Literature Review

New hospice special focus programAmerican Health Association / National Center for Assisted Living; by Amy Miller; 10/22/23 ​​As required under the Consolidated Appropriations Act of 2021, CMS has established a hospice special focus program (SFP) in the Calendar Year (CY) 2024 Home Health Prospective Payment System (HH PPS) final rule (88 FR 77676). Through increased regulatory oversight and enforcement of the selected poor performing hospice programs, the SFP will address issues that could place hospice beneficiaries at risk of receiving poor quality of care. The hospice SFP is like the current Special Focus Facility (SFF) program in place for nursing homes. As many nursing homes refer residents to hospice programs and may receive questions from residents or their families, it will be important to keep informed if there are noted quality of care issues. 

3 strategies for hospice GIP compliance Hospice News; by Jim Parker; 10/21/24 Utilization of the general inpatient level of care (GIP) is frequently the subject of audits by Medicare Administrative Contractors (MACs), and avoiding or responding to that scrutiny requires strict compliance to a complex web of rules. Audits are becoming more frequent in the hospice space, and GIP is an increasing focus, including ​for the most common types — Supplemental Medical Review Contractor (SMRC) and Targeted Probe and Educate (TPE). In a survey earlier this year, more than half of hospice providers reported having undergone multiple types of audits within a six-month period. ... In addition to these routine MAC audits, the U.S. Department of Health and Human Services Office of the Inspector General (GIP) has been performing a national audit of GIP utilization, as well as an additional investigation into management of the associated payment cap. The inpatient cap limits the number of days of inpatient care for which Medicare will pay to 20% of a hospice’s total Medicare patient care days, according to OIG. If GIP billing exceeds that metric, the hospice must refund those payments to Medicare.

Gentiva reaches $19.4 million False Claims Act Settlement Policy & Medicine; by Thomas Sullivan; 10/15/24 Gentiva – formerly known as Kindred at Home – reached a $19.4 million settlement with the United States, resolving allegations that it violated the False Claims Act by holding on to overpayments for hospice services provided to patients who were ineligible to receive hospice benefits under various federal health care programs. Kindred is made up of entities that were previously part of an enterprise that did business through various subsidiaries as Kindred at Home. Kindred provided health care services, including hospice services, using various business names during the time periods relevant to the settlement. The settlement resolves allegations brought by the United States and the State of Tennessee against certain Kindred entities alleging that from 2010 until February 2020, the entities knowingly submitted (or caused to be submitted) false claims for hospice services to hospice patients in Tennessee and other states who were ineligible for Medicare or Medicaid hospice benefit because they were not terminally ill. The settlement further resolved allegations that the defendants improperly concealed or otherwise avoided the obligation to repay the hospice claims at issue. The settlement also resolves allegations that SouthernCare New Beacon – a subsidiary – allegedly violated the Anti-Kickback Statute by willfully paying remuneration to a consulting physician to induce Medicare beneficiary hospice referrals.

Humana, UnitedHealthcare, Aetna fall in new MA star ratings Modern Healthcare; by Nona Tepper; 10/10/24 The Centers for Medicare and Medicaid Services sought to make it more challenging for Medicare Advantage insurers to win top quality scores and the payment bonuses that go along with them. It's working. On Thursday, CMS released the latest Medicare Advantage star ratings, and the contrast to just a few years ago is stark. In 2022, 74 Medicare Advantage with prescription drug coverage contracts garnered five-out-of-five stars. For the 2025 plan year, only seven did.

Two Los Angeles-area residents arrested on indictment alleging scheme to fraudulently obtain and launder Medicare proceedsUnited States Attorney's Office - Central District of California; Press Release; 10/9/24 A Los Angeles woman and a San Fernando Valley man were arrested today on a 24-count federal grand jury indictment alleging a scheme to defraud Medicare out of more than $54 million via hospice and diagnostic testing services that were never provided and then laundered their illicit proceeds, including by buying millions of dollars’ worth of gold bars and coins. Sophia Shaklian, 36, of the Larchmont area of Los Angeles, and Alex Alexsanian, 47, of Burbank, were arrested early this morning. They are scheduled to be arraigned this afternoon in United States District Court in downtown Los Angeles. ... According to the indictment that a federal grand jury returned on October 2, Shaklian, often using aliases, managed and submitted claims for seven health care providers enrolled with Medicare and located in Los Angeles County. These businesses included a hospice company she owned – the Pasadena-based Chateau d’Lumina Hospice and Palliative Care – and several diagnostic testing companies: Saint Gorge Radiology in Sylmar; Hope Diagnostics in North Hollywood; Direct Imaging & Diagnostics and Lab One – both located in Hollywood; and Labtech and Lifescan Diagnostics in Claremont.

Concurrent/simultaneous services from Hospice and a Home and Community Based Services waiver Media.Alabama.gov; State of Alabama Press Release - Medicaid; 10/8/24 The Alabama Medicaid Agency (Medicaid) updated the policy to allow concurrent services from hospice and a Home and Community-Based Services (HCBS) Waiver. However, it is vital that the hospice and HCBS waiver case manager coordinate to avoid duplication of services. The HCBS waiver person-centered care plan (PCCP) and hospice plan of care (POC) of the recipient should be coordinated between the hospice, HCBS waiver case manager, and the recipient and his/her caregiver. A conference that includes these parties must be held before concurrent services can start.  The PCCP/POC conference shall be documented in both the recipient’s hospice and waiver record. The PCCP/POC should specify all concurrent services, the frequency of services, and which entity will provide the service. Each HCBS Waiver service included in the PCCP/POC should have an explanation as to why the service is not covered under hospice. [Click on the title's link for more information.] 

CMS finalizes rule to curtail major DME fraud concernsMcKnight's Home Care; by Adam Healy; 9/26/24The Centers for Medicare & Medicaid Services finalized a rule this week that will help it better track anomalous and highly suspicious billing activity for durable medical equipment. The rule allows CMS to more closely monitor two Healthcare Common Procedure Coding System (HCPCS) billing codes for urinary catheters: A4352, an intermittent urinary catheter with a curved tip, and A4353, an intermittent urinary catheter with insertion supplies. These two billing codes were behind what may be the largest case of Medicare fraud in the program’s history. In February, the National Association of ACOs (NAACOS) uncovered evidence that fraudsters had used the two codes to loot as much as $3 billion or more from government health programs.

‘Think like a reviewer’: How hospices can use communication, documentation to boost quality McKnights Home Care; by Adam Healy; 9/24/24 Regulators are tightening their scrutiny of the hospice industry, so providers must prioritize the documentation and communication practices that help them obtain higher quality scores. That’s according to hospice industry experts who spoke during an educational session at the National Hospice and Palliative Care Organization’s annual meeting in Denver. “They’re looking closely at the hospice industry,” Angela Huff, senior managing consultant at Forvis Mazars, said last week during the conference. “They have increasing concerns about fraud, waste and abuse in this space. … Don’t think this is going to stop.” ... A key part of hospice quality assurance is communication, Gallarneau said. Providers should support open, friendly channels of communication. This helps staff and clients feel comfortable raising concerns, making quality issues easier to tackle quickly and effectively. Also, prioritizing accuracy in documentation will help providers stay ready for any surveys or audits, Gallarneau noted. Hospices should ensure patient consent and election of benefit forms are properly filled out, signed and dated, and staff should all be trained to do so accordingly. 

Cigna to cut Medicare Advantage plans in several statesModern Healthcare; by Lauren Berryman; 9/19/24Cigna Group's health insurance unit is scaling back Medicare Advantage offerings in eight states next year, according to a notice to third-party marketers published by the insurance brokerage Pinnacle Financial Services. Members in 36 health plans will be affected by Cigna Healthcare’s cuts and service area reductions in Colorado, Florida, Illinois, Missouri, North Carolina, Tennessee, Texas and Utah. Most people will have another Cigna Medicare Advantage plan available in their counties. The company's Medicare Advantage business is fully exiting at least three counties: two in Missouri and one in North Carolina, the notice said.

CMS: Kidney Care Choices Model boosted home-based dialysis, but more data needed Hospice News; by Holly Vossel; 9/23/24 The Center for Medicare & Medicaid Innovation’s (CMMI) Kidney Care Choices (KCC) Model demonstration has increased utilization of dialysis in the home and has fostered greater clinician training in addressing related conditions. However, more time and data are needed to evaluate the reimbursement model’s impact on quality and cost, according to the first annual model evaluation report from the U.S. Centers for Medicare & Medicaid Services (CMS). The report includes the agency’s analysis of KCC model results during the first performance year since its launch on Jan. 1, 2022. Having this reimbursement path available could ease pressures for palliative care patients making decisions about their serious illness care options.

CMS revises instructions for AOs conducting initial certification surveysNAHC Report; 9/20/24... The revision clarifies initial certification processes for providers/suppliers seeking deemed status via a CMS-approved Accrediting Organization (AO). Specifically, for home health and hospice providers, the AO must not conduct an initial survey until the state agency has provided approval to the AO.Publisher's notes: 1) NAHC article may require member login; 2) CMS Admin Info: 24-22-ALL posted here.

CVS' Oak Street Health pays $60M to settle kickback allegationsModern Healthcare; by Katherine Davis; 9/18/24Chicago-based healthcare firm Oak Street Health has agreed to pay $60 million to resolve allegations from the U.S. Department of Justice that it paid kickbacks to third-party insurance agents in exchange for recruiting seniors to Oak Street’s primary care clinics. The DOJ alleged in a statement today that Oak Street’s Client Awareness Program, designed to grow patient membership, had third-party insurance agents contacting seniors eligible for or enrolled in Medicare Advantage plans, seeking to recruit them to Oak Street locations.

New red flags emerge in hospice UPIC auditing Hospice News; by Holly Vossel; 9/20/24 Unified Program Integrity Contractor (UPIC) auditors are taking a sharper look at nursing home room-and-board for hospice patients. Hospices have increasingly faced more regulatory scrutiny in recent years amid rising program integrity concerns, including ramped up UPIC audits, among various others. These audits are designed to instill oversight measures aimed at safeguarding against bad actors in the hospice industry. Regulators have been zeroing in around hospices’ data when it comes to patient interviews and Medicaid skilled nursing room-and-board payments, among other aspects of care delivery. These data could give UPIC auditors clues as to potential malfeasance. However, auditors’ data extrapolation methodology is flawed and poses risks for quality hospice providers, according to Bryan Nowicki, partner at the law firm Husch Blackwell.