy to allow concurrent services from hospice and a Home and Community-Based Services (HCBS) Waiver. However, it is vital that the hospice and HCBS waiver case manager coordinate to avoid duplication of services.The HCBS waiver person-centered care plan (PCCP) and hospice plan of care (POC) of the recipient should be coordinated between the hospice, HCBS waiver case manager, and the recipient and his/her caregiver. A conference that includes these parties must be held before concurrent services can start. The PCCP/POC conference shall be documented in both the recipient’s hospice and waiver record. [Click on the title's link to continue reading.]

The most-read Health Affairs Forefront articles of 2024 Health Affairs; by Health Affairs; 1/8/25... [We] offer a look back at the most-read Health Affairs Forefront articles of 2024. Each year’s list has its own character. This year’s list is heavy on work by authors at the Centers for Medicare and Medicaid Services—in particular, articles from our Forefront Featured Topic “Accountable Care For Population Health,” which claimed the first three spots on the “top ten” roster.

MA Special Needs Beneficiaries more likely to receive lower quality hospice care Hospice News; by Jim Parker; 1/2/25 Medicare Advantage special needs plan (SNP) beneficiaries were more likely to use lower-quality hospices than those enrolled in fee-for-service Medicare. Researchers from the Perelman School of Medicine at University of Pennsylvania in Philadelphia examined Medicare enrollment and claims data for 4.2 million decedents and 2.2 million hospice enrollees from Jan 1, 2018 to Dec. 31, 2019. Among other findings, results indicated that MA SNP beneficiaries were more likely to receive care from hospices with lower Hospice Quality Reporting Program (HQRP) scores. “These results suggest that policymakers should consider incentivizing referrals to high-quality hospices and approaches to educating beneficiaries on identifying high-quality hospice care,” researchers wrote in the study, published in JAMA Network Open. Editor's note: Click here for the CMS.gov Special Needs Plans webpage.

Accountable Health Communities (AHC) Model: Third evaluation report (2018-2023)CMS press release; 12/27/24The Accountable Health Communities (AHC) Model tested whether connecting beneficiaries to community resources for their health-related social needs (HRSNs) improved health care utilization outcomes and reduced costs. [The five core HRNS's include housing instability, food insecurity, transportation problems, utility difficulties, and interpersonal violence.] Collectively, these findings provide evidence that navigation can transform the delivery of care in ways that address major HRSN barriers to health and promote health equity for underserved populations.

Inside the CMS plan to streamline quality measurement Modern Healthcare; by Bridget Early; 12/23/24 Quality measurement is burdensome and complicated. The government and the private sector are struggling to figure out a good fix. The Centers for Medicare and Medicaid Services uses quality data to inform its reimbursement rates, so it's a high-stakes matter for providers and health insurance companies. CMS has proposed an overarching framework meant to streamline the process: the Universal Foundation. ... The Universal Foundation consists of two dozen quality measures across several categories that track wellness and prevention, chronic conditions, behavioral health, and "person-centered" care. Those include measures of breast and colorectal cancer screenings, blood pressure, blood sugar levels, vaccinations, and hospital readmissions. ... CMS has incorporated this framework into recent regulations such as the Medicare Advantage final rule for 2024 and the Physician Fee Schedule final rule for 2025. 

You heard that correctly: Scammers are committing hospice fraud Federal Trade Commission - Consumer Advice; by Kira Krown, Consumer Education Specialist; 12/13/24 Did someone reach out and offer free, in-home perks like cooking and cleaning in exchange for your Medicare number? Don’t give it. That could be a scammer trying to commit hospice fraud.Scammers are targeting older adults — with calls, texts, emails, fake ads, and even door-to-door visits — claiming they’ll set you up with services like free cooking, cleaning, and home health care. What they likely won’t tell you is how: They want to commit fraud by signing you up for Medicare hospice — that’s right, hospice — care. Then, they can bill Medicare for all kinds of services in your name. Here’s what to know: ..Editor's note: Share this crucial information information from the Federal Trade Commission with communities you serve, your employees, and your volunteers. 

[OIG] Health Care Fraud and Abuse Control Program Fiscal Year 2023 ReportOIG press release; 12/6/24Today, OIG, the Department of Health and Human Services, and the Department of Justice released the Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2023, which details the latest interagency efforts to decrease health care fraud and recover over $1.8 billion. [Click link above to read the Fiscal Year 2023 Report.]

Regulators extend some telemedicine flexibilities, gauge telehealth’s ‘new path forward’ in hospice Hospice News; by Holly Vossel; 12/4/24 Regulators recently extended certain temporary telemedicine waivers granted during the pandemic, with some flexibilities now sunsetting in 2025 rather than the end of this year. The U.S. Drug Enforcement Administration (DEA) and the U.S. Department of Health and Human Services (HHS) have announced the extension of telemedicine flexibilities for the prescribing of controlled medications until Dec. 31, 2025. ... The move was made in response to feedback the agencies received from more than 38,000 comments and two days of public listening sessions. The extension allows for more time to consider a “new path forward” for telemedicine, according to the DEA and HHS. “We continue to carefully consider the input received and are working to promulgate a final set of telemedicine regulations,” the agencies stated in an announcement. “With the end of 2024 quickly approaching, DEA, jointly with HHS, has extended current telemedicine flexibilities through December 31, 2025.” The temporary rule, entitled as the Third Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications, was recently submitted to the Federal Register and will take effect/become effective Jan. 1, 2025.

What is compliance risk? TechTarget; by Katie Terrell Hanna and Francesca Sales; 11/26/24 Compliance risk is an organization's potential exposure to legal penalties, financial forfeiture and material loss, resulting from its failure to act in accordance with industry laws and regulations, internal policies or prescribed best practices. Compliance risk is also known as integrity risk. Organizations of all types and sizes are exposed to compliance risk, whether they are public or private entities, for-profit or nonprofit, state or federal. An organization's failure to comply with applicable laws and regulations can affect its revenue, which can lead to loss of reputation, business opportunities and valuation. Types of compliance risk ... An organization might be implicated in the following types of compliance risks:

OIG issues nursing facility industry segment-specific Compliance Program Guidance; first in a series in Furtherance of its Modernization Initiative Butzel - Attorneys and Counselors Client Alerts; 11/22/24 On November 20, 2024, the U.S. Department of Health & Human Services, Office of Inspector General (“OIG”) issued the first Industry Segment-Specific Compliance Program Guidance (“ICPG”), which applies to the Nursing Facility Industry. This follows from the OIG’s Modernization Initiative to update publicly available resources for the healthcare industry first announced in September 20211 and finalized in April 2023. This ICPG comes just over a year after the OIG issued the General Compliance Program Guidance (“GCPG”) that kicked off the OIG’s efforts to modernize and consolidate numerous Compliance Program Guidance documents issued between 1998 and 2008. Editor's note: Click here to download the U.S. HHS OIG's 59-page November 2024 "NURSING FACILITY Industry Segment-Specific Complicance Program Guidance." A word search finds 30 references to "hospice."

Hospices leaders: ‘Vigilant’ compliance pivotal in MAC auditing climate Hospice News; by Holly Vossel; 11/18/24 e auditing environment has heated up in the hospice industry, with inconsistencies reportedly proliferating among the various types of regulatory enforcement activity — particularly those performed by Medicare Administrative Contractors (MACs). The issue has some hospice providers delving deeper into a range of compliance strategies. Differences exist in the scope of data being reviewed by MAC auditors, as well as the audit appeals approval and denial processes, said Ashley Arnold, senior vice president of quality at St. Croix Hospice. The Minnesota-headquartered hospice provides care across 85 locations in 10 Midwestern states and has an average daily census of roughly 5,200 patients.