Literature Review

In or out: The hospice, Medicare Advantage conundrum Hospice News; by Jim Parker; 1/2/26 Opposition to a Medicare Advantage hospice “carve-in” remains strong in the field, though some say the lack of one creates a serious gap in the MA program. Medicare Advantage enrollment continues to grow. As of 2025, 54% of Medicare beneficiaries were enrolled in Medicare Advantage, about 31.4 million people, according to the Kaiser Family Foundation. However, MA health plans, by design, do not cover hospice care. When an MA beneficiary elects hospice, they transition to the traditional Medicare benefit, though they may keep their Medicare Advantage coverage for care or services deemed unrelated to their terminal condition.

Hospice care for medicaid cancer patients in Puerto Rico: implications on healthcare costs and utilization JNCI Cancer Spectrum; by Karen J Ortiz-Ortiz, Marjorie Vázquez-Roldán, Axel Gierbolini-Bermúdez, María Ramos-Fernández, Carlos R Torres-Cintrón, Yisel Pagán-Santana, Tonatiuh Suárez-Ramos, Kalyani Sonawane; 12/27/25 Online ahead of print Background: ... In Puerto Rico, Medicaid had no provisions for hospice care until July 2024, representing a significant public health challenge. This study examined the association between hospice coverage policy and EoL outcomes among patients with cancer enrolled in Medicaid.Conclusion: Hospice enrollment among Medicaid enrollees was associated with lower health expenditure, lower healthcare resource utilization, and a lower likelihood of mortality in an acute setting. The recent policy change to include hospice services coverage in Puerto Rico Medicaid is a positive step that must be sustained beyond 2027.

Medicaid agencies made millions in unallowable capitation payments to managed care organizations on behalf of deceased enrolleesOIG press release; 12/23/25A new OIG audit found that from July 2021 to June 2022, state Medicaid programs made an estimated $207.5 million in capitation payments to managed care organizations for enrollees who were already deceased. This estimate is based on the results of our review of 100 statistically sampled capitation payments. We determined that Medicaid agencies made unallowable capitation payments after enrollees’ deaths for 99 of the 100 sample capitation payments.

Long-term hospice stay: New edit to prevent overpayment CMS - MLN Matters - Medicare Learning Network; by the U.S. Department of Health & Human Services; 12/5/25Related CR Release Date: December 5, 2025Effective Date: April 1, 2026Implementation Date: April 6, 2026Action Needed: Make sure your billing staff knows about a new edit that will help identify and prevent overpayments of long-term hospice care for claims submitted with matching “admission” and “from” dates.Key Updates: This new edit in the CWF will close the gap in the system that allows claims to pay at a higher rate when the “admission” and “from” dates match. MACs will reject hospice claims when the “admission” date doesn’t match the election period start date on the corresponding election period. ...

Medicare's AI prior authorization pilot sparks backlash over incentives to deny care Complete AI Training | Insurance; by Joren Erne; 12/7/25 CMS will pilot AI prior auth in traditional Medicare across AZ, NJ, OH, OK, TX, WA through 2031. Expect tougher reviews, vendor incentives, and pushback on denials and delays. ... For insurance professionals, this is a signal: CMS is importing private-plan utilization tactics into fee-for-service Medicare, with financial incentives tied to denial-driven cost savings. Expect policy, operations, and provider relations to feel it. 

MedPAC to recommend 7% cut to 2027 home health payment rate Home Health Care News; by Morgan Gonzales; 12/8/25 Just over a week after home health providers were hit with the announcement that their 2026 Medicare payment rates would be reduced by a 1.3% aggregate cut, the Medicare Payment Advisory Commission (MedPAC) agreed to recommend a significantly more drastic cut for the following year. On Friday, MedPAC released a draft report recommending that Congress reduce the Medicare base payment rate for home health care services for calendar year 2027 by 7%. 

The alphabet soup of laboratory compliance Parkview Health; by Amy Stiles; 12/4/25 Every fall, Medicare beneficiaries can review their healthcare coverage and choose to enroll in or switch between Original (Traditional) Medicare and Medicare Advantage plans for the upcoming year. However, many people may not realize that the type of plan they choose can affect how certain laboratory tests are processed and billed. In this post, we aim to unscramble the letters and bring clarity to common Medicare terminology, helping you better understand what your plan offers and how to maximize the value of your benefits.

BULLETIN: HHS repeals nursing home staffing rule provisions McKNights Long-Term Care News; by Kimberly Marselas; 12/2/25 The Department of Health and Human Services today repealed key provisions of the minimum staffing standards for long-term care facilities finalized in 2024. The move follows months of legal and legislative challenges, which had already rendered hourly staffing and registered nurse requirements moot. HHS said it was repealing provisions in alignment with the One Big Beautiful Bill Act, which imposed a nine-year moratorium on the rule’s staffing measures. ... Notice of the appeal was posted in the Federal Register Tuesday morning. Editor's Note: Click here for the official publication of this repeal, scheduled to be published on 12/3/25.

New from MedPAC: 2025 Payment Basics series MedPAC - Medicare Payment Advisory Commission; 11/24/25 MedPAC announces the release of the updated 2025 Medicare Payment Basics series. MedPAC's mission is to advise the Congress on Medicare issues, and part of that mission is providing clear and accessible information about how Medicare works. Payment Basics is a series of explainers on how Medicare's payment systems function. These "basics" are typically no more than 5 pages long and feature handy diagrams that visually depict how the payment systems calculate providers' payments. MedPAC produces "basics" for the major payment systems (20 in all), and updates the series once a year in the fall. The updated versions are now available here.

Calendar Year (CY) 2026 End-Stage Renal Disease (ESRD) Prospective Payment System Final Rule CMS Newsroom - Fact Sheets; by CMS; 11/20/25 Key points:

AGG Files Amicus Brief on Behalf of the National Alliance for Care at Home and AAHPM JD Supra; by Jason Bring, Bill Dombi, and T. Chase Ogletree; 11/20/25 AGG Healthcare attorneys Bill Dombi and Jason Bring and Litigation & Dispute Resolution attorney TC Ogletree filed an amicus (or “friend of the court”) brief on behalf of the National Alliance for Care at Home (the “Alliance”) and the American Academy of Hospice and Palliative Medicine (the “AAHPM”) with the United States Court of Appeals for the Sixth Circuit. The case involves a hospice audit that proceeded through the administrative appeals process to an administrative law judge (“ALJ”) hearing, in which the ALJ denied the hospice’s Medicare reimbursement claims.

Four California residents sentenced to prison in connection with $16m Hospice fraud and money laundering scheme Office of Public Affairs - U.S. Department of Justice; Press Release; 11/18/25 Four California residents were sentenced to prison for their roles in defrauding Medicare of nearly $16 million through sham hospice companies and laundering the fraudulent proceeds.

Attorney General Bonta secures felony sentencing of Inland Empire Hospice operators for Medicare and Medi-Cal fraud  Rob Bonta - Office of the Attorney General, California Government; Press Release; 11/5/25 California Attorney General Rob Bonta today announced the sentencing of Inland Empire Hospice operators, Ralph and Rochell Canales, for submitting false claims to the Medicare and Medi-Cal programs. Ralph was sentenced by the San Bernardino County Court to seven years and four months in state prison and was jointly ordered to pay $1,455,233, alongside his wife Rochell Canales. Rochelle was sentenced to one year in jail, and ordered to abstain from working with Medicare and Medi-Cal beneficiaries ...