Literature Review

Inside the CMS plan to streamline quality measurement Modern Healthcare; by Bridget Early; 12/23/24 Quality measurement is burdensome and complicated. The government and the private sector are struggling to figure out a good fix. The Centers for Medicare and Medicaid Services uses quality data to inform its reimbursement rates, so it's a high-stakes matter for providers and health insurance companies. CMS has proposed an overarching framework meant to streamline the process: the Universal Foundation. ... The Universal Foundation consists of two dozen quality measures across several categories that track wellness and prevention, chronic conditions, behavioral health, and "person-centered" care. Those include measures of breast and colorectal cancer screenings, blood pressure, blood sugar levels, vaccinations, and hospital readmissions. ... CMS has incorporated this framework into recent regulations such as the Medicare Advantage final rule for 2024 and the Physician Fee Schedule final rule for 2025. 

Santa Paula doctor sentenced to 2 years in federal prison for role in hospice fraud that bilked Medicare out of $3.2 million United States Attorney's Office - Central District of California; Press Release, Los Angeles, CA; 12/16/24 A Ventura County physician who worked for two Pasadena hospices was sentenced today to 24 months in federal prison for defrauding Medicare out of more than $3 million through claims for medically unnecessary hospice services. Dr. Victor Contreras, 69, of Santa Paula, was sentenced today by United States District Judge André Birotte Jr., who also ordered him to pay $3,289,889 in restitution. Contreras pleaded guilty on July 24 to one count of health care fraud. From July 2016 to February 2019, Contreras and co-defendant Juanita Antenor, 62, formerly of Pasadena, schemed to defraud Medicare by submitting nearly $4 million in false and fraudulent claims for hospice services submitted by two hospice companies: Arcadia Hospice Provider Inc., and Saint Mariam Hospice Inc. Antenor controlled both companies. Editor's note: This press release follows-up on the post we recently posted: Glendale woman and Lakewood man found guilty of $3.2 million hospice fraud scheme involving kickbacks for patient referrals. 

What's new for Medicare in 2025? Fidelity; by Kate Ashford, Nerdwallet; 11/25/24, updated 12/11/24Each year, Medicare comes with a new set of prices, new plan ratings and sometimes new regulations. What you’ll pay may be different from last year, and your network and prescription drug coverage may change, depending on your plan. Here’s how Medicare looks in 2025. ...

HHS OIG's Fall 2024 Semiannual Report to CongressU.S. Department of Health and Human Services [HHS] - Office of Inspector General [OIG]; by OIG; issued on 12/4/24, posted on 12/4/24 The Fall 2024 Semiannual Report to Congress highlights OIG's work focusing on the most significant and high-risk issues in health care and human services related to HHS programs and operations during the semiannual reporting period of April 1 through September 30, 2024. The semiannual reports are intended to keep the HHS Secretary and Congress informed of OIG’s crucial findings and recommendations.  ...

CGS Administrators, LLC, did not reopen and recalculate most selected hospices’ caps for years prior to 2020 USA HHS Ofice of Inspector General (OIG), Washington, DC; issued 11/27/24, posted 12/4/24Why OIG Did This Audit: ... Our audit determined whether CGS accurately calculated cap amounts and collected cap overpayments in accordance with CMS requirements. This audit is part of a series that reviewed MAC calculations and collections of hospice aggregate and inpatient cap overpayments.What OID Recommends: [... that CGS] 

Providers hoping for better days ahead with ‘suspicious,’ unannounced CMS site visits McKnights Long-Term Care News; by James M. Berklan; 11/25/24 A campaign to strip mystery out of unannounced, often thinly explained site visits by Centers for Medicare & Medicaid Services contractors may be bearing some fruit. Providers have been rattled by visitors’ demands for information and the ability to take photos with little explanation. They’re hoping that the government-hired fact-checkers communicate and execute their mission better moving forward. ... “When the people who educate consultants and others don’t know about something, it’s concerning. It was so suspicious with the way they [contractors] came into facilities,” McCarthy said. Upon investigation, provider advocates were able to confirm the site visits are legitimate and can happen to any provider or supplier as part of their Medicare enrollment or verification process. And while explicit advance notice may not be given, a record of the visits’ orders can be confirmed in the Provider Enrollment, Chain, and Ownership System (PECOS). [Click on the title's link to continue reading.]

Empassion achieves $34 million in savings in novel Medicare program serving high needs patients Globe Newswire, New York City; 11/21/24 Empassion Health, Inc., the nation’s largest managed care provider of high-quality end-of-life care for adults living with serious illness so that they can have more good days, today reported near-record results for four Medicare Accountable Care Organizations (ACOs) serving Original Medicare lives in 35 states.  Specifically, Empassion achieved total gross savings of $34.1m in the High Needs Population Track of ACO REACH for Performance Year 2023 while managing a record number of lives – nearly 9,000 across 35 states – in total cost-of care arrangements.  This includes a 50-percent reduction of unnecessary hospital stays.  Empassion also earned the highest quality scores for provider communication and care coordination.  “While we are enormously proud of the $34 million in Medicare savings, more important is that Empassion provided high-quality end-of-life care for adults living with serious illness so that they had more good days,” said Robin Heffernan, the CEO of Empassion. “These outcomes are specific to Empassion and its unique model. ..." 

CMS Innovation Center reimagines rural health care approaches Center for Medicare and Medicaid Innovation; 11/12/24 Re-Imagining Rural Health: Themes, Concepts, and Next steps from the CMS Innovation Center "Hackathon" Series. ... Over sixty million Americans currently live in areas identified as rural, Tribal, frontier, and geographically isolated areas, including the U.S. Territories. Compared to people living in urban areas, rural Americans are more likely to experience poverty, be older, be uninsured, and have a disability. At the same time, rural communities face unique barriers to accessing care due to more limited availability of health care providers, including primary care, specialty care and home and community-based services, and residents often have to travel long distances to obtain health care. [Click on the title's link to continue reading (and distribute) this important 20 page whitepaper.]

CMS ramps up efforts to root out ‘door knocker’ hospice schemes Hospice News; by Holly Vossel; 11/15/24 The U.S. Centers for Medicare & Medicaid Services (CMS) recently elaborated on its plans to expand public education campaigns designed to help protect hospice beneficiaries from fraudulent actors in the space. ... “One of the areas we’re working with right now is to enhance education — beneficiary education specifically,” Pryor said during a recent CMS webinar. “We have hospice beneficiaries who are unfortunately fraudulently signed up for the benefit in these kind of, what we call, ‘door knocker scams.’” The scams include bad actors reaching out to beneficiaries with offers of free goods and services, such as groceries, TVs, reclining chairs and furniture, Pryor explained. The fraudulent marketing tactics are posing significant complications for Medicare beneficiaries, he said.

Strengthening nondiscrimination protections and advancing civil rights in health care through Section 1557 of the Affordable Care ActHHS press release; 11/13/24Publisher's note: While the final rule was released this Spring, compliance deadlines begin this month and might be burdensome for some providers to implement. In addition to the link above, guidance can be found here: final rule, press release, fact sheet.

Arrest warrant issued gor a California hospice care executive PRLog - Press Release Distribution, Los Angeles, CA; 11/8/24 The Superior Court of California in Los Angeles has issued a Bench Warrant for the arrest of Darline Singh, owner of Zola Hospice LLC, and associated with numerous other hospice companies throughout the state. Singh failed to appear in court on 9/12/2024 and on 10/24/2024 for a judgment debtor exam stemming from a $15MM judgment against Singh, Zola Hospice LLC, and E&E Hospice, LLC. Darline Singh's resume indicates she has a degree in Chemical engineering from UC Davis, AI Machine learning at MIT, as well as Harvard University. Her work experience highlights consulting and executive roles at Brookdale Senior Living, ACE Hospice, Suncrest Healthcare, Vitas Healthcare, Kindred Healthcare, and Bridge Hospice. In March of 2022 Acting California State Auditor, Michael S. Tilden, reported in a letter to the Governor, "my office conducted an audit of the State's licensure and oversight of hospice agencies and found that the State's weak controls have created the opportunity for large-scale fraud and abuse. We identified numerous indicators of such fraud and abuse by hospice agencies."

Healthcare billing fraud: 10 recent casesBecker's Hospital Review; by Andrew Cass; 10/28/24

New from MedPAC: 2024 Payment Basics series - HospiceMedPAC press release; 10/25/24MedPAC announces the release of the updated 2024 Medicare Payment Basics series. MedPAC's mission is to advise the Congress on Medicare issues, and part of that mission is providing clear and accessible information about how Medicare works. Payment Basics is a series of explainers on how Medicare's payment systems function. These "basics" are typically no more than 5 pages long and feature handy diagrams that visually depict how the payment systems calculate providers' payments. MedPAC produces "basics" for the major payment systems (20 in all), and updates the series once a year in the fall. The updated versions are now available here.Publisher's note: Hospice Payment Basics linked in the title above.