Literature Review

The top strategies healthcare organizations can use to reduce denials MedCityNews, by Laxmi Patel; 3/5/24Here are six actionable steps healthcare organizations can take to reduce their likelihood of denials and write-offs.

A whistleblower lawsuit cost ChristianaCare $47M. Why are whistleblower cases increasing? Delaware Online, by Esteban Parra and Xerxes Wilson; 3/4/24A former medical director specializing in neurosurgery at southern Delaware’s largest health care provider claims in a lawsuit that Bayhealth Medical Center misclassified “brain-dead” patients in order to overbill for services. ... [The whistleblower reported that] hospital officials discussed a "new hospital initiative" in which suspected "brain-dead" patients would be discharged and admitted to hospice before any declaration of brain death, according to the lawsuit. The scheme allowed for prolonged billing where previous billing ended with the patient’s death, the complaint states. [Please refer to the article for details.]

Medicare’s new Dementia GUIDE Model: How can physicians, hospices, and home health agencies participate? Morgan Lewis Blog Post; 3/1/24If you have had a loved one suffer from dementia, you know the emotional, physical, and financial toll of this terrible disease. With advancements in dementia treatment, however, there is renewed hope on addressing this disease and increasing emphasis on fostering innovative care models. A central pillar of this effort is the Guiding an Improved Dementia Experience (GUIDE) model, announced by the US Department of Health and Human Service’s Centers for Medicare & Medicaid Services (CMS) in July 2023. This initiative—a new voluntary, nationwide alternative payment model—is designed to support Medicare beneficiaries with dementia, as well as their caregivers.

What the UnitedHealth Group Antitrust Investigation means for Amedisys, home health industry Home Health Care News, by Andrew Donlan; 3/1/24 Since the news surfaced Tuesday that the Department of Justice had opened an antitrust investigation into UnitedHealth Group (NYSE: UNH), additional questions have bubbled up. Namely, those questions surround the home health provider Amedisys Inc. (Nasdaq: AMED), which agreed to be acquired by UnitedHealth Group’s Optum in June of last year.

Untangling the history, causes behind the precipitous home health aide utilization drop Home Health Care News, by Patrick Filbin; 2/28/24In the last home health proposed rule from the Centers for Medicare & Medicaid Services (CMS), the federal agency in charge of reimbursement rates sent out a request for information on home health aide utilization. Specifically, the agency wondered why Medicare-covered home health aide visits and utilization had fallen off a cliff over the last few decades. According to the Center for Medicare Advocacy, home health aide visits declined by 90% from 1998 to 2019. 

The state where all hospitals are on track to earn new Joint Commission [Equity] CertificationBecker's Clinical Leadership, by Erica Carbajal; 2/28/24All hospitals in Massachusetts are meeting a health equity accreditation standard that The Joint Commission introduced last year, making it the first state to be recognized for the accomplishment. ... Achieving the standard is the first step to obtain The Joint Commission's recently launched health equity certification, which all of the state's hospitals plan to earn by 2025, according to a joint news release from the Massachusetts Health & Hospital Association and accrediting body.

HCA Mission Hospital regains CMS complianceBecker's Hospital Review, by Mariah Taylor; 2/26/24CMS found Asheville, N.C.-based HCA Mission Hospital in compliance with its plan of correction and recommended removing the immediate jeopardy designation, Blue Ridge Public Radio reported Feb. 23. The hospital's plan of correction to address serious deficiencies it was cited for in January focuses on improving policies and educating staff.

[Updated] CMS crackdown on fraudulent hospice providers in full effect in 2024, expert says McKnights Product Theater, by Adam Healy; 2/22/24In recent years, unscrupulous hospice providers have cropped up in California and other states. In response, the Centers for Medicare & Medicaid Services has prepared a slew of tools to curtail the fraud. States continue to feel the effects. As an example, a California hospice operator last week was convicted in a Medicare fraud scheme for billing nearly $3 million for services that patients did not need, according to the Department of Justice. 

How CMS’ rule could tighten accrediting organization oversightModern Healthcare, by Mari Devereaux; 2/20/24Accrediting organizations may have to reduce their fee-based consultation services and prohibit survey participation for employees with ties to health facilities or face penalties for violating conflict-of-interest provisions if the Centers for Medicare and Medicaid Services sticks with recent oversight proposals.Editor's Note: Full access to this article requires a subscription.

Reduced federal share may force state Medicaid programs to cut services, HCBS expert saysMcKnights Home Care, by Adam Healy; 2/15/24The Congressional Budget Office this month released its “Budget and Economic Outlook” report for the coming decade. In its report, CBO predicted a roughly $58 billion drop in federal Medicaid outlays for 2024 compared to 2023 — a 9% decrease in federal Medicaid spending, due in part to fewer beneficiaries on states’ Medicaid rolls. 

Reduced federal share may force state Medicaid programs to cut services, HCBS expert saysMcKnights Home Care, by Adam Healy; 2/15/24The Congressional Budget Office this month released its “Budget and Economic Outlook” report for the coming decade. In its report, CBO predicted a roughly $58 billion drop in federal Medicaid outlays for 2024 compared to 2023 — a 9% decrease in federal Medicaid spending, due in part to fewer beneficiaries on states’ Medicaid rolls. Reduced Medicaid outlays ... has placed an even greater strain on states to pay for these Medicaid programs, according to Damon Terzaghi, director of Medicaid HCBS for the National Association for Home Care & Hospice.

CMS issues additional guidance on program to allow people with Medicare to pay out-of-pocket prescription drug costs in monthly paymentsCMS.gov; 2/15/24The Inflation Reduction Act’s Medicare Prescription Payment Plan will allow people to pay Medicare Part D out-of-pocket costs over the course of the year starting in 2025. [On February 15th,] the Centers for Medicare & Medicaid Services (CMS) released the second part of draft guidance for the Medicare Prescription Payment Plan that outlines requirements for Medicare Part D plan sponsors, including outreach and education requirements, pharmacy processes, and operational considerations, for the program’s first year, 2025. 

Private equity Medicare Advantage investment slumps: reportModern Healthcare, by Nona Tepper; 2/13/24Private equity investment in Medicare Advantage has declined in recent years amid rising interest rates and an unfavorable regulatory environment, according to a report the Private Equity Stakeholder Project published Tuesday.