Literature Review

Medicare administrative contractor news includes a data breach and potential consolidation HFMA, Downers Grove, IL; by Nick Hut; 9/9/24 Recent happenings involving Medicare administrative contractors (MACs) include a notice of a data breach and a request for feedback on possible consolidation. CMS sent out word that nearly 950,000 Medicare beneficiaries whose claims go through Wisconsin Physicians Service Insurance Corporation (WPS) are being informed that their protected health information or other personally identifiable information may have been compromised due to a security vulnerability in third-party software. The breach also could have affected those with other insurance if their information was collected to support CMS’s audits of healthcare providers, according to a news release. Belying its name, WPS handles Medicare Parts A and B claims spanning Indiana, Iowa, Kansas, Michigan, Missouri and Nebraska (not Wisconsin). 

The 'great disruption' coming for Medicare Advantage Becker's Payer Issues; by Jakob Emerson; 9/9/24 Come mid-October, the Medicare Advantage program will enter its annual enrollment period, marked by significant changes for older adults. Among these changes are increased government scrutiny, tighter CMS regulations, reduced base payments, and rising healthcare costs. ... "Taken together, some are calling these cuts 'the great disruption,'" wrote Sachin Jain, MD, CEO of SCAN Group, a nonprofit MA carrier with more than 285,000 members, in a LinkedIn post on Sept. 4. Dr. Jain outlined five key observations about the evolving landscape:

Medicare Advantage vendors brace for supplemental benefits cutsModern Healthcare; by Lauren Berryman; 9/4/24Companies that have profited from the largesse of Medicare Advantage insurers seeking to lure customers with generous perks are looking ahead to a tough 2025. Humana and CVS Health subsidiary Aetna are among those signaling that curtailing supplemental benefits such as transportation, fitness memberships, in-home support services, and vision, dental and hearing coverage will be a key part of their strategies to restore margins in a business troubled by high costs and a more restrictive regulatory environment.

Humana to depart 13 Medicare Advantage markets Modern Healthcare; by Lauren Berryman; 9/4/24 Humana previewed its Medicare Advantage strategy for the coming plan year, including a decision to quit 13 counties where performance has been unsatisfactory, at the Wells Fargo Healthcare Conference on Wednesday. The Medicare Advantage heavyweight, which had 6.2 million members in those plans as of the second quarter, expects to lose a few hundred thousand enrollees in 2025 as it prioritizes profitable markets, Chief Financial Officer Susan Diamond told investors at the event in Everett, Massachusetts. In addition to leaving those 13 counties, Humana will offer fewer plans in some other areas, Diamond said. About 560,000 members will have to choose new policies for 2025, most of whom will have other Humana plans available to them, she said. ... Diamond did not specify what markets will be affected, but Humana will continue selling Medicare Advantage plans in every state. The company is committed to a presence in certain favorable regions, including south Florida, she said. 

[CMS] Disparities impact statementCMS press release; 8/20/24This tool can be used by health care stakeholders to promote efforts to identify and address health disparities while improving the health of all people, including those from racial and ethnic minorities; people with disabilities; members of lesbian, gay, bisexual, and transgender communities; individuals with limited English proficiency; and rural, Tribal, and geographically isolated communities. This worksheet has 5 steps to be completed over time...

False Claims Act decisions to know from Q2 2024 JD Supra; by Bass, Berry & Sis PLC; 8/22/24 In case you missed it, this post recaps some key False Claims Act (FCA) decisions and case updates from the second quarter of this year. Courts weighed in on the FCA’s anti-retaliation provision, its first-to-file bar, and issues around judgments and awards. ... In U.S. ex rel. Rosales v. Amedisys, Inc., the relator alleged that Amedisys, a hospice operator, falsely certified patients as terminally ill and submitted claims for reimbursement to Medicare and North Carolina Medicaid for patients who were not properly eligible for hospice care. Amedisys filed a motion to dismiss Rosales’ Amended Complaint for lack of subject-matter jurisdiction, ...

TCN podcast: The need to know on the 2025 Hospice Wage Index Telios Collaborative Network (TCN); podcast hosted by Chris Comeaux; 8/21/24 In this episode of TCN Talks, Chris interviews Annette Kiser, Chief Compliance Officer with Teleios and Judi Lund Person, Principal with Lund Person & Associates LLC.  The conversation covers the need to know around the final published 2025 Wage Index for Hospices.  Some of the key points discussed are:

Wisconsin DHS to create an HCBS minimum fee schedule Open Minds, Gettysburg, PA; 8/15/24 The Wisconsin Department of Health Services (DHS) is developing a minimum fee schedule for a subset of Medicaid home- and community-based services (HCBS) for which no specific rates exist in fee-for-service Medicaid. The minimum fee schedule will apply to adult family homes, community-based residential facilities, residential apartment complexes, supportive home care (SHC) agencies, and self-directed SHC. The affected programs include Family Care, Family Care Partnership, and Program of All-Inclusive Care for the Elderly (PACE), which together serve nearly 57,000 older adults and adults with disabilities. 

Humana will pay $90 million in Medicare drug fraud settlement Bloomberg Law; by Daniel Seiden; 8/16/24 Humana Inc. agreed to pay $90 million to the federal government to settle a whistleblower’s False Claims Act suit alleging that the company submitted fraudulent bids for Medicare Part D prescription drug contracts. Whistleblower Steven Scott alleged that, since 2011, Humana began offering its Medicare Part D prescription drug plan, known as the basic Walmart Plan, and “knowingly provided benefits under that plan that have been significantly less valuable than Humana promised in its bids,” according to Scott’s suit filed in 2016 in the US District Court for the Central District of California. ... This suit was among several in 2016, including suits against Humana, United Health, Cigna Corp., and Optum RX Inc., accusing health insurers of secretly overcharging for prescription drugs.

Stay ahead of Medicare fraudsters ... Watch out for Medicare fraudsters The Times of Noblesville, Indiana; Information provided by the U.S. Department of HEalth & Human Services 8/16/24 (Family Features) ... Watch Out for Medicare Hospice Fraud: Beware of scammers offering older Americans in-home perks, like free cooking, cleaning and home health services, while they are unknowingly being signed up for hospice services. The scammers then unlawfully bill Medicare for these services in your name. Remember this advice to avoid hospice scams: [practical tips for the public] ... Report Medicare Fraud ...Editor's Note: This information for the public--provided by the U.S. Department of Health & Human Services--provides an important resource for your community outreach, marketing, and admissions employees.

Cost report prompts tweaks to ACO REACH model Modern Healthcare; by Bridget Early; 8/12/24 The Centers for Medicare and Medicaid Services is making changes to its largest accountable care organization experiment to ensure it’s actually saving money. In a notice published on its website Aug. 1, CMS outlines a slew of planned updates to the ACO Realizing Equity, Access and Community Health, or ACO REACH, model in 2025. Notably, the agency is changing how it establishes benchmarks for "high-needs population" ACOs to guard against overspending while addressing the so-called "ratcheting effect," under which ACOs that contain spending face higher hurdles to earning shared savings in future years because of their past successes. [Limited access due to paywall.]

The tangled web of pediatric palliative care payment and policy Hospice News; by Holly Vossel; 8/13/24 A complex web of state regulations and reimbursement systems can challenge pediatric palliative care access for seriously ill children and their families. The nation’s fragmented health care system lacks clear guidance when it comes to navigating chronic, complex conditions in children, adolescents and young adults, according to Jonathan Cottor, CEO and founder of the National Center for Pediatric Palliative Care Homes. Much of the current state palliative regulations and reimbursement pathways focus on adult patient populations, representing a significant barrier to improved quality and support in the pediatric realm, Cottor said.