Literature Review

Empassion achieves $34 million in savings in novel Medicare program serving high needs patients Globe Newswire, New York City; 11/21/24 Empassion Health, Inc., the nation’s largest managed care provider of high-quality end-of-life care for adults living with serious illness so that they can have more good days, today reported near-record results for four Medicare Accountable Care Organizations (ACOs) serving Original Medicare lives in 35 states.  Specifically, Empassion achieved total gross savings of $34.1m in the High Needs Population Track of ACO REACH for Performance Year 2023 while managing a record number of lives – nearly 9,000 across 35 states – in total cost-of care arrangements.  This includes a 50-percent reduction of unnecessary hospital stays.  Empassion also earned the highest quality scores for provider communication and care coordination.  “While we are enormously proud of the $34 million in Medicare savings, more important is that Empassion provided high-quality end-of-life care for adults living with serious illness so that they had more good days,” said Robin Heffernan, the CEO of Empassion. “These outcomes are specific to Empassion and its unique model. ..." 

CMS Innovation Center reimagines rural health care approaches Center for Medicare and Medicaid Innovation; 11/12/24 Re-Imagining Rural Health: Themes, Concepts, and Next steps from the CMS Innovation Center "Hackathon" Series. ... Over sixty million Americans currently live in areas identified as rural, Tribal, frontier, and geographically isolated areas, including the U.S. Territories. Compared to people living in urban areas, rural Americans are more likely to experience poverty, be older, be uninsured, and have a disability. At the same time, rural communities face unique barriers to accessing care due to more limited availability of health care providers, including primary care, specialty care and home and community-based services, and residents often have to travel long distances to obtain health care. [Click on the title's link to continue reading (and distribute) this important 20 page whitepaper.]

CMS ramps up efforts to root out ‘door knocker’ hospice schemes Hospice News; by Holly Vossel; 11/15/24 The U.S. Centers for Medicare & Medicaid Services (CMS) recently elaborated on its plans to expand public education campaigns designed to help protect hospice beneficiaries from fraudulent actors in the space. ... “One of the areas we’re working with right now is to enhance education — beneficiary education specifically,” Pryor said during a recent CMS webinar. “We have hospice beneficiaries who are unfortunately fraudulently signed up for the benefit in these kind of, what we call, ‘door knocker scams.’” The scams include bad actors reaching out to beneficiaries with offers of free goods and services, such as groceries, TVs, reclining chairs and furniture, Pryor explained. The fraudulent marketing tactics are posing significant complications for Medicare beneficiaries, he said.

Strengthening nondiscrimination protections and advancing civil rights in health care through Section 1557 of the Affordable Care ActHHS press release; 11/13/24Publisher's note: While the final rule was released this Spring, compliance deadlines begin this month and might be burdensome for some providers to implement. In addition to the link above, guidance can be found here: final rule, press release, fact sheet.

Arrest warrant issued gor a California hospice care executive PRLog - Press Release Distribution, Los Angeles, CA; 11/8/24 The Superior Court of California in Los Angeles has issued a Bench Warrant for the arrest of Darline Singh, owner of Zola Hospice LLC, and associated with numerous other hospice companies throughout the state. Singh failed to appear in court on 9/12/2024 and on 10/24/2024 for a judgment debtor exam stemming from a $15MM judgment against Singh, Zola Hospice LLC, and E&E Hospice, LLC. Darline Singh's resume indicates she has a degree in Chemical engineering from UC Davis, AI Machine learning at MIT, as well as Harvard University. Her work experience highlights consulting and executive roles at Brookdale Senior Living, ACE Hospice, Suncrest Healthcare, Vitas Healthcare, Kindred Healthcare, and Bridge Hospice. In March of 2022 Acting California State Auditor, Michael S. Tilden, reported in a letter to the Governor, "my office conducted an audit of the State's licensure and oversight of hospice agencies and found that the State's weak controls have created the opportunity for large-scale fraud and abuse. We identified numerous indicators of such fraud and abuse by hospice agencies."

Healthcare billing fraud: 10 recent casesBecker's Hospital Review; by Andrew Cass; 10/28/24

New from MedPAC: 2024 Payment Basics series - HospiceMedPAC press release; 10/25/24MedPAC announces the release of the updated 2024 Medicare Payment Basics series. MedPAC's mission is to advise the Congress on Medicare issues, and part of that mission is providing clear and accessible information about how Medicare works. Payment Basics is a series of explainers on how Medicare's payment systems function. These "basics" are typically no more than 5 pages long and feature handy diagrams that visually depict how the payment systems calculate providers' payments. MedPAC produces "basics" for the major payment systems (20 in all), and updates the series once a year in the fall. The updated versions are now available here.Publisher's note: Hospice Payment Basics linked in the title above.

Doctor sues to save Medicare billing rights over hospice role Bloomberg Law; by Ganny Belloni; 10/24/24 A medical director designee at a California hospice sued the US Department of Health and Human Services to prevent the termination of his physician billing privileges after an independent contractor found his affiliation with the facility posed a fraud risk to the Medicare program. The lawsuit filed Wednesday by internal medicine physician Rami Shaarawy seeks injunctive relief from the US District Court for the Central District of California preventing the HHS’ Centers for Medicare & Medicaid Services from sanctioning the doctor until his dispute is resolved through Medicare’s internal appeals process.

New hospice special focus programAmerican Health Association / National Center for Assisted Living; by Amy Miller; 10/22/23 ​​As required under the Consolidated Appropriations Act of 2021, CMS has established a hospice special focus program (SFP) in the Calendar Year (CY) 2024 Home Health Prospective Payment System (HH PPS) final rule (88 FR 77676). Through increased regulatory oversight and enforcement of the selected poor performing hospice programs, the SFP will address issues that could place hospice beneficiaries at risk of receiving poor quality of care. The hospice SFP is like the current Special Focus Facility (SFF) program in place for nursing homes. As many nursing homes refer residents to hospice programs and may receive questions from residents or their families, it will be important to keep informed if there are noted quality of care issues. 

3 strategies for hospice GIP compliance Hospice News; by Jim Parker; 10/21/24 Utilization of the general inpatient level of care (GIP) is frequently the subject of audits by Medicare Administrative Contractors (MACs), and avoiding or responding to that scrutiny requires strict compliance to a complex web of rules. Audits are becoming more frequent in the hospice space, and GIP is an increasing focus, including ​for the most common types — Supplemental Medical Review Contractor (SMRC) and Targeted Probe and Educate (TPE). In a survey earlier this year, more than half of hospice providers reported having undergone multiple types of audits within a six-month period. ... In addition to these routine MAC audits, the U.S. Department of Health and Human Services Office of the Inspector General (GIP) has been performing a national audit of GIP utilization, as well as an additional investigation into management of the associated payment cap. The inpatient cap limits the number of days of inpatient care for which Medicare will pay to 20% of a hospice’s total Medicare patient care days, according to OIG. If GIP billing exceeds that metric, the hospice must refund those payments to Medicare.

Gentiva reaches $19.4 million False Claims Act Settlement Policy & Medicine; by Thomas Sullivan; 10/15/24 Gentiva – formerly known as Kindred at Home – reached a $19.4 million settlement with the United States, resolving allegations that it violated the False Claims Act by holding on to overpayments for hospice services provided to patients who were ineligible to receive hospice benefits under various federal health care programs. Kindred is made up of entities that were previously part of an enterprise that did business through various subsidiaries as Kindred at Home. Kindred provided health care services, including hospice services, using various business names during the time periods relevant to the settlement. The settlement resolves allegations brought by the United States and the State of Tennessee against certain Kindred entities alleging that from 2010 until February 2020, the entities knowingly submitted (or caused to be submitted) false claims for hospice services to hospice patients in Tennessee and other states who were ineligible for Medicare or Medicaid hospice benefit because they were not terminally ill. The settlement further resolved allegations that the defendants improperly concealed or otherwise avoided the obligation to repay the hospice claims at issue. The settlement also resolves allegations that SouthernCare New Beacon – a subsidiary – allegedly violated the Anti-Kickback Statute by willfully paying remuneration to a consulting physician to induce Medicare beneficiary hospice referrals.

Humana, UnitedHealthcare, Aetna fall in new MA star ratings Modern Healthcare; by Nona Tepper; 10/10/24 The Centers for Medicare and Medicaid Services sought to make it more challenging for Medicare Advantage insurers to win top quality scores and the payment bonuses that go along with them. It's working. On Thursday, CMS released the latest Medicare Advantage star ratings, and the contrast to just a few years ago is stark. In 2022, 74 Medicare Advantage with prescription drug coverage contracts garnered five-out-of-five stars. For the 2025 plan year, only seven did.

Two Los Angeles-area residents arrested on indictment alleging scheme to fraudulently obtain and launder Medicare proceedsUnited States Attorney's Office - Central District of California; Press Release; 10/9/24 A Los Angeles woman and a San Fernando Valley man were arrested today on a 24-count federal grand jury indictment alleging a scheme to defraud Medicare out of more than $54 million via hospice and diagnostic testing services that were never provided and then laundered their illicit proceeds, including by buying millions of dollars’ worth of gold bars and coins. Sophia Shaklian, 36, of the Larchmont area of Los Angeles, and Alex Alexsanian, 47, of Burbank, were arrested early this morning. They are scheduled to be arraigned this afternoon in United States District Court in downtown Los Angeles. ... According to the indictment that a federal grand jury returned on October 2, Shaklian, often using aliases, managed and submitted claims for seven health care providers enrolled with Medicare and located in Los Angeles County. These businesses included a hospice company she owned – the Pasadena-based Chateau d’Lumina Hospice and Palliative Care – and several diagnostic testing companies: Saint Gorge Radiology in Sylmar; Hope Diagnostics in North Hollywood; Direct Imaging & Diagnostics and Lab One – both located in Hollywood; and Labtech and Lifescan Diagnostics in Claremont.