Literature Review

MedPAC recommends Congress tie physician pay to inflation for 2026 Healthcare Dive; by Susanna Vogel; 3/17/25 Dive Brief:

Medicaid’s role in health and in the health care landscape: LDI expert insights and key takeaways from select publications Penn LDI - Leonard Davis Institute of Health Economics, Philadelphia, PA; by Julia Hinckley, JD; 3/17/25... Medicaid accounts for one-fifth of U.S. health care spending and covers more than a quarter of Americans. LDI researchers have examined the services it provides in supporting aging adults, people with disabilities, and children, as well as its role in health crises such as chronic disease and suicide. ... Below are select key findings from recent peer-reviewed research, along with expert insights for policymakers considering changes to Medicaid funding in the federal budget.

Hospice industry gets reprieve as Trump admin pauses oversight program Axios; by Maya Goldman; 3/13/25 A federal effort to increase oversight of hospice care has been put on hold by the Trump administration, resetting efforts to root out fraud and abuse in an industry that receives more than $25 billion from Medicare annually. Why it matters: Federal officials in recent years have ramped up efforts to identify instances in which hospice operators fraudulently bill the government or enroll patients who aren't terminally ill. But the new administration last month halted a Biden-era plan for noncompliant hospices to take corrective action or risk being kicked out of Medicare. The big picture: Medicare is required by law to implement some version of the targeted oversight program. But it's not clear how that will evolve in President Trump's second term. 

13th Annual Healthcare Fraud & Abuse Review - 2024 JD Supra; by Bass, Berry & Sims PLC; 3/7/25 Bass, Berry & Sims is pleased to announce the release of the 13th annual Healthcare Fraud & Abuse Review examining important healthcare fraud developments in 2024. Compiled by the firm's Healthcare Fraud & Abuse Task Force, the Review provides a comprehensive analysis of enforcement developments affecting the healthcare industry, significant court decisions involving the False Claims Act, and an overview of settlements involving healthcare fraud and abuse issues.We began the Review over a decade ago with the intention of providing comprehensive coverage of the most significant civil and criminal enforcement issues facing healthcare providers each year. Over that time, the challenges facing the healthcare industry have been significant. ...

DOJ launches probe into UnitedHealth’s Medicare billing practices after investigative reports MSN; by Taylor Herzlich; 3/22/25 The Department of Justice has reportedly launched an investigation into UnitedHealth Group’s Medicare billing practices as scrutiny over the health insurance industry intensifies — sending the company’s stock plummeting.The probe is analyzing the company’s practice of frequently logging diagnoses that trigger larger payments to its Medicare Advantage plans, according to The Wall Street Journal. UnitedHealth shares plunged nearly 9% Friday. A series of Wall Street Journal reports last year found that Medicare paid UnitedHealth billions of dollars for questionable diagnoses.

Hospices traverse the ‘new twists’ in increasingly complex auditing processes Hospice News; by Holly Vossel; 2/20/25 Auditors are raising new questions around two common issues in hospices’ Medicare claims — documentation supporting patient eligibility and the physician narrative. Program integrity issues and quality concerns have raised the bar of regulatory oversight in recent years, with auditing activity ramping up as more providers undergo multiple audits simultaneously each year. ... Claim denials most frequently occur due to insufficiently documented evidence that demonstrates a patient’s eligibility within the physician narrative explanation, Nowicki stated. Auditors have increasingly required more details to support a patient’s six month terminal illness prognosis, potentially stretching the boundaries of hospice requirements stipulated by the U.S. Centers for Medicare & Medicaid Services (CMS), he indicated. [Click on the title's link to continue reading.]

[Updated] Trump administration suspends hospice Special Focus Program Hospice News; by Jim Parker; 2/14/25 The Trump Administration has suspended implementation of the hospice Special Focus Program. Finalized in the 2024 home health payment rule, the program is designed to identify poor performing hospices, mandate quality improvement and in some cases impose additional penalties. However, stakeholders in the hospice space have contended that the agency’s methodology for selecting hospices for the program is deeply flawed. Notice of the suspension appeared [Friday, 2/14] on the U.S. Centers for Medicare & Medicaid Services (CMS) website.

What you need to know about the HOPE Tool HomeCare; by Jennifer Kennedy and Kimberly Skehan; 2/10/25 The Hospice Outcomes and Patient Evaluation (HOPE) assessment tool is scheduled to be implemented Oct. 1, 2025, meaning the clock is ticking for hospice providers to complete internal preparations. Providers can collect and submit hospice item set (HIS) data until Sept. 30, 2025, after which only HOPE data will be accepted for all patients admitted or discharged on or after Oct. 1, 2025. The HOPE tool is a standardized interdisciplinary assessment that aims to meet these goals from the Centers for Medicare & Medicaid Services (CMS): [click here for goals] ... CMS said it is important for providers to ensure their documentation software vendor maintains CoP content while building their HOPE content. The HOPE tool will replace the HIS content, but the core of the HIS data items will be captured in the HOPE tool. Additionally, CMS posted a change table that compares the HIS and HOPE data elements.

DOGE probes CMS for Medicare, Medicaid fraud: WSJ Becker's Hospital Review; by Rylee Wilson; 2/5/25Members of Elon Musk's Department of Government Efficiency have been granted access to payment and contracting systems at CMS, The Wall Street Journal reported Feb. 5. Department representatives have been on-site at CMS' offices this week, examining spending data for potential fraud or waste and reviewing the agency's organization and staffing, unnamed sources told the Journal. ... DOGE aims to cut federal spending by $1 trillion, with Medicaid emerging as a likely target, according to The New York Times. CMS spent more than $1.5 trillion on healthcare programs in fiscal year 2024, accounting for 22% of total federal spending, according to the agency's 2024 annual report. "Yeah, this [CMS] is where the big money fraud is happening," Mr. Musk wrote on X in response to the Journal's article.  

Vital directions for health and health care: Priorities for 2025Health Affairs; by Victor J. Dzau, J. Michael McGinnis; 1/22/25The current series, titled Vital Directions for Health and Health Care: Priorities for 2025, contains six articles on priority areas in US health and medicine that demand urgent attention. Here we provide an overview of the articles, which spotlight key areas for action and transformative change:

Former Apex Hospice director can proceed with retaliation suit Bloomberg Law; by Daniel Seiden; 1/31/25 A former medical director at Illinois-based Apex Hospice and Palliative Care can move forward with her claim that the company violated the False Claims Act by firing her in retaliation for calling attention to Medicare fraud, a federal district court said. [She] adequately alleged that Apex fired her because she refused to certify patients who would be covered by Medicare but were otherwise ineligible for hospice care, Judge Virginia M. Kendall of the US District Court for the Northern District of Illinois said Thursday.

U.S. Attorney’s Office recovers more than $55 million in civil settlements and judgments in calendar year 2024United States Attorney's Office - Western District of Texas, San Antonio, TX; 1/28/25U.S. Attorney Jaime Esparza announced today that the Western District of Texas recovered $55,969,678.60 in settlements and judgments in over 25 affirmative civil enforcement cases between January 1, 2024, and December 31, 2024. ... The office’s largest civil recoveries were obtained in False Claims Act (FCA) matters. The most significant FCA recoveries include: ...

Medicare spending, insurance claim denials top concerns: KFF poll Modern Healthcare; by Hayley Desilva; 1/17/25 A majority of individuals, regardless of their political leanings, say the federal government needs to spend more on healthcare programs, according to a KFF Health Tracking Poll released Friday. The survey of 1,310 people earlier this month highlights several areas in healthcare where the public would like to see things done differently. The results were published three days before a new administration is set to take over in Washington, D.C.