Literature Review

Countdown to 2026: New Year changes in telehealth impacting Medicare providersJD Supra; by Christopher Guthrie, Kenya Hagans, Shamika Mazyck, Aaron Sagedahl, Quarles & Brady LLP; 12/16/25 The manner in which services are provided via telehealth has the potential to look very different for healthcare providers—particularly those providing services to Medicare patients—in 2026. ...

Medicare's AI prior authorization pilot sparks backlash over incentives to deny care Complete AI Training | Insurance; by Joren Erne; 12/7/25 CMS will pilot AI prior auth in traditional Medicare across AZ, NJ, OH, OK, TX, WA through 2031. Expect tougher reviews, vendor incentives, and pushback on denials and delays. ... For insurance professionals, this is a signal: CMS is importing private-plan utilization tactics into fee-for-service Medicare, with financial incentives tied to denial-driven cost savings. Expect policy, operations, and provider relations to feel it. 

Healthcare fraud enforcement trends to expect in 2026 JD Supra; by Arnall Golden Gregory; 12/8/25Key Takeaways

The alphabet soup of laboratory compliance Parkview Health; by Amy Stiles; 12/4/25 Every fall, Medicare beneficiaries can review their healthcare coverage and choose to enroll in or switch between Original (Traditional) Medicare and Medicare Advantage plans for the upcoming year. However, many people may not realize that the type of plan they choose can affect how certain laboratory tests are processed and billed. In this post, we aim to unscramble the letters and bring clarity to common Medicare terminology, helping you better understand what your plan offers and how to maximize the value of your benefits.

The complex quandary over hospice relatedness Hospice News; by Jim Parker; 12/5/25 Questions over which services are deemed related to patients’ terminal diagnosis in hospice care are crucial, and physicians’ determinations of those factors may be growing more complex. ... CMS has taken a stance that essentially all the care needed by a terminally ill patient should be covered through the benefit. However, that is not always what happens in practice. ...  When considering relatedness, physicians must take a holistic approach, according to Dr. Lauren Templeton, hospice physician consultant at Weatherbee Resources and Physician Council member at The Pennant Group. ... In most cases, hospices should err on the side of considering conditions related, when possible, for the sake of their patients, Templeton indicated. “If it’s impacting the plan of care for our patients, that would make it related for us,” Templeton said.

Combating durable medical equipment fraudOIG video; 11/25/25Durable Medical Equipment (DME) refers to medical devices prescribed by a health care provider to help patients manage health conditions and is essential for millions of people. DME includes medical devices like wheelchairs, oxygen tanks, and glucose monitors. Unfortunately, DME is a frequent target for fraud – costing taxpayers billions of dollars and putting patients at risk. [Click above to view a three-minute video on this topic.]

Vohra Wound Physicians and its owner agree to pay $45M to settle fraud allegations of overbilling for wound care servicesDepartment of Justice press release; 11/21/25Dr. Ameet Vohra and his companies, including Vohra Wound Physicians Management LLC (Vohra), have agreed to pay $45 million to resolve allegations that they violated the False Claims Act by knowingly causing the submission of claims to Medicare for medically unnecessary surgical procedures, for more lucrative surgical procedures when only routine non-surgical wound management had been done, and for evaluation and management services that were not billable under Medicare coverage and coding rules... “Billing Medicare for medically unnecessary procedures and manipulating documentation to maximize profits not only defrauds taxpayers — it puts vulnerable patients at risk,” said Deputy Inspector General for Investigations Christian J. Schrank at the U.S. Department of Health and Human Services, Office of Inspector General (HHS-OIG).Publisher's note: While these allegations specifically occurred in nursing homes and skilled nursing facilities, similar practices have occurred in hospice.

He built a nursing home empire despite state investigations. Now, lawsuits are piling upCal Matters; by Jocelyn Wiener; 11/20/25California nursing homes affiliated with Shlomo Rechnitz are facing lawsuits alleging that patients were raped, ignored and unnecessarily exposed to COVID-19. His companies deny the allegations. In February 2024, a Los Angeles County jury awarded $2.34 million to an 84-year-old nursing home resident named Betsy Jentz, finding that the facility had violated her rights on 132 occasions, at times leading to serious injuries. [Three more equally offensive cases.] All of these facilities have one thing in common: state records list Shlomo Rechnitz as an owner. Court documents show Rechnitz and his companies have denied all allegations in all of the cases.

Three Palmetto GBA ReportsPalmetto press release; 11/21/25

Hospice: Track errors, payment caps to avoid facing costly penalties Home Health Line, DecisionHealth; by MaryKent Wolff; 11/13/25 Keep a close eye on possible claim and billing mistakes that could lead to issues related to your payment cap. While increased revenue may seem like a good thing for providers, overpayments could lead to heightened scrutiny and financial hardships for your agency. [May require subscription for additional information]

7 women now charged in $100M Fort Bend hospice fraud scheme Houston Chronicle, Houston, TX; by John Wayne Ferguson; 11/3/25 Four more people have been charged in connection with a Fort Bend County Medicare scam, meaning seven are now accused of stealing tens of millions of dollars from the government by charging the health care fund for hospice care for patients who weren't actually dying. Hattie Banks, Lydia Obere, Cheryl Brooks and Ena Cowart were indicted by a federal grand jury on Oct. 8. All four were charged with healthcare fraud and two felony conspiracy charges related to the fraud and a plan to receive kickbacks. Banks, Obere and Brooks were also accused of receiving kickbacks.

CMS’s Special Focus Facility Program for Nursing Homes has not yielded lasting improvementsOIG press release; 10/29/25This report evaluated the effectiveness of the Centers for Medicare & Medicaid Services’ (CMS) Special Focus Facility (SFF) program, the agency’s flagship effort to address quality problems at the nation’s poorest-performing nursing homes. OIG found nearly two-thirds of facilities that graduated from the SFF program between 2013 and 2022 later exhibited recurring quality issues. Among nursing homes that received a serious deficiency in the three years after graduating, 38% put residents at risk of serious injury, harm, impairment or death. For program improvement, OIG recommended that CMS use more nonfinancial remedies, assess enforcement effectiveness—especially for staffing deficiencies—and incorporate ownership data.Publisher's note: It's interesting to see what works - and what doesn't work - from the CMS / OIG perspective.

Survey update during government shutdown - REVISED Guidance, 10/21/2025CHAP blog; 10/21/25CMS posted and update to the memo, Contingency Plans – State Survey & Certification Activities in the Event of Federal Government Shutdown (QSO- 26-01-ALL-Revised) on 10/21/2025 that provides updates to state survey activity during the ongoing federal government shutdown. The revised guidance appears in red text. CMS has instructed CHAP that our survey activity is unaffected, and we will conduct our survey accreditation business as usual.