Literature Review

You heard that correctly: Scammers are committing hospice fraud Federal Trade Commission - Consumer Advice; by Kira Krown, Consumer Education Specialist; 12/13/24 Did someone reach out and offer free, in-home perks like cooking and cleaning in exchange for your Medicare number? Don’t give it. That could be a scammer trying to commit hospice fraud.Scammers are targeting older adults — with calls, texts, emails, fake ads, and even door-to-door visits — claiming they’ll set you up with services like free cooking, cleaning, and home health care. What they likely won’t tell you is how: They want to commit fraud by signing you up for Medicare hospice — that’s right, hospice — care. Then, they can bill Medicare for all kinds of services in your name. Here’s what to know: ..Editor's note: Share this crucial information information from the Federal Trade Commission with communities you serve, your employees, and your volunteers. 

[OIG] Health Care Fraud and Abuse Control Program Fiscal Year 2023 ReportOIG press release; 12/6/24Today, OIG, the Department of Health and Human Services, and the Department of Justice released the Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2023, which details the latest interagency efforts to decrease health care fraud and recover over $1.8 billion. [Click link above to read the Fiscal Year 2023 Report.]

Regulators extend some telemedicine flexibilities, gauge telehealth’s ‘new path forward’ in hospice Hospice News; by Holly Vossel; 12/4/24 Regulators recently extended certain temporary telemedicine waivers granted during the pandemic, with some flexibilities now sunsetting in 2025 rather than the end of this year. The U.S. Drug Enforcement Administration (DEA) and the U.S. Department of Health and Human Services (HHS) have announced the extension of telemedicine flexibilities for the prescribing of controlled medications until Dec. 31, 2025. ... The move was made in response to feedback the agencies received from more than 38,000 comments and two days of public listening sessions. The extension allows for more time to consider a “new path forward” for telemedicine, according to the DEA and HHS. “We continue to carefully consider the input received and are working to promulgate a final set of telemedicine regulations,” the agencies stated in an announcement. “With the end of 2024 quickly approaching, DEA, jointly with HHS, has extended current telemedicine flexibilities through December 31, 2025.” The temporary rule, entitled as the Third Temporary Extension of COVID-19 Telemedicine Flexibilities for Prescription of Controlled Medications, was recently submitted to the Federal Register and will take effect/become effective Jan. 1, 2025.

What is compliance risk? TechTarget; by Katie Terrell Hanna and Francesca Sales; 11/26/24 Compliance risk is an organization's potential exposure to legal penalties, financial forfeiture and material loss, resulting from its failure to act in accordance with industry laws and regulations, internal policies or prescribed best practices. Compliance risk is also known as integrity risk. Organizations of all types and sizes are exposed to compliance risk, whether they are public or private entities, for-profit or nonprofit, state or federal. An organization's failure to comply with applicable laws and regulations can affect its revenue, which can lead to loss of reputation, business opportunities and valuation. Types of compliance risk ... An organization might be implicated in the following types of compliance risks:

OIG issues nursing facility industry segment-specific Compliance Program Guidance; first in a series in Furtherance of its Modernization Initiative Butzel - Attorneys and Counselors Client Alerts; 11/22/24 On November 20, 2024, the U.S. Department of Health & Human Services, Office of Inspector General (“OIG”) issued the first Industry Segment-Specific Compliance Program Guidance (“ICPG”), which applies to the Nursing Facility Industry. This follows from the OIG’s Modernization Initiative to update publicly available resources for the healthcare industry first announced in September 20211 and finalized in April 2023. This ICPG comes just over a year after the OIG issued the General Compliance Program Guidance (“GCPG”) that kicked off the OIG’s efforts to modernize and consolidate numerous Compliance Program Guidance documents issued between 1998 and 2008. Editor's note: Click here to download the U.S. HHS OIG's 59-page November 2024 "NURSING FACILITY Industry Segment-Specific Complicance Program Guidance." A word search finds 30 references to "hospice."

Hospices leaders: ‘Vigilant’ compliance pivotal in MAC auditing climate Hospice News; by Holly Vossel; 11/18/24 e auditing environment has heated up in the hospice industry, with inconsistencies reportedly proliferating among the various types of regulatory enforcement activity — particularly those performed by Medicare Administrative Contractors (MACs). The issue has some hospice providers delving deeper into a range of compliance strategies. Differences exist in the scope of data being reviewed by MAC auditors, as well as the audit appeals approval and denial processes, said Ashley Arnold, senior vice president of quality at St. Croix Hospice. The Minnesota-headquartered hospice provides care across 85 locations in 10 Midwestern states and has an average daily census of roughly 5,200 patients.  

New report for 2024: Rural-urban disparities in health care in Medicare Centers for Medicare & Medicaid Services (CMS); 11/14/24 Advancing Health Equity in Rural, Tribal, and Geographically Isolated Communities. FY2023 Year in Review, November 2023. From the Co-Chairs: ... This year’s annual report demonstrates CMS’ ongoing commitment to advancing health equity for individuals living and working across diverse geographies. These actions span a wide breadth of the agency’s authorities and roles, including regulation, payment, coverage, tools and publications, partner engagement, health system innovations, quality of care, and regional coordination. Across these actions, CMS maintains a focus on the goal of improving the lives of our enrollees and those who care for them. We eagerly anticipate our continued collaboration and partnership with all those CMS serves to advance health care in rural, tribal, and geographically isolated communities.

CMS to surveyors: Keep eyes open for hospice fraud Hospice News; by Jim Parker; 11/14/24 The U.S. Centers for Medicare & Medicaid Services (CMS) has issued a memo to accreditation bodies and state agencies advising surveyors to watch out for potential hospice fraud. The memo directs surveyors to refer issues to CMS if they suspect fraudulent activity. These actions were spurred by a rash of fraudulent hospices that have emerged primarily in California, Texas, Nevada and Arizona. “While the primary purpose of [state agencies and accreditation organization] surveys is to determine compliance with the Medicare Hospice CoPs, there are several elements of the survey process that can uncover concerns that would necessitate a referral to CMS for potential fraud,” CMS indicated in the memo. 

Medicare premiums increasing in 2025 Fox 29 Philadelphia; by Megan Ziegler; 11/12/24The Centers for Medicare and Medicaid Services (CMS) announced this month that standard monthly premiums for its Part B plan are increasing by about 6% in the new year. The jump outpaces both inflation and the cost-of-living adjustment (COLA) recently announced by Social Security. Inflation was up in September about 2.4% from a year ago, and the COLA increase is set for 2025 at 2.5%, which is estimated to be about $48. ... The standard monthly premium for Medicare Part B enrollees is increasing next year to $185, an increase of $10.30, or just less than 6%, from $174.70 in 2024, the CMS announced. The annual deductible for all Medicare Part B beneficiaries is also increasing by $17 to $257. 

Calendar Year (CY) 2025 Home Health Prospective Payment System Final Rule Fact Sheet (CMS-1803-F) CMS Newsroom; Final Rule Fact Sheet (CMS-1803-F); 11/1/24On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) issued the Calendar Year (CY) 2025 Home Health Prospective Payment System (HH PPS) final rule, which updates Medicare payment policies and rates for Home Health Agencies (HHAs). This rule also updates the intravenous immune globulin (IVIG) items and services’ payment rate for CY 2025 for Durable Medical Equipment (DME) suppliers. As described further below, CMS estimates that Medicare payments to HHAs in CY 2025 would increase in the aggregate by 0.5%, or $85 million, compared to CY 2024. [Click on the title's link for more information.]

20 Medicare FAQs: Do you know the answers? WealthUp; by Riley Adams, CPA; 10/29/24 Medicare is instrumental in ensuring that older adults, as well as individuals of all ages with certain medical conditions, have access to affordable health care. It’s also infuriatingly complex in some respects. According to the 2024 KFF Survey of Consumer Experiences, 37% of respondents said it was either “somewhat difficult” or “very difficult” to understand at least one of five aspects of their Medicare coverage. That’s at least better than employer-sponsored insurance (54%) or Medicaid (46%), but it’s still a high percentage that shows many Americans don’t know Medicare inside and out. ... I’ve compiled a list of some of the most frequently asked questions (FAQs) about Medicare, and (more importantly) answers to those questions. The better you understand this vital social program, the easier it should be to make educated decisions regarding it. [Click here and scroll down to "Common Medicare Questions."] 

Medicare Part D paid millions for drugs for which payment was available under the Medicare Part A Skilled Nursing Facility Benefit HHS Office of Inspector General; Report Highlights; 10/27/24 What OIG Found: ... On the basis of our sample results, for 2018 through 2020, we estimated that up to the entire Part D total cost of $465.1 million was improperly paid for drugs for which payment was available under the Part A SNF benefit. Of that amount, we estimated that approximately $245.4 million was for drugs that the medical records showed were administered to Part D enrollees during their Part A SNF stays.What OIG Recommends: We made five recommendations, including that CMS work with its plan sponsors to adjust or delete PDEs, as necessary, and determine the impact to the Federal Government related to the Part D total costs of $953,370 for drugs associated with our sample items for which payment was available under the Part A SNF benefit; work with its plan sponsors to identify similar instances of noncompliance that occurred during our audit period and determine the impact to the Federal Government, which could have amounted up to an estimated $465.1 million in Part D total cost; and provide plan sponsors with timely and accurate information, such as dates of covered Part A SNF stays, to reduce instances of inappropriate Part D payment for drugs for which payment is available under the Part A SNF benefit. ... CMS concurred with all five recommendations.

What hospices need to know about whistleblower lawsuits Hospice News; by Holly Vossel; 10/22/24 Hospices need to understand the range of risks involved in qui tam cases and how best to navigate whistleblower concerns amid an evolving regulatory landscape. Qui tam actions occur when a whistleblower, called a “relator” by the courts, files a False Claims Act suit on behalf of the government. The relator has the potential to receive a portion of any funds recovered by the government via the lawsuit, with amounts typically ranging from 15% to 25%. A federal judge recently found the qui tam clause unconstitutional, ruling that the relator’s role in sparking enforcement actions effectively makes them an executive branch officer appointed without due process.