Literature Review
All posts tagged with “Regulatory News.”
A glossary of Medicare terms
06/03/25 at 02:00 AMA glossary of Medicare termsMedicalNewsToday; by Mandy French, medically reviewed by Oluwatoyin Kuloyo, Pharm.D., BCPS; 6/2/25 When a person first signs up for Medicare, they may come across many terms and abbreviations. Learning the definitions of these terms can help make it easier to understand and navigate Medicare. Medicare information can be confusing. This A to Z glossary can help individuals understand some common terms, acronyms, and abbreviations. ... Editor's note: A must-have resource to use and distribute, with multiple links to more depth information at Medicare.gov and MedicalNewsToday.
Why CMS’ GUIDE Model could move home care from side act to main stage
06/02/25 at 03:00 AMWhy CMS’ GUIDE Model could move home care from side act to main stage Home Health Care News; by Joyce Famakinwa; 5/29/25 The Guiding an Improved Dementia Experience (GUIDE) Model might be one of the biggest steps in the right direction for recent Medicare policy. The eight-year voluntary nationwide program was launched last year by the Centers for Medicare & Medicaid Services (CMS), with the goal of supporting individuals living with dementia, as well as their unpaid caregivers. The program’s focus is more important than ever, with an estimated 6.7 million people living with dementia. This amount is expected to skyrocket to 14 million cases by 2060, according to data made available by CMS.
Door remains closed on CMS forums as new rules, requirements are phased in
05/30/25 at 03:00 AMDoor remains closed on CMS forums as new rules, requirements are phased in McKnights Long-Term Care News; by Kimberly Marselas; 5/28/25 Four months into the new presidential administration, skilled nursing leaders have had no opportunity to hear directly from Centers for Medicare & Medicaid Services staff during traditional Open Door Forums or National Stakeholder Calls. Open Door Forums have been held three-to-five times annually in a practice that started more than 20 years ago. The online meetings give providers, vendors and other stakeholders an opportunity to learn more about regulatory and logistical changes being pursued by CMS, as well as providing question-and-answer sessions with policy architects. In addition to skilled nursing forums, CMS has in the past also hosted similar events for home health, long-term care services and supports, rural health and other provider types. But CMS in January cancelled a skilled nursing forum and all others planned for February and has yet to add any new forums or stakeholder calls — which often feature the administrator discussing major policy or clinical updates — to its calendar.
CMS: Kidney Care Choices (KCC) Model
05/29/25 at 03:00 AMCMS: Kidney Care Choices (KCC) Model CMS.gov - Centers for Medicare & Medicaid Services; 5/27/25 The Centers for Medicare & Medicaid Services (CMS) is announcing a coordinated set of changes to the Kidney Care Choices (KCC) Model starting in performance year 2026 that are expected to improve the model test by adjusting the financial methodology and participation options to improve model sustainability. In addition, the model is being extended by one year for continuation of quality care to beneficiaries through 2027. For more information, please visit KCC Model Performance Year 2026 Updates.
CMS rolls out aggressive strategy to enhance and accelerate Medicare Advantage audits
05/27/25 at 03:00 AMCMS rolls out aggressive strategy to enhance and accelerate Medicare Advantage audits CMS Newsroom; Press RElease; 5/21/25 Agency Will Begin Auditing All Eligible Medicare Advantage Contracts Each Payment Year and Add Resources to Expedite Completion of 2018 to 2024 AuditsToday, the Centers for Medicare & Medicaid Services (CMS) announced a significant expansion of its auditing efforts for Medicare Advantage (MA) plans. Beginning immediately, CMS will audit all eligible MA contracts for each payment year in all newly initiated audits and invest additional resources to expedite the completion of audits for payment years 2018 through 2024.
Proposed California budget calls for prior authorization for hospice in Medicaid
05/23/25 at 03:00 AMProposed California budget calls for prior authorization for hospice in Medicaid Hospice News; by Jim Parker; 5/22/25 The proposed California budget would require prior authorizations for hospice care within the state’s Medicaid program. Currently, Medicaid managed care plans who provide coverage through the state’s Medicaid system, Medi-Cal, may not perform prior authorizations for hospice. California’s Department of Health Care Services (DHCS) indicated in a 2025-2026 budget revision that this could save $25 million over the next two years and more than $50 million in the long term. If enacted, this would make California the first state in the nation to implement such a rule, according to the California Hospice & Palliative Care Association (CHAPCA). The association contends that the anticipated $25 million in cost savings is “speculative and fails to account for the downstream costs and systemic burdens this proposal would create,” according to a position paper shared with Hospice News. ... CHAPCA recommended to the state government three alternative approaches: ...
‘We need you to work with us’: Home health providers renegotiate better Medicare Advantage deals
05/22/25 at 03:00 AM‘We need you to work with us’: Home health providers renegotiate better Medicare Advantage deals Home Health Care News; by Joyce Famakinwa; 5/20/25 As Medicare Advantage (MA) enrollment continues to surge, home health providers have seen slim margins deteriorate further. Some providers have openly expressed their decision to reject financially unsustainable MA contracts. Abandoning unfavorable MA contracts may sometimes be necessary, industry executives told Home Health Care News. However, some providers have improved their MA standing by renegotiating rates or returning after walking away, leveraging data and understanding the needs of payer partners. “We have walked away, in specific states, from payers and Medicare Advantage groups because of rates and the inability to raise those rates, and pre-authorization terms,” G. Scott Herman, CEO of New Day Healthcare, told HHCN.
AHA urges HHS to cut regulations that burden hospitals and staff
05/19/25 at 03:00 AMAHA urges HHS to cut regulations that burden hospitals and staff OR Manager; by Matt Danford; 5/16/25 The American Hospital Association (AHA) has called on the Department of Health and Human Services (HHS) to eliminate or ease a variety of federal regulations, arguing that excessive administrative rules drive up costs, reduce patient access, and hinder innovation, Modern Healthcare reported May 13. According to the article, the AHA submitted more than 100 deregulatory suggestions to HHS, the Centers for Medicare and Medicaid Services (CMS), and the Office of Management and Budget. [Continue reading for descriptions specific to billing and payment, quality and safety regulations, and workforce-related recommendations.]
HHS wants input on how to improve digital health tech for Medicare patients
05/19/25 at 03:00 AMHHS wants input on how to improve digital health tech for Medicare patients Fierce Healthcare; by Heather Landi; 5/14/25 The Department of Health and Human Services (HHS) wants feedback on how it can develop better digital health tools for Medicare beneficiaries and drive adoption. The Centers for Medicare & Medicaid Services (CMS), in partnership with HHS' health IT arm, now called the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC), is seeking public input on how best to "advance a seamless, secure, and patient-centered digital health infrastructure."
Medicaid hospice payments for room-and-board to resume in California
05/16/25 at 03:00 AMMedicaid hospice payments for room-and-board to resume in California Hospice News; by Jim Parker; 5/15/25 After years of nonpayment, the California Department of Health Care Services (DHCS) has instructed Medicaid managed care plans to pay hospices for nursing home room and board. The issue pertains to patients who are dually eligible for Medicare and Medicaid. When caring for patients in nursing homes, hospices typically pay for their room and board with the expectation that they will be reimbursed by Medicaid for those expenses. However, due to confusion among managed care plans that oversee Medicaid in most states, those hospices have not been receiving those payments.
UnitedHealth Group is under criminal investigation for possible Medicare fraud
05/16/25 at 02:00 AMUnitedHealth Group is under criminal investigation for possible Medicare fraud The Wall Street Journal; by Christopher Weaver and Anna Wilde Mathews; 5/15/25 The Justice Department is investigating UnitedHealth Group for possible criminal Medicare fraud, people familiar with the matter said. The healthcare-fraud unit of the Justice Department’s criminal division is overseeing the investigation, the people said, and it has been an active probe since at least last summer. While the exact nature of the potential criminal allegations against UnitedHealth is unclear, the people said the federal investigation is focusing on the company’s Medicare Advantage business practices. UnitedHealth said in a statement it hadn’t been notified by the Justice Department of the criminal investigation. The statement said the company stands “by the integrity of our Medicare Advantage program.” A DOJ spokesman declined to comment.
Dementia patient discharged from hospice over Medicare requirement. Here’s why it happened
05/15/25 at 03:00 AMDementia patient discharged from hospice over Medicare requirement. Here’s why it happened WKMG-6, Deltona, FL; by Erika Briguglio and Louis Bolden; 5/14/25A Volusia County family is left scrambling after their loved one is abruptly dropped from hospice care. To qualify for hospice, patients must have a life expectancy of six months or less. However, for dementia patients, the prognosis can be unpredictable. Hospice care can be extended as long as the patient continues to meet Medicare requirements. Unfortunately, these requirements are why Amy Yates lost coverage for her 91-year-old grandmother. ... “I think it’s she hasn’t died fast enough, and it’s costing them money that they don’t want to spend,” Yates told News 6. ... What Yates’ family is dealing with is what Medicare calls live discharge, and they are not alone. The Hospice Foundation of America reports that 17% of people in 2022 who were admitted to hospice care were discharged; about 6% of the total caseload was discharged because they no longer met Medicare requirements for care under the hospice benefit.Editor's note: What are your hospice stats for live discharges? For Length of Stay (LOS)? This factor--with the face-to-face recertification requirement--is crucial. Unfortunately, many hospices misused President Jimmy Carter's extraordinarily long LOS with misleading information about hospice care. They watered down "end-of-life" care and never mentioned anything about a basic recertification process. Warm, user-friendly language can be used with integrity, authenticity, and patient/caregiver support.
CMS seeks public input on improving technology to empower Medicare beneficiaries
05/14/25 at 03:00 AMCMS seeks public input on improving technology to empower Medicare beneficiaries CMS Newsroom; Press Release; 5/13/25 The Centers for Medicare & Medicaid Services (CMS) is taking bold steps to modernize the nation’s digital health ecosystem with a focus on empowering Medicare beneficiaries through greater access to innovative health technologies. The agency, in partnership with the Assistant Secretary for Technology Policy/Office of the National Coordinator for Health Information Technology (ASTP/ONC), is seeking public input on how best to advance a seamless, secure, and patient-centered digital health infrastructure. The goal is to unlock the power of modern technology to help seniors and their families take control of their health and well-being, manage chronic conditions, and access care more efficiently. ...
Be ready for updated Special Focus Program, hospice experts say
05/13/25 at 03:00 AMBe ready for updated Special Focus Program, hospice experts sayMcKnight's Home Care; by Adam Healy; 5/9/25A revised hospice Special Focus Program is coming, and providers should make sure they have plans and procedures in place to be successful under this strict oversight program, Linda Woodle, director of accreditation at Community Health Accreditation Partner (CHAP), and Patricia D’Arena, vice president of clinical excellence at Enhabit Home Health and Hospice, said... When that program will be reinstated is anyone’s guess... The Centers for Medicare & Medicaid Services has indicated that assessments will place a high emphasis on four specific Conditions of Participation: patient’s rights; initial and comprehensive assessment of the patient; interdisciplinary group, care planning and coordination of care; and quality assessment and performance improvement. So providers should ensure they meet all of these conditions’ requirements.
National Alliance: Medicaid cuts would adversely impact home-, community-based services
05/13/25 at 03:00 AMNational Alliance: Medicaid cuts would adversely impact home-, community-based services Hospice News; by Jim Parker; 5/12/25 A tax bill currently before Congress could lead to Medicaid cuts that would inhibit access to home- and community-based services (HCBS). The bill, which promises sweeping tax and spending cuts, currently is undergoing a reconciliation process. The amount of tax cuts could reach $4.5 trillion, with spending cuts in the area of $4.5 billion, with a significant portion coming from Medicaid. However, the bill remains a work in progress for now with some resistance to the proposed cuts from both Democrats and a contingent of Republicans. The National Alliance for Care at Home released a statement Monday opposing the Medicaid reductions.
States sue HHS over layoffs, restructuring: 5 updates
05/08/25 at 03:00 AMStates sue HHS over layoffs, restructuring: 5 updates Becker's Hospital Review; by Madeline Ashley and Mackenzie Bean; 5/5/25 Nineteen states and the District of Columbia filed a lawsuit against the federal government May 5 aiming to block the Trump administration’s large-scale restructuring of HHS. In the lawsuit, New York Attorney General Letitia James and 19 other AGs argue the restructuring is an “unconstitutional and illegal dismantling of the department.” They contend the government has violated hundreds of laws and bypassed congressional authority by enacting the plan, which has erased decades of public health progress and left HHS unable to execute many vital functions.
The Joint Commission cuts 55 administrative employees
05/08/25 at 03:00 AMThe Joint Commission cuts 55 administrative employees Modern Healthcare; by Hayley Desilva; 5/6/25The Joint Commission said Tuesday it laid off 55 administrative employees last week as the organization navigates structural changes to improve its operational efficiency. All affected employees worked at the organization’s central office in Oakbrook Terrace, Illinois. The Joint Commission declined to say whether those employees could apply for other roles or if additional cuts are planned. ... The organization also declined to comment on the status of any funding from the federal government. In its most recent federal tax filing, for 2023, it reported more than $207 million in total revenue, a $1.4 million decrease from 2022.
California man sentenced to 12 years’ imprisonment in connection with $17m Medicare fraud schemes
05/08/25 at 03:00 AMCalifornia man sentenced to 12 years’ imprisonment in connection with $17m Medicare fraud schemes U.S. Department of Justice - Office of Public Affairs; Press Release; 2/6/25 A California man was sentenced yesterday to 12 years in prison and three years of supervised release for his role in a years-long scheme to defraud Medicare of more than $17 million through sham hospice companies and his home health care company. According to court documents, Petros Fichidzhyan, 44, of Granada Hills, schemed with others to bill Medicare for hospice services that were not medically necessary and never provided. Fichidzhyan and his co-schemers controlled hospice entities and used foreign nationals’ personal identifying information (PII) to conceal the scheme, using the PII to, among other things, open bank accounts, submit information to Medicare, and sign property leases.
CMS Proposed Rules and Comment Deadlines
05/06/25 at 03:00 AMCMS Proposed Rules and Comment Deadlines HealthIT Answers; by HHS/ONC/CMS Communications; 5/5/25 Center for Medicare & Medicaid Services have issued the following proposed rules and have opened comment periods.
RFK Jr. is gutting minority health offices across HHS that are key to reducing health disparities
05/05/25 at 03:05 AMRFK Jr. is gutting minority health offices across HHS that are key to reducing health disparities NBC New York 4, in partnership with CNBC; by Annika Kim Constantino; 4/30/25
[Palmetto] Hospice Coalition Questions and Answers: March 6, 2025
05/05/25 at 03:00 AM[Palmetto] Hospice Coalition Questions and Answers: March 6, 2025Palmetto GBA press release; 4/18/25The March 6, 2025, Hospice Coalition Meeting Minutes are now available. Please review this information and share it with your staff.
Courts diverge in challenges to CMS's minimum staffing requirements for LTC facilities
05/02/25 at 03:10 AMCourts diverge in challenges to CMS's minimum staffing requirements for LTC facilities JD Supra; by Kayla Stachniak Kaplan, Scott Memmott, Sydney Menack, Jonathan York, Howard Young; 4/30/25On May 10, 2024, the Centers for Medicare and Medicaid Services (CMS) published its Final Rule to implement minimum staffing standards for long-term care (LTC) facilities in the United States. However, as discussed in our prior blog post, the Final Rule was immediately challenged under the Administrative Procedure Act (APA) in two major lawsuits. These cases have resulted in divergent rulings, injecting more uncertainty across the LTC industry about the future of the application and validity of the Final Rule. ... This and further developments in these cases will have significant impact on the future of CMS’s oversight of the country’s nursing homes.
HHS OIG: Greater oversight needed among new hospices
05/02/25 at 03:00 AMHHS OIG: Greater oversight needed among new hospices Hospice News; by Holly Vossel; 4/28/25 The U.S. Department of Health & Human Services (HHS) Office of Inspector General (OIG) is readying to unveil a new report that will unveil common billing trends among potentially fraudulent newly licensed hospices. The report, “Trends, Patterns, and Key Comparisons Related to New Medicare Hospice Provider Enrollments May Indicate the Need for Further Oversight” is expected to publish in Fiscal Year (FY) 2026. It will examine potential red flags of fraud, waste and abuse among newly enrolled Medicare hospice providers’ claims data. ... “The data brief may help CMS evaluate the need for additional monitoring and program integrity efforts to ensure that hospices meet all the requirements,” OIG stated in a recent announcement. “Our objective is to identify trends, patterns and key comparisons that indicate potential vulnerabilities related to new Medicare hospice provider enrollments.”
Administration to close HHS Civil Rights office
05/02/25 at 03:00 AMAdministration to close HHS Civil Rights office Newsmax; by Brian Freeman; 4/28/25 As part of massive cutbacks at the Department of Health and Human Services, the Centers for Medicare & Medicaid Services will shut down their civil rights office in June, according to an email sent to staff on Monday and viewed by Politico. HHS has already been reduced by some 20% as part of overall downsizing, with Secretary Robert F. Kennedy Jr. and President Donald Trump focusing on eliminating those programs and agencies they say promote diversity, equity, and inclusion. ... Complaints that are nearing completion connected to workplace harassment and discrimination will be closed out in the coming weeks, and remaining complaints will be "transferred to an appropriate entity," the email stated.Editor's note: Data from the 2024 NHPCO Facts and Figures Report states: "In CY 2022, 51.6% of White Medicare decedents used the Medicare Hospice Benefit. 38.1% of Asian American Medicare decedents and 37.4% of Black Medicare decedents enrolled in hospice. 38.3% of Hispanic and 37.1% of North American Native Medicare decedents used hospice in 2022." The discrepancies between white and non-white decedents demonstrate double-digit differences. Extensive evidence-based research validates wide gaps in hospice/healthcare for persons whom the HHS Civil Rights office is charged with protecting. For more, visit Office of Civi Rights Home | HHS.gov and Office of Civil Rights About Us.
Part D Plans cover a larger share of Medicare Beneficiaries in rural counties
05/01/25 at 03:10 AMPart D Plans cover a larger share of Medicare Beneficiaries in rural counties Managed Healthcare Executive; by Denise Myshko; 4/25/25 Medicare beneficiaries living in more rural counties are enrolled in traditional Medicare and rely on stand-alone prescription drug plans (PDPs), according to recent analysis from KFF.In fact, in 27 states, at least half of Medicare Part D enrollees living in the most rural areas are enrolled in stand-alone prescription drug plans. This includes 8 states with 75% or more of Part D enrollees in the most rural areas in prescription drug plans (Nevada, Alaska, Massachusetts, California, Kansas, Wyoming, Nebraska, and South Dakota). Nationwide, 58% of beneficiaries living in rural areas are enrolled in stand-alone prescription drug plans in 2025. The remainder (42%) are enrolled in Medicare Advantage drug plans (MA-PDs).