Literature Review

Hospice Certifying Physician edit in effectAAPC - American Academy of Professional Coders; by Rebecca Johnson; 6/3/24 The Centers for Medicare & Medicaid Services (CMS) and its Home Health and Hospice (HHH) Medicare Administrative Contractors (MACs) are all systems go for the new — and potentially troublesome — claims system edit. The edit went into effect June 3. ... In the 2024 Hospice Payment Rate Update final rule, CMS adopted a requirement that two categories of physicians must be enrolled in or validly opted out of Medicare for hospice services to be paid: the hospice medical director or the physician member of the hospice interdisciplinary group; and the attending physician that certifies the patient for hospice. CMS did at least grant hospices’ requests for an implementation delay at that time, moving the deadline from the proposed Oct. 1, 2023, to May 1, 2024. Then, on the eve of that start date, CMS bumped the edit for one more month. ...

NHPCO: CMS did not account for full burden of implementing HOPE Tool Hospice News; by Jim Parker; 5/29/24 The U.S. Centers for Medicare & Medicaid Services (CMS) may not have accounted for the financial and administrative burdens associated with its implementation of the Hospice Outcomes and Patient Evaluation (HOPE) Tool. In comments on the 2025 proposed hospice rule, the National Hospice and Palliative Care Organization (NHPCO) voiced concerns that the agency’s regulatory impact assessment may not have taken all the details into account, including the need for staffing and technology investments. “Clinical and administrative cost calculations do not align with the reality of the true costs of implementation,” NHPCO indicated in a letter to CMS. “In the proposed rule, CMS significantly underestimated the burden and costs hospices will incur to comply with HOPE requirements. The agency’s estimated cost burden of approximately $185 million across all hospices fails to account for several important factors.”

Hospice Owner Sentenced to 240 Months Imprisonment and Ordered to Repay $42,000,000 for Defrauding MedicareDepartment of Justice; 5/16/24New Orleans - U.S. Attorney Duane A. Evans announced that on May 15, 2024, U.S. District Judge Lance Africk sentenced SHIVA AKULA (“AKULA”), age 68, of New Orleans, to 240 months of imprisonment, three years of supervised release and $2,300 in mandatory special assessment fees, in relation to an extensive health care fraud scheme orchestrated by AKULA. In November 2023, a federal jury convicted AKULA of all 23 counts of his underlying indictment. AKULA owned and oversaw the day-to-day operations of Canon Healthcare, LLC, a hospice facility with offices in the New Orleans area, Baton Rouge, Covington, and Gulfport, Mississippi. At sentencing, the Court found that between January 2013 and December 2019, Canon billed Medicare approximately $84 million in fraudulent claims and was paid approximately $42 million relating to these fraudulent claims. The Court ordered that AKULA repay the $42 million of fraudulent proceeds back to Medicare.

Compliance Strategies for Forthcoming Hospice HOPE ToolHospice News; by Holly Vossel; 5/16/24Hospices will have a learning curve when it comes to implementing the Hospice Outcomes and Patient Evaluation Tool (HOPE) tool. The U.S. Centers for Medicare & Medicaid Services (CMS) is currently developing quality measures that will be included in the HOPE tool, which will replace the current Hospice Item Set (HIS). After years of development, the agency in its recent hospice proposed rule indicated that the HOPE tool’s implementation would begin in 2025.Notable Mentions: Jennifer Kennedy, CHAP; Kimberly Skehan, CHAP.

Humana, Aetna likely to lose Medicare Advantage members Modern Healthcare; by Nona Tepper and Lauren Berryman; 5/14/24 Industry heavyweights CVS Health Aetna and Humana foresee Medicare Advantage membership losses next year. Anticipated changes to health plan offerings and benefit design to achieve long-term business profitability could mean losing a significant portion of their Medicare Advantage membership, executives told investors at the Bank of America Securities Healthcare Conference on Tuesday. ... Headed into next year, Aetna may adjust benefits, tighten its prior authorization policies, reassess its provider networks and exit markets, CVS Health Chief Financial Officer Tom Cowhey told investors.  ... [Humana Chief Financial Officer Susan Diamond] anticipates losing about 5% of its 6.1 million Medicare Advantage members, ... Conversely, UnitedHealth Group’s UnitedHealthcare insurance business appears to be better positioned for growth heading into 2025 ... , executives said. UnitedHealth Group CEO Andrew Witty said, ... “The thing we don't want is unsustainable ups and downs in our performance in any particular regard. ... You should just expect more of the same from us in terms of what we’re doing.” 

Treasury extends Medicare insolvency date, citing savings from home health McKnights Home Care; by Adam Healy; 5/13/24 Medicare insolvency received a five-year extension — and part of the reprieve can be attributed to the cost of home health. Myriad factors, including job growth and low unemployment rate, contributed to the extension. The projections were also partly influenced by home health spending which has been “significantly lower than estimated prior to the pandemic,” according to the Social Security and Medicare Trustees report. “As a result of the recent home health staffing shortages, the trustees continue to consider the spending level for this service to be suppressed,” they said in the report. “Thus, they have increased their home health spending growth factor by 2.9 percentage points in each of the next 3 years.”

Hospice Certifying Physician Medicare Enrollment InformationPalmetto GBA email; 5/6/24Pursuant to our authority under section 6405 of the Affordable Care Act, and as part of CMS' larger strategy to address hospice program integrity and quality of care, certifying physicians, including hospice physicians and hospice attending physicians, must be enrolled in or opted-out of Medicare for the hospice service to be paid. Effective June 3, 2024, (delayed from May 1, 2024) CMS will begin implementing edits to enforce this new rule and will deny hospice claims if the physician entered in the Attending field on the claim is not in the Provider Enrollment Chain and Ownership System (PECOS) as an enrolled or opted-out physician.

Ordered to pay $1.536B in criminal fines and forfeiture for distributing misbranded opioid medication Office of Public Affairs, U.S. Department of Justice; Press Release; 5/3/24Endo Health Solutions Inc. (EHSI) was ordered to pay $1.086 billion in criminal fines and an additional $450 million in criminal forfeiture — the second-largest set of criminal financial penalties ever levied against a pharmaceutical company —for violations of the Federal Food, Drug and Cosmetic Act related to the distribution of the opioid medication Opana ER with INTAC (Opana ER). ...

Star ratings of Leapfrog's 25 straight-'A' and 'F' hospitals Becker's Hospital Review; by Mackenzie Bean; updated 5/3/24 A comparison of data from CMS and The Leapfrog Group suggests that a hospital's strong performance in one national quality rating system does not necessarily mean it will be a top performer in another. Leapfrog updated its spring safety grades May 1, recognizing 15 hospitals that have received an "A" grade in every consecutive update since 2012. Of these hospitals, only eight received a five-star rating from CMS. Similar discrepancies are seen across Leapfrog's "F" hospitals. While two did receive one star — the lowest possible rating — another five received two stars, and one hospital earned four stars. [Click on the title's link for the list.]

CMS: Advance health equity during National AANHPI Heritage Month CMS.gov; email 5/2/24 During May, the Centers for Medicare & Medicaid Services Office of Minority Health (CMS OMH) recognizes National Asian American, Native Hawaiian, and Pacific Islander (AANHPI) Heritage Month by highlighting disparities for Asian Americans, Native Hawaiians, and Pacific Islanders. These communities account for more than 7% of the U.S. population and have the fastest population growth rate among all racial and ethnic groups, having almost doubled since 2000. Between 2017 and 2019, the number of Asian Americans enrolled in Medicare grew by 11%, which was the highest percentage increase in enrollment compared to White, Black, and Hispanic enrollees. ... [Read for more descriptions, data and resources.]

New federal rule meant to strengthen nondiscrimination protections, advance civil rights in healthcare McKnights Senior Living; by Kathleen Steele Gaivin; 4/30/24 The Department of Health and Human Services on Friday released a final rule aiming to protect individuals from discrimination in healthcare, including members of the LBGTQ+ community. ... The rule “reverses a Trump-era regulation and restores gender identity and sexual orientation discrimination protections under Section 1557 of the Affordable Care Act,” Bloomberg Law reported. Section 1557 prohibits discrimination on the basis of race, color, national origin, sex, age or disability by entities that primarily provide healthcare and receive federal funding. It is enforced by the HHS Office for Civil Rights.

Federal Court halts lawsuit over Medicare home health payments Bloomberg Law; by Tony Pugh; 4/28/24 A federal court in Washington DC tossed a lawsuit against HHS over a disputed payment system that has slashed reimbursements for thousands of home health agencies since it was implemented in 2020. The US District Court for the District of Columbia ruled in a memorandum opinion on April 26 that plaintiffs in the suit by the National Association for Home Care & Hospice (NAHC) failed to exhaust their administrative rememdies because they "skipped the agency's process for seeking expedited judicial review." Because of that, the court "will grant the federal government's motion for summary judgment." [Additional content may require subscription.]