Literature Review

Enhabit walks away from UnitedHealthcare after ‘9 months of unsuccessful negotiations’Home Health Care News; by Joyce Famakinwa;8/7/24Staying on course with its payer innovation strategy, Enhabit Inc. (NYSE: EHAB) has decided to walk away from certain Medicare Advantage (MA) payers – and namely UnitedHealth Group’s (NYSE: UNH) UnitedHealthcare. That decision, and the recent home health proposed payment rule, were top of mind for Enhabit leaders on Tuesday.

Healthcare providers wary CMS dementia pilot will not cover costsModern Healthcare; by Diane Eastabrook;7/23/24Hospitals, primary care practices and other healthcare providers are split over whether Medicare will pay them enough to cover dementia patients at home as part of a new pilot. Nearly 100 providers began enrolling patients July 1 in the Centers for Medicare and Medicaid Services’ Guiding an Improved Dementia Experience model, known as GUIDE. Another 300 others will begin enrolling patients in the program on July 1, 2025. Some participants that previously provided comprehensive wrap-around services for dementia patients at home said getting a monthly care management payment for each fee-for-service beneficiary will cover costs they had been absorbing. But others aren’t sure the reimbursement will be enough to scale up programs or cover the cost of care for these complex patients.

PharMerica reaches $100 million settlement over alleged SNF pharmacy kickbacksMcKnight's Long-Term Care News; by Josh Henreckson; 7/18/24One of the nation’s leading pharmacy companies has agreed to pay $100 million to resolve allegations of false claims and kickbacks in its dealings with long-term care providers. The legal claims against PharMerica have been ongoing in the District Court of New Jersey since 2011, when whistleblower Marc Silver accused the company of undercharging skilled nursing facilities for their Medicare Part A patients in order to secure more lucrative Medicare Part D and Medicaid contracts.

Help improve the PEPPER ProgramPEPPER email; 7/30/24There is a temporary pause in distributing Program for Evaluating Payment Patterns Electronic Reports (PEPPERs) as the Centers for Medicare & Medicaid Services (CMS) work to improve and update the program and reporting system. This pause will remain in effect through the fall of 2024. We recognize the importance of these reports to your practice. Therefore, during this time, CMS will be working diligently to enhance the quality and accessibility of the reports. In fulfilling this commitment, CMS seeks responses to a series of questions listed in the Request for Information (RFI). These questions will provide CMS with information that may be used to reevaluate PEPPERs and improve the effectiveness and accessibility of the program. The RFI (PDF) is available here. Responses are due on or before 08/19/2024 and must be provided via online submission at the following address: CBRPEPPERInquiries@cms.hhs.gov. 

AIDS Healthcare Foundation files Antitrust Action against Express Scripts PBM AIDS Healthcare Foundation (AHF), Los Angeles, CA; by Ged Kenslea; 7/29/24 AIDS Healthcare Foundation (AHF) – the world’s largest HIV/AIDS healthcare organization which cares for more than 195,000 people in the United States and is an essential safety-net provider for disenfranchised, high-risk HIV/AIDS populations – has filed a federal lawsuit (U.S.D.C., E.D. Mo., Case No. 4:24-01043) against the pharmacy benefit manager (PBM) Express Scripts, Inc. and its subsidiary, Accredo Health Group, Inc. AHF asserts federal antitrust claims and claims of state unfair trade practices over Express Scripts’ use of its monopoly power as a PBM in Louisiana to impose anticompetitive restraints to destroy competition among specialty pharmacies like AHF’s. AHF’s lawsuit comes on the heels of a blistering 115-page FTC report documenting how powerful PBMs like Express Scripts squeeze mom-and-pop and independent pharmacies, driving many out of business.

How Medicare Advantage, traditional Medicare differ on end-of-life care Becker's Payer Issues; by Rylee Wilson; 7/24/24 Medicare Advantage enrollees were less likely to receive burdensome treatments or transfers in the last months of life compared to their peers in traditional Medicare, a study published July 19 in JAMA Health Forum found. MA beneficiaries were less likely to die in a hospital than their counterparts in traditional Medicare, the study found. MA enrollees were more likely to receive home-based care at the end-of-life. This home-based care can improve quality but can also leave patients without adequate assistance after a hospitalization, the study's authors wrote. Though Medicare Advantage beneficiaries were less likely to be hospitalized during the last months of life than their counterparts in traditional Medicare, once hospitalized, MA enrollees were more likely to die in the hospital and less likely to be discharged to rehabilitative or skilled nursing facilities. 

Medicare physician pay has plummeted since 2001. Find out why. American Medical Association - AMA; by Tanya Albert Henry; 7/17/24 Medicare physician payment—often called Medicare reimbursement—must be tied to an inflation index called the Medicare Economic Index (MEI). As part of its campaign to fix the unsustainable Medicare pay system, the AMA has outlined in a quick, easily navigable fashion why this payment fix needs to happen now. ... The AMA’s two-page explainer on the Medicare Economic Index (PDF) outlines how it incorporates these two categories reflecting the resources used in medical practices:

Local whistleblowers help in federal hospice investigation CBS WKBN-27, Austintown, OH; by Patty Coller; 7/22/24 The parent company that operates a hospice provider in Austintown has agreed to a settlement in a federal lawsuit alleging that the local location, along with others in the southern part of the country, defrauded the government, according to federal prosecutors. Gentiva, formerly known as Kindred at Home, has agreed to pay $19 million to resolve allegations that it and other entities of Gentiva knowingly submitted, or caused to be submitted, false claims for hospice services provided to patients who were ineligible for hospice benefits under Medicare and other federal health care programs because the patients were not terminally ill, according to Department of Justice. ... The Employment Law Group said in a news release that there were 20 whistleblowers in the case, including two from the Youngstown area involving SouthernCare, who helped to recover about $2.13 million in alleged fraudulent billing.

Texas pharmaceutical marketer sentenced for $59 million medications fraud conspiracy ArentFox Schiff; by  D. Jacques Smith, Randall A. Brater, Michael F. Dearington, Nadia Patel, Hillary M. Stemple, Mattie Bowden, Elizabeth Satarov; 7/19/24 On July 12, Quintan Cockerell, a Texas pharmaceutical marketer, was sentenced to over two years in prison and ordered to pay more than $59 million for receiving illegal kickbacks in exchange for prescription referrals for compounded medications intended to be made specific for individual patient needs. ... Court documents and evidence presented at trial demonstrated that Cockerell used preloaded prescription pads and “standing orders” for doctors to easily select expensive compounded medications. The pharmacy could then switch ingredients in the medications actually prescribed by doctors to maximum insurance reimbursements.

‘Bad apples in a barrel’: How fraudsters in home health care impact the entire space Home Health Care News; by Joyce Famakinwa; 7/19/24 The home health industry has its very own boogeyman--the bad actor. However, there's a difference between providers that had made errors in claims ... [Subscription required to continue reading]

Glitzy Scottsdale couple jailed in $900M fraud Gilbert Sun News; by Tom Scanlon; 7/14/24 ... According to a federal indictment, “Alexandra Gehrke and Jeffrey King were charged for targeting elderly Medicare patients, many of whom were terminally ill in hospice care, for medically unnecessary wound grafts.” Gehrke – known to friends and associates as “Lexie” – and King allegedly filed $900 million in fraudulent claims, pocketing “$330 million in illegal kickbacks as a result of their fraudulent scheme.” According to the indictment, they were responsible for “allograft” bandages being applied frivolously to hundreds of patients, many of them dying. According to Gehrke’s LinkedIn profile, “APEX Medical is a national medical device distribution company. 

C-TAC: CMS’ ‘Palliative’ Definition in 2025 Proposed Hospice Rule ‘Misaligned, Problematic’ Hospice News; by Holly Vossel; 7/12/24 Efforts to establish potential payment mechanisms for high-acuity palliative services within the Medicare Hospice Benefit will require greater clarity from regulators, according to the Coalition to Transform Advanced Care (C-TAC). The U.S. Centers for Medicare & Medicaid Services’ (CMS) 2025 proposed hospice payment rule contained a request for information (RFI) on the potential implementation of reimbursement pathways for “high intensity palliative care services,” such as chemotherapy, blood transfusion and dialysis. CMS in its proposed rule indicated that, “Hospice care changes the focus of a patient’s illness to comfort care (palliative care) for pain relief and symptom management from a curative type of care.” C-TAC’s recommendations are as follows: [Click on the title's link to read more.]

Chevron deference derailed The Rowan Report; by Kristin Rowan; 7/12/24 ... Chevron Deference in Home Health: Since the advent of the PDGM model, CMS has calculated payment rates based on its interpretation of budget neutrality. The National Association for Home Care and Hospice [NAHC] has disputed the validity of both the interpretation of budget neutrality and the formulas used to calculate it. Last year’s 2024 CMS Proposed Rule cut payment rates even further with a 2.890% Budget Neutrality permanent payment rate adjustment and a temporary rate adjustment to account for alleged overpayments from 2020-2022. The lawsuit filed against CMS in response to the 2024 Final Rule was dismissed. NAHC began pursuing an administrative review with CMS. [Click on the title's link to continue reading the discourse between CMS and NAHC, specific to home health.]