Literature Review

‘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.

The home health and hospice moratorium at six months: what CMS’ anti-fraud CRUSH initiative has meant for providers JD Supra; by Lanchi Nguyen Bombalier; 10/1/26 Key Takeaways

What hospitals need to change before data catches up ICD10 monitor; by Penny Jefferson, MSN, RN, CCDS, CCDS-O, CCS, CDIP, CRC, CHDA, CRCR, CPHQ, ACPA-C; 9/29/26 Medicare Advantage has traditionally occupied a familiar space in hospital operations: prior authorization, utilization management, denials, risk adjustment, and reimbursement. With the FY 2027 Inpatient Prospective Payment System final rule, healthcare organizations need to add another significant area to that list—hospital mortality performance. The Centers for Medicare & Medicaid Services (CMS) finalized modifications to five existing 30-day, all-cause, risk-standardized mortality measures to include eligible Medicare Advantage beneficiaries ...: acute myocardial infarction (AMI), heart failure, pneumonia, chronic obstructive pulmonary disease (COPD), and coronary artery bypass graft (CABG) surgery.

Taxpayer-funded health care programs hit with $17.5 billion in fraud in one year Before It's News; 9/23/26 Fraud in taxpayer-funded health care programs like Medicare and Medicaid is so pervasive that the government identified a breathtaking $17.5 billion in scams in just one year, according to an analysis conducted by the U.S. Treasury’s Financial Crimes Enforcement Network (FinCEN), ... The crimes occurred in all 50 states, as well as Washington D.C, and U.S. territories including Guam, Puerto Rico and the Virgin Islands. A lengthy report made public this month identifies the largest number of offenders in California (3,141), followed by Florida (1,378), New York (989) and Minnesota (946) with some of the scams involving criminal networks connected to foreign entities.

Prior authorization under CMS-0057-F: how payers are rebuilding utilization management for compressed timeline The National Law Review, Tampa, FL; Press Release; 9/20/26 Prior authorization has moved to the center of healthcare payer operations. With the Centers for Medicare & Medicaid Services finalizing the Interoperability and Prior Authorization Final Rule (CMS-0057-F), health plans, managed care organizations, and third-party administrators face shorter decision windows and new transparency obligations at the same time review volumes continue to climb. For many organizations, the response has been a careful review of their prior authorization medical review services and the operational systems that support them.

LA County fraud: stolen IDs fuel California hospice fraudFilm Daily; by Simone Barbon; 9/20/26 Stolen identities turned Medi-Cal hospice billing into a $267 million cash machine in LA County, with no patients and no care behind any of the claims. California Attorney General Rob Bonta announced the arrests last week after Operation Skip Trace dismantled the largest single scheme of its kind. The case shows how dark-web data, shell companies, and weak licensing rules let a handful of operators loot state and federal funds on an industrial scale. The ring bought names, Social Security numbers, and birth dates of non-California residents from dark-web sellers. They used the stolen profiles to open Medi-Cal accounts through Covered California portals. ...

Medicare moments: The scarcity of Medicare caregiver benefits Allied News; by Joel Mekler; 9/14/26 ... AARP and the National Alliance for Caregiving released the 2025 Caregiving in the U.S. report, their newest update since 2020. This comprehensive document offers an in-depth look at the evolving landscape of family caregiving for adults, highlighting key trends, challenges, and potential reforms. A key discovery is the swift growth in family caregiving. Almost 25% of adults — 63 million Americans — spent the last year caring for an adult (59 million) or a child (4 million) with complex medical needs or disabilities, marking a 45% increase since 2015. This trend underscores the essential role of family caregivers and exposes systemic shortcomings that place significant burdens on them, highlighting the pressing need for reforms.

Update to 2026 hospice payment rate correctionFrom CMS; by Guest Editor Judi Lund Person; 9/9/26CMS has informed us on September 9, 2026 that there is a correction notice in clearance right now, which hopefully will be out soon. The change is minor and the wage index issue was across all payment systems, not just hospice. 

CMS oversight did not prevent Medicare Part D sponsors from making $587.7 million in ineligible payments to pharmacies for drugs available over the counter but labeled as prescription-only United States Government HHS-OIG; Report number OAS-24-02-004; issued on 8/31/26, posted on 9/2/26 

Hospice exclusion correction announced for the long-stay antipsychotic measure American Health Care Association (AHCA) and National Center for Assisted Living (NCAL); by Amy Miller; 9/1/26 The Centers for Medicare and Medicaid Services (CMS) has identified a subset of hospice residents who should have been excluded from the long-stay (LS) antipsychotic measure for the first quarter of 2026. These residents were inadvertently included because of incomplete hospice data in the CMS Centralized Data Repository. The issue affected approximately 2% of residents included in the measure for the quarter. CMS does not anticipate that it will significantly affect facilities’ overall measure results or quality measure ratings. CMS is updating its calculation to ensure that these residents are appropriately excluded going forward. The correction to first-quarter 2026 data will appear in the October 28, 2026, refresh of Nursing Home Care Compare.