Literature Review

Nurse pleads guilty to federal charge for stealing pain medications at Baxter clinicBrainerd Dispatch; 1/9/24A registered nurse pleaded guilty to fraudulently obtaining prescription opioid pain medications from a hospice clinic, United States Attorney Andrew M. Luger announced Tuesday, Jan. 9. ... Cambie Elizabeth Broker, 33, was a registered nurse case manager at a hospice clinic in Baxter. Broker used her position to fraudulently obtain controlled substances from the clinic. Broker entered false prescription requests into the clinic’s e-prescribing software to fraudulently obtain oxycodone, hydromorphone, and fentanyl for illegal sale and personal use. 

Home healthcare company agrees to pay nearly $10 million to resolve false claims act allegations relating to its participation in the energy employees occupational illness compensation programOffice of Public Affairs; 1/5/24Atlantic Home Health Care LLC (AHH), a home health care agency operating in Arizona and eight other states, has agreed to pay $9,990,944 to resolve allegations that it violated the False Claims Act by submitting false claims to the Energy Employees Occupational Illness Compensation Program (EEOICP or the Energy Program), a healthcare program administered by the Department of Labor (DOL) for the benefit of Department of Energy employees and contractors with occupational illnesses.

The 10 biggest Medicare Advantage stories in 2023Becker's Payer Issues, by Rylee Wilson; 12/21/232023 was an eventful year for Medicare Advantage. As the program continued to grow, with enrollment surpassing 30 million in 2023, some hospitals are beginning to push back on private Medicare plans. CMS also introduced new rates and regulations in 2023 that are taking effect in 2024. Here are 10 of the biggest Medicare Advantage stories Becker's reported in 2024...

Evaluation of Phase II of the Medicare Advantage Value-Based Insurance Design Model Test: First three years of implementation (2020–2022)CMS Report; 12/29/23Year Two Evaluation Report - Key Takeaways: The Medicare Advantage (MA) Value-Based Insurance Design (VBID) model test enables MA insurers to offer one or more innovative benefit design options in eligible MA plans. The model aims to encourage the use of high-value care and promote healthy behavior, with goals of enhancing care quality, improving beneficiary health, and reducing spending. Most VBID benefits can be targeted based on beneficiaries’ chronic conditions or socioeconomic status (SES). A separate Hospice Benefit component is also included in the model. 

Unlicensed Saratoga County nursing home operator to pay $650,000Times Union (Albany, NY)December 21, 2023Ballston Spa, NY—The unlicensed operator of a now shuttered Saratoga County nursing home is set to repay Medicaid $656,000 after an investigation by the state attorney general’s office and U.S. attorney for the Northern District of New York found years’ worth of fraud and resident neglect at the facility. 

Steward Health Care hit with False Claims Act lawsuitHealthcare DiveDecember 20, 2023The federal government is suing Dallas-based Steward Health Care and its facilities, Steward Medical Group and Boston-based St. Elizabeth’s Medical Center, for violating the False Claims Act and a physician self-referral law, according to a Monday announcement. The complaint, filed in Massachusetts District Court, alleges Steward Medical Group improperly linked a lead cardiologist’s compensation with his referrals, leading the group to award him nearly $5 million in incentive-based pay—and violating physician self-referral rules, known as the Stark Law. 

After six months of study, Kentucky certificate of need task force says more study neededKentucky LanternDecember 15, 2023Lawmakers wrapped up a six-month study of Kentucky’s certificate of need law Thursday by saying more study is needed before they can make solid recommendations for reform.

NAHC President Bill Dombi—History Repeating Itself on Hospice Program IntegrityHospice NewsDecember 14, 2023Issues of fraud in the hospice industry echo events that previously affected the home health space, and providers can learn from that prior experience. This is according to Bill Dombi, president of the National Association for Home Care and Hospice, who spoke Thursday in a Relias webinar. ... “What I’m seeing is history repeating itself. Back in the 1990s, the microscope ended up focusing on the Medicare Home Health Program. 

US Supreme Court refuses to hear fraud appeal for South Florida health care executive pardoned by TrumpSouth Florida Sun-SentinelDecember 11, 2023The U.S. Supreme Court on Monday refused to take up an appeal by a South Florida nursing-home operator whose 20-year prison sentence was commuted by former President Donald Trump after being convicted in what prosecutors called a “massive health care fraud scheme.” The Supreme Court rejected a petition by attorneys for Philip Esformes, who was found guilty in 2019 on 20 counts related to kickbacks, money laundering, obstruction of justice and conspiracy, according to court documents. 

In letter to CMS, lawmakers call for more MA transparencyMcKnight’s Home Care DailyDecember 11, 2023Four senators demanded the Centers for Medicare & Medicaid Services make more data surrounding prior authorizations in Medicare Advantage publicly available. “In the last few years, federal watchdogs have released numerous reports examining concerning trends in MA,” Sens. Bill Cassidy, MD (R-LA), Elizabeth Warren (D-MA), Marsha Blackburn (R-TN) and Catherine Cortez Masto (D-NV), the letter’s signees, said in a statement. “Without publicly available plan-level data ... policymakers and regulators are unable to adequately oversee the program and legislate potential reforms.” The senators specifically requested CMS gather and publish data regarding prior authorization requests, denials and appeals, justifications for denials and the timeliness of prior authorization decisions. 

UnitedHealth hit with Medicare Advantage marketing complaintModern HealthcareDecember 7, 2023Advocates for people with disabilities are calling on regulators [to] halt what they describe as misleading Medicare Advantage marketing by UnitedHealth Group. The Center for Medicare Advocacy, National Health Law Program, Disability Rights Connecticut and National Disability Rights Network wrote the Centers for Medicare and Medicaid Services, the Federal Trade Commission and other state and federal officials Thursday to protest UnitedHealthcare advertisements for Dual Eligible Special Needs Plans appearing in Connecticut. The ads target people with both Medicare and Medicaid and spotlight extra benefits from Medicare Advantage plans that state and federal laws already require, the groups wrote. “Unquestionably, this misleading advertising is intended to induce, and has induced, thousands if not tens of thousands of older adults and disabled low-income individuals we are charged with representing to sign up for UnitedHealthcare’s plan, having been led to believe this means they can get extra benefits,” the letter says. UnitedHealth Group did not immediately respond to an interview request.

OIG’s Audit of Nursing Home Workers in Louisiana Finds Flaws in Background Check ProcessSkilled Nursing NewsDecember 6, 2023A federally commissioned report released Wednesday found that nursing homes in Louisiana failed to complete background checks on a portion of their non-licensed employees. In conducting the audit to examine whether Louisiana nursing homes complied with federal requirements for backgrounds checks, the Office of Inspector General chose a sample of 9 Louisiana nursing homes out of a total of 276 licensed facilities in the state, basing its sample size on a variety of risk factors and on the need to select nursing homes in urban and rural settings, the agency said. ... The OIG report states. “Although Federal requirements do not specify the methods or types of information that should be considered for a background check to be regarded as having been satisfactorily completed, we identified potential limitations in the nursing homes’ background check searches and adjudication methods for 49 of the 209 non-licensed employees we reviewed.” In response to OIG’s findings and recommendations, Louisiana has agreed to update its standard survey process to ensure routine monitoring of nursing homes’ compliance with background check requirements by reviewing a sample of 5% of current non-licensed staff and by directing nursing homes to conduct self-audits of current personnel files. ... Among the findings, some disturbing practices emerged. Of the 9 nursing homes closely investigated, six nursing homes, and some of the staffing companies with which they contracted, had employee background check searches conducted that did not include a statewide search of State police records.