Literature Review

Navigating the Wage Index: Insights from industry experts Teleios Collaborative Network (TCN); podcast by Chris Comeaux with Annette Kiser and Judi Lund Person; 8/20/25 The healthcare landscape is transforming before our eyes, shifting away from hospital-centered care toward home-based models.  This fundamental change raises urgent questions about Medicare's outdated reimbursement systems, particularly for Hospice providers facing a mere 2.6% rate increase while battling significant inflation. Join us in this illuminating conversation and in-depth discussion with industry experts Annette Kiser, Chief Compliance Officer with Teleios, and Judi Lund Person, Principal, Lund Person & Associates LLC, as they sit down with Chris and explore the complexities of the final 2026 Hospice Wage Index and its impact on Hospice organizations.

Addressing hospice care Medicare fraud: Awareness and actionInvestors Hangout; by Lucas Young; 8/18/25 The New York StateWide Senior Action Council (StateWide) is an impactful 53-year-old non-profit organization dedicated to assisting approximately 2.5 million senior citizens. Recently, they have spotlighted a concerning trend in their monthly Medicare Fraud identification: Hospice Care Medicare Fraud. This initiative is part of the Senior Medicare Patrol (SMP), which equips older adults and their caregivers with the knowledge to detect, prevent, and report healthcare fraud, errors, and abuse. StateWide administers this program for New York State, acting as a crucial resource for senior citizens across the region. [This article provides simple, clear facts for the public.]

Merging clinical and legal: How home health providers achieve medical appeals success Home Health Care News; by Joyce Famakinwa; 7/31/25 For home-based care providers, medical appeals can be extremely costly. When navigating the medical appeals process, home health clinical and legal teams must operate in lockstep in order to achieve successful results and avoid financial blowback, ... ROI should be the biggest determining factor when deciding to appeal, according to Bill Dombi, senior counsel for Arnall Golden Gregory law firm. He formerly served as the president of the National Alliance for Care at Home. ... Despite the hefty costs that medical appeals can potentially rack up, sometimes figuring out the ROI can go beyond dollars and cents. For example, if a provider is going through the Medicare Targeted Probe and Educate (TPE) audit process.

Glendale woman sentenced to 9 years in federal prison for $10.6 million hospice fraud scheme involving kickbacks for patients United States Attorney's Office - Central District of California, Los Angeles, CA; Press Release; 8/5/25 A Glendale woman was sentenced today to 108 months in federal prison for participating in a scheme in which hundreds of thousands of dollars in illegal kickbacks were paid and received for patient referrals that resulted in the submission of approximately $10.6 million in fraudulent claims to Medicare for purported hospice care. Nita Almuete Paddit Palma, 75, of Glendale, was sentenced by United States District Judge Dolly M. Gee, who also ordered her to pay $8,270,032 in restitution. 

HHS sets its sights on $50b in cost savings: Medicare payments to nonhospice providers potentially under fire JD Supra; by Taylor Henderson, Callan Stein, Rebecca Younker; 7/31/25 In May 2025, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) published a review, titled " Potential Cost Savings HHS Programs – HHS Actions," which provided some insight into the OIG's direction to accomplish the Trump administration's stated goal of cutting federal spending. This review spans 35 reports, adding up to $50 billion in potential cost savings — including a reported $6.6 billion in potential savings by preventing Medicare payments for nonhospice items or services furnished to active hospice beneficiaries (nonhospice payments). When a beneficiary qualifies for and elects hospice benefits, the beneficiary signs a statement choosing hospice care over other Medicare-covered treatments for their terminal illness, and the hospice provider is paid a daily, per diem rate to provide these comprehensive services. With nonhospice payments accounting for a significant portion of HHS's potential savings, providers across the health care industry — including nursing and long-term care facilities, hospice and home health agencies, hospitals, individual providers, pharmacies, and medical equipment distributors — will need to be ready for the OIG's possible next steps.

Georgia may be next for enhanced hospice oversight, regulatory affairs expert predicts McKnights Home Care; by Adam Healy; 7/29/25 Warning, hospice providers in Georgia. Your state may be the next target for the Centers for Medicare & Medicaid Services’ Provisional Period of Enhanced Oversight (PPEO). “If you are from Georgia, do not be surprised if something like this comes to your town soon,” Katie Wehri, vice president of regulatory affairs, quality and compliance for the National Alliance for Care at Home, said on the closing day of the Alliance’s Financial Management Summit Tuesday. “The reason is that the Medicare Payment Advisory Commission and CMS have both mentioned Georgia as an area where there’s a high number of new hospices.” Four states are currently the subject of PPEO: California, Arizona, Nevada and Texas. California — and specifically Los Angeles County — has been a hotbed of hospice fraud in recent years. 

Hospice | CMS.gov/Fraud Fast FactsCMS.gov/Fraud; by CMS; July 2025 ... Medicare hospice utilization has increased in recent years. In Fiscal Year 2024, Medicare payments for hospice reached over $27 billion, with approximately 1.8 million Medicare beneficiaries receiving hospice care. CMS has taken significant action to address likely fraudulent behavior occurring in Medicare-enrolled hospices, including long lengths of stay, co-located hospices, and high rates of beneficiaries discharged alive. [This Fast Facts one-page sheet includes:]

Home-based hospice operators welcome CMS anti-fraud efforts Home Health Care News; by Joyce Famakinwa; 7/24/25 In an effort to combat fraud, the hospice industry may see increased scrutiny from the U.S. Centers for Medicare & Medicaid Services (CMS). Home-based care providers that offer hospice services, including AccentCare and Elara Caring, told Home Health Care News they hope that CMS will act on their statements about bad actors in the industry – and that a crackdown would protect “high-integrity” providers. ... Companies like AccentCare, which offer both home health and hospice services, welcome CMS’s active approach to rooting out fraud. “We hope it materializes,” Dr. Balu Natarajan, chief medical officer at AccentCare, told HHCN. ... Similar to AccentCare, Elara Caring believes that this would be a step in the right direction. “We fully support CMS’s efforts to crack down on fraud in hospice and home health,” an Elara Caring spokesperson told HHCN in an email.  

Humana renews challenge to downgrade of US Medicare 'star' ratings Reuters; by Daniel Wiessner; 7/21/25 Humana ... filed a new lawsuit over the U.S. government's reduction in the health insurer's star ratings for government-backed Medicare plans, after an earlier challenge was dismissed on technical grounds. Humana, in the lawsuit in Fort Worth, Texas, federal court, says the lower ratings could cause it to lose customers and potentially billions of dollars in bonus payments from the government, which would have been used to reduce premiums and increase benefits for its members. U.S. District Judge Reed O'Connor in Fort Worth dismissed those claims last week, finding Humana had failed to exhaust all of its out-of-court options to challenge the ratings. In the new lawsuit, Humana says it has in recent months exhausted an administrative appeals process, giving the insurer standing to sue. 

Perform detail-oriented internal audits to avoid common denials DecisionHealth - Home Health Line; by MaryKent Wolff; 7/18/25 The most common reason for hospice denials in the first quarter of 2025 was that the claim was not hospice appropriate, according to Palmetto GBA, a Medicare Administrative Contractor (MAC) servicing 16 states. Palmetto released its list of the top 10 hospice medical review denial reasons from January to March 2025 on May 16. [Subscription required.]

AAPA asks CMS to remove regulatory restrictions on PAs providing hospice care American Academy of Physician Associates (AAPA); by Trevor Simon; 7/9/25 In June 2025, AAPA submitted comments to the Centers for Medicare and Medicaid Services (CMS) regarding the topics of hospice, skilled nursing facilities, inpatient rehabilitation facilities, and inpatient psychiatric facilities. These comments, in response to annually released proposed rules that make adjustments to the hospice wage index and respective fee schedules, responded directly to inquiries made within the rules, as well as identified policy obstacles faced by PAs in these settings. [Continue reading for] a brief summary of the topics AAPA discussed in each, with links to the full letters.

DOJ & HHS announce reinvigoration of False Claims Act Working Group and Healthcare Fraud Enforcement Priorities Dorsey & Whitney LLP; Press Release; 7/9/25 The Department of Justice and the Department of Health and Human Services announced the reinvigoration of a False Claims Act (“FCA”) Working Group, a joint effort between the two agencies.  The announcement was made on July 2 during remarks at the American Health Law Association (“AHLA”) Annual Meeting by Brenna Jenny, the new Deputy Assistant Attorney General of DOJ’s Commercial Litigation Branch, and in a press release that same day. This working group underscores that healthcare fraud is a priority for the Administration, despite recent staff changes and recent policy announcements about enforcement priorities in civil rights and DEI. It also underscores that robust compliance programs should continue to be a priority for healthcare-industry stakeholders.

Joint Commission cuts standards by 50% in sweeping overhaul Becker's Clinical Leadership; by Paige Twenter; 6/30/25 The Joint Commission is transforming its accreditation process by reducing the number of requirements by 50% — from 1,551 to 774 standards — in its most significant rewrite since Medicare was established in 1965. The overhaul, first shared with Becker’s, underscores the organization’s effort to reduce the regulatory burden on hospitals and healthcare organizations, uphold public trust and help organizations achieve the highest level of safety and quality, according to Jonathan Perlin, MD, PhD, president and CEO of The Joint Commission Enterprise. ... The redesign, called Accreditation 360: The New Standard, features an updated manual with clearer definitions of CMS conditions of participation and the Joint Commission’s national performance goals, now distilled into 14 critical categories.