Literature Review

Patients with suboptimal discharges – a follow-up (and rescinding hospice billing)RACmonitor; by Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI; 10//28/26 Let me start with an update on my project to get a way to indicate on a hospital claim that a patient has discharged to a less-than-optimal location. ... [That began] with a push to use the “against medical advice” designation for such patients. But the stigma behind that term led me to adopt the suggestion of Valerie Rinkle, a nationally known revenue integrity expert, who proposed adoption of a condition code instead of using a discharge status code. Last week I once again presented to the National Uniform Billing Committee (NUBC), asking for such a code to be established. During that meeting, one of the members came up with an even better idea: establishing two condition codes, one for when the patient chooses a less-than-optimal location, and a different condition code for when the payer refuses to approve the suggested post-acute care.

Work requirements put new pressure on Medicaid member retention MedCity News; by John Marchisin; 10/28/26 According to a recent report by the JAMA Network, one in five adults covered under Medicaid could lose their benefits due to new work requirements taking effect in January 2027. The community engagement (work) requirements apply to the able-bodied, non-pregnant Medicaid expansion population and affect 41 states plus Washington, D.C. These members will be required to participate in at least 80 hours per month of qualifying activities, which can include work programs, community service or at least half-time enrollment in an educational program. Although 64% of Medicaid members are currently working either part time or full time, inconsistent work hours could prevent many members from completing the 80 hours a month required to remain eligible. 

Physician organizations back new challenge to Medicaid work rule American Medical Association (AMA), Chicago, IL; Press Release; 10/27/26 The American Medical Association (AMA) and the Maryland State Medical Society (MedChi), joined by several national physician organizations, filed an amicus brief in Taylor v. Kennedy, a new lawsuit challenging federal regulations that make it harder for people with serious or complex medical conditions to qualify for an exemption from Medicaid work requirements. The brief, filed in the U.S. District Court for the District of Maryland, supports the plaintiffs’ motion for summary judgment and argues that the Centers for Medicare & Medicaid Services (CMS) exceeded its statutory authority by imposing narrow restrictions on the medical frailty exemption established by Congress under H.R. 1, the One Big Beautiful Bill Act.

Attorney General Bonta: 103 criminal cases filed in statewide Medi-Cal fraud enforcement efforts Office of the Attorney General - California Department of Justice, Los Angeles, CA; Press Release by Rob Bonta, Attorney General; 10/22/26 California Attorney General Rob Bonta today announced the results of a statewide effort over the last year targeting fraud in California’s In-Home Supportive Services (IHSS) program. As a result of these efforts, felony charges were filed against 103 individual IHSS providers for allegedly defrauding the Medi-Cal program out of over $4.5 million dollars. “By enabling parents to care for their adult children with disabilities and allowing elderly individuals to age in place, IHSS provides a vital lifeline for families across the state. We are here to protect that lifeline,” said Attorney General Rob Bonta. “This isn’t a political game for us. This is about protecting taxpayer dollars, protecting the programs that sick and vulnerable Californians rely on, and protecting our state. ..."

DOJ launches first fast-track whistleblower rewards for tips leading to criminal fraud charges Mondaq | Legal 500 | Intelligence; by Meredith Auten, William Brady, Jack Shean, and Jessica R. Sievert; 10/23/26 The U.S. Department of Justice has launched a groundbreaking whistleblower rewards program that pays upfront awards when criminal charges are filed, rather than waiting years for case resolution. This new initiative targets healthcare fraud and government program fraud, with particular focus on hospice, home health, daycare and special services sectors. Companies should understand how this accelerated timeline affects their compliance strategies and internal reporting systems.

Feds hold back an additional $1.2 billion in California Medicaid reimbursements ArcaMax; by Ana Ceballos, Los Angeles Times; 10/20/26 The Trump administration is deferring an additional $1.2 billion in Medicaid reimbursements to California, citing concerns about potential fraud in a state program that helps older adults and people with disabilities with everyday tasks. Dr. Mehmet Oz, the administrator for the Centers for Medicare and Medicaid Services, said federal officials took action after they grew concerned about the rapid expansion of California's personal care services program in recent years. State officials were notified of the decision Tuesday, he said.

Home health and hospice personnel file audit checklist for ACHC, CHAP and Joint Commission Surveys (2026) Corvara HR; 10/15/26 When ACHC, CHAP or The Joint Commission surveys a Medicare-certified home health agency or hospice for deemed status, the federal Conditions of Participation are the floor. This checklist turns the personnel parts of those rules into a file-by-file audit, adds the OSHA and Form I-9 records every file needs, marks what each accreditor publishes on top, and shows how to run the audit before a surveyor does.

LA County fraud: Which 2026 scandal tops the list?Film Daily; by Simone Barbon; 10/14/26Los Angeles County’s 2026 docket of public-fund thefts keeps growing, and the dollar figures are hard to ignore. Homelessness contracts, Medi-Cal billings, and a landmark sex-abuse settlement now sit under overlapping state and federal probes that stretch from Culver City boardrooms to hospice billing offices. The cases together expose how oversight gaps turned routine county spending into slush funds and how recovery efforts may drag into 2027.

Millions of Americans will have fewer options during Medicare open enrollment this yearMorningstar; by Jessica Hall; 10/9/26There will be no Medicare Advantage plans in 181 counties in 2027, up from 67 in 2026. Medicare Advantage controls more than half of the overall Medicare market of about 69.6 million subscribers. Millions of older adults will need to find new healthcare coverage for 2027 after several insurers exited markets and cut back on their offerings to protect profit margins.

‘Byzantine ownership arrangements’: Calls to scrutinize coding and profit incentives in nursing home medicare paymentsSkilled Nursing News; by Zahida Siddiqi; 10/9/26Policy analysts at the nonpartisan agency that advises Congress on Medicare policy are planning to investigate potential coding distortions, payment inaccuracies and whether financial incentives influence patient selection by nursing home providers as part of an assessment of payment accuracy in fee-for-service Medicare’s skilled nursing facility and home health payment systems. At its October meeting Friday, the Medicare Payment Advisory Commission (MedPAC) discussed a research work plan, with commissioners calling attention to for-profit providers seeking to game the system, with a rising role of hidden private equity influence. [MedPAC presentation slides here.]Publisher's note: Bold and italics above are ours; if MedPAC is looking at this in SNF and HHA, hospice is likely not too far behind...

In current anti-fraud climate, no room for error for home health, hospice agenciesMcKnights Home Care; by Liza Berger; 10/6/26After operating hospice, home health and other companies for over a decade in Arizona, Peter prided himself on his sound reputation in the community and employees’ loyalty. He never dreamed that a technical error on a routine hospice renewal application would lead to a revocation of his hospice’s Medicare enrollment and billing privileges and leave him fighting for his livelihood.

Hospice medical review top denial reason codes Q2 2026Palmetto GBA; 8/28/26Hospice Medical Review Top Denial Reason Codes: April to June 2026. We encourage all providers to review this information when filing claims to prevent denials and to ensure their claims are processed timely. The following information affects providers billing 81X bill types. Top five denial reasons include [see article for entire list]:

Medicaid provider allegedly billed $165K for dead patient's rides among fraud exposed in explosive reportNew York Times Post; staff writers; 10/5/26A Colorado resident [Wesam Yassin] was charged with trying to steal hundreds of thousands of taxpayer dollars by billing the state’s Medicaid program for transporting a patient to doctor’s appointments — rides that would have taken place after that person had already died... It also pointed to charges against Ashley Marie Stevens, who is accused of trying to bilk the state for over $1 million in taxpayer dollars. She is accused of billing the state some $400,000 for non-medical rides for herself and her family in addition to “ghost rides,” which never even took place.