Literature Review

All the payment factors included in the 2025 Home Health Proposed Rule Home Health Care News; by Joyce Famakinwa; 7/8/24 Providers examining the 2025 home health proposed payment rule may be experiencing some déjà vu, according to William A. Dombi, the president of the National Association for Home Care & Hospice’s (NAHC). “Much of what we see in the rule is just, on the payment side of it in particular, an update from ‘23 and ‘24,” he said during a recent webinar hosted by NAHC. On June 26, the U.S. Centers for Medicare & Medicaid Services (CMS) unveiled its home health proposed payment rule for 2025. The proposal includes a payment decrease in the aggregate by 1.7%, or by about $280 million. “That needs qualification,” Dombi said. “That’s $280 million, not to what it would otherwise have been, but rather, in contrast to what it’s expected to be for 2024.” Providers examining the proposed rule will also see a 2.5% net inflation rate update. ... 

Long-term care providers among 193 criminally charged, $2.75 billion in fraud recoveries so far in 2024McKnight's Senior Living; by Kathleen Steele Gaivin; 7/1/24The Justice Department has recovered more than $2.75 billion in false claims against healthcare providers and charged 193 defendants so far this year in criminal cases through its 2024 National Health Care Fraud Enforcement Action, and many of the cases involve nursing homes, home health or hospice agencies, and assisted living providers, according to a Thursday report from the department’s criminal division.

Survey: Adults dropped from Medicaid after pandemic faced healthcare access, affordability issues CIDRAP - Center for Infectious Disease Research & Policy Research and Innovation Office, University of Minnesota; by Mary Van Beusekom, MS; 7/2/24 A survey of low-income adults in four southern US states shows that nearly half of those disenrolled from Medicaid after COVID-19 pandemic protections ended had no insurance in late 2023, leading to struggles to afford healthcare and prescription drugs and threatening to broaden a gap that had narrowed during expanded governmental benefits. The data were derived from 89,130 adult residents of Arkansas, Kentucky, Louisiana, and Texas participating in the National Health Interview Survey in 2019, 2021, and 2022. In 2023, states rechecked Medicaid eligibility after COVID-19 governmental protections expired, disenrolling millions. The average participant age was 48.0 years, and 51.6% were women. Researchers from Beth Israel Medical Center and Harvard Medical School published the results late last week in JAMA Health Forum.

10 key Medicare Advantage updates in 2024 Becker's Payer Issues; by Rylee Wilson; 6/27/24 The first half of 2024 brought shifting trends for Medicare Advantage. Payers continued to warn of rising medical costs in the MA population, and some are predicting they will lose members next year. Insurers picked up a win in June when CMS said it would recalculate star ratings for 2024. Here are 10 key Medicare Advantage updates to know: 

DOJ slaps $20M opioid prescription penalty on OptumRx Fierce Healthcare; by Noah Tong; 7/2/24 OptumRx will pay $20 million to resolve claims the company violated the Controlled Substances Act by improperly filling certain opioid prescriptions, the Department of Justice recently announced. The agency claims OptumRx did not fill prescriptions correctly for "trinity prescriptions" like benzodiazepines and other muscle relaxants from April 2013 to April 2015. These prescriptions, which are addictive, may not have been “intended for legitimate medical use” and carry “significant risk of harm,” according to a news release. “Pharmacies providing opioids and other controlled substances have a duty under the Controlled Substances Act to ensure that they fill prescriptions only for legitimate medical purposes,” said Principal Deputy Attorney General Brian Boynton, head of the Justice Department’s Civil Division, in a statement. “The department will continue to work with its law enforcement partners to ensure that pharmacies do not contribute to the opioid addiction crisis.”

Lawmakers say CMS should ban Medicare Advantage’s use of AI to deny care McKnights Long-Term Care News; by Josh Henreckson; 6/26/24 The Centers for Medicare & Medicaid Services should consider banning artificial intelligence from being used to deny Medicare Advantage coverage pending a “systematic review,” a group of 49 congressional leaders is urging. ...  Skilled nursing providers have been sounding the alarm for years on Medicare Advantage coverage access, especially when informed by AI and other algorithms. Sector leaders have frequently noted that these methods can deny or prematurely end coverage for patients who need it to afford necessary long-term care. Providers and consumer advocates both spoke out in favor of the lawmakers’ letter this week. “LeadingAge’s nonprofit and mission driven members … have firsthand experience of Medicare Advantage (MA) plans’ inappropriate use of prior authorization to deny, shorten and limit MA enrollees’ access to medically necessary Medicare benefits,” wrote Katie Smith Sloan, president and CEO of LeadingAge. ... “Implementation by [the] Centers for Medicare and Medicaid Services (CMS), which we fully support, would ensure MA plans fulfill their obligation to provide enrollees equitable access to Medicare services.”

National Health Care Fraud Enforcement Action results in 193 defendants charged and over $2.75 billion in false claims United States Attorney's Office - Western District of Virginia, Charlottesville, VA; 6/27/24 The Justice Department today announced the 2024 National Health Care Fraud Enforcement Action, which resulted in criminal charges against 193 defendants, including 76 doctors, nurse practitioners, and other licensed medical professionals in 32 federal districts across the United States, for their alleged participation in various health care fraud schemes involving approximately $2.75 billion in intended losses and $1.6 billion in actual losses. In connection with the coordinated nationwide law enforcement action, and together with federal and state law enforcement partners, the government seized over $231 million in cash, luxury vehicles, gold, and other assets. 

‘Lot of work to be done’: What home health leaders expect from payment rulemaking in 2024Home Health Care News; by Joyce Famakinwa; 6/24/24 In recent years, home health care has faced relentless cuts from the Centers for Medicare & Medicaid Services (CMS). It has plagued the industry, but providers and advocates alike are still hopeful a light at the end of the tunnel is ahead. ... Home Health Care News recently caught up with PQHH CEO Joanne Cunningham and David Totaro, the president and executive director of Hearts for Home Care. ... [Cunningham said,] "I anticipate that what we will see, given CMS’s posture and prior rulemaking cycles, is the continuation of the policy that will put in place permanent cuts to the Medicare home health program. We’re bracing ourselves for an additional sizable permanent cut. We don’t know exactly what CMS has planned for the temporary cuts, otherwise known as the clawback cuts. We will certainly see, at a minimum, CMS identify what their new projected value of the temporary cuts are. ...

CMS - Roadmap to Better Care: Tribal Version CMS; 6/17/24This version of the Roadmap has been updated to help members of the American Indian and Alaskan Native community connect to their health care, including benefits provided through the Indian Health Service (IHS), Medicare, Medicaid, Marketplaces, or private insurance. Unlike Medicare, Medicaid, the IHS is not an insurance program or an established benefits package. IHS cannot guarantee funds are available each year, and as a result sometimes needs to prioritize patients of greatest need. The preservation of legacy, heritage, and traditions is vital. This roadmap is designed to help sustain cultural richness and strengthen the well-being of present and future American Indian and Alaska Natives for generations. To learn more about enrollment in Marketplace, Medicare, or Medicaid see pages 4 and 5 or visit ihs.gov/forpatients.

CMS recalculates Medicare Advantage star ratings Becker's Payer Issues; by Rylee Wilson; 6/13/24CMS has recalculated Medicare Advantage plans' star ratings after insurers challenging the agency's methodology were handed court victories. In a memo sent to MA plans on June 13, the agency said it would recalculate plans' star ratings for 2024 without eliminating extreme outliers.  

Care provider to pay $14.9M over false claims involving assisted living communitiesMcKnight's Senior Living; Kimberly Bonvissuto; 6/10/24A chronic disease management provider will have to shell out $14.9 million over allegations related to false claims involving assisted living communities, memory care communities and group homes. Bluestone Physician Services of Florida LLC, Bluestone Physician Services PA of Minnesota and Bluestone National LLC of Wisconsin agreed to a $14.9 million settlement with the Justice Department. The federal government alleged that Bluestone knowingly submitted false claims to Medicare, Medicaid and TRICARE — the healthcare program for active duty service members and their families — for certain evaluation and management codes for services related to chronic care management of assisted living residents. The settlement agreement resolves allegations that Bluestone submitted “inflated” claims between Jan. 1, 2015, and Dec. 31, 2019, that did not support the level of service provided. The federal government will receive $13.8 million from the settlement, with more than $1 million going to the states of Florida and Minnesota.

U.S. Rep. Beth Van Duyne: Crack down on hospice fraud Hospice News; by Jim Parker; 6/12/24 Rep. Beth Van Duyne, (R-Texas) has emerged as one of Washington’s most vocal advocates for hospice providers in Congress. ... Van Duyne was among a group of lawmakers that wrote to CMS Administrator Chiquita Brooks LaSure last month requesting updates on the agency’s battles against fraudulent providers, as well as a U.S. Government Accountability Office (GAO) report on quality issues in the hospice space. Hospice News spoke with Rep. Van Duyne in Washington D.C. on congressional efforts to root out fraud and where they should go next. 

Five arrested over 'sham hospices' alleged to bilk Medicare for over $15 million Los Angeles Times; by Emily Alpert Reyes; 6/8/24 Angeles over an alleged scheme to bilk the Medicare program of more than $15 million. The U.S. Department of Justice said three of the San Fernando Valley residents who were arrested — Petros Fichidzhyan, also known as Peter; Juan Carlos Esparza; and Karpis Srapyan, also known as Tony Levy — were accused of running "sham hospice companies" and turning in fraudulent claims to Medicare for hospice services. ... As part of the alleged scheme, the three defendants misappropriated the identifying information of doctors to claim those physicians had deemed hospice services necessary for patients, federal prosecutors said. They also allegedly used the names and Social Security numbers of Russian and Ukrainian citizens who had left the U.S. to open bank accounts and sign leases, indicating that the "impersonated identities" were the owners of the hospice companies that they in fact controlled, according to the federal indictment.