Literature Review

Returning to the community: Health care after incarceration: A guide for health care reentryCMS; 6/6/24This joint publication by CMS and the U.S. Department of Justice Office of Justice Programs helps people recently released from incarceration take charge of their health, connect to health services, and find additional resources. It is available in Spanish on the Access Care webpage and more languages are coming soon.

Kickbacks and medically unnecessary treatments: Five major qui tam settlements from May 2024 JD Supra; by Geoff Schweller; 6/5/24 Under the FCA’s qui tam provisions, a crucial tool in combating healthcare fraud, whistleblowers have the power to file suits on behalf of the federal government if they possess the knowledge of an individual or company defrauding the government. The government may choose to intervene and take over the suit, but if a qui tam lawsuit results in a successful settlement, the whistleblower is eligible to receive between 15-30% of the monies collected. The settlements announced in May cover a wide range of alleged misconduct that violates the FCA, including cases concerning kickbacks and the billing of federal healthcare programs for medically unnecessary treatments. Each settlement represents a victory in the ongoing battle against fraud. ... [Non-hospice examples followed by this hospice case] $4.2 Million Settlement with Elara Claring for Allegedly Billing Medicare for Ineligible Hospice Patients ...

Hospice groups to CMS: Don’t rush CAHPS changes Hospice News; by Jim Parker; 6/3/24Hospice industry organizations have voiced support for proposed updates to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys, but raised questions on the implementation timeline. ... One key concern about the timeline is the need for vendors to develop updated electronic medical record (EMR) systems as well as methods of collecting the data, according to Katy Barnett, director of home care and hospice operations for LeadingAge. ... The proposed changes include:

Reap what you sowFraud of the Day; by Larry Benson; 6/4/24Newly released Federal Trade Commission data show that consumers reported losing more than $10 billion to fraud in 2023, marking the first time that fraud losses have reached that benchmark. This marks a 14% increase over reported losses in 2022. The short of this report is that there is more opportunity in fraud than ever before. And fraudsters don’t care who they are scheming from. Including the dying. Shiva Akula owned and oversaw the day-to-day operations of Canon Healthcare, LLC, a hospice facility with offices in Louisiana and Mississippi. ... Between January 2013 and December 2019, Akula billed Medicare approximately $84 million in fraudulent claims. He was paid approximately $42 million relating to these fraudulent claims. And leaving the dying to just do that. Die without the extra care he profited from. ... [Akula was sentenced to serve 20 years in prison and to repay $42 million in fraudulent Medicare billing claims.]

National aging framework outlines governmentwide initiatives promoting home-based careMcKnight's Home Care; by Adam Healy; 6/3/24The Department of Health and Human Services released a new framework for its National Plan on Aging on Thursday. The framework aims to guide a multifaceted, governmentwide approach to help caregivers and home- and community-based service providers enable older adults to age comfortably in place.

LeadingAge: CMS on right track with high-acuity hospice RFIHospice News; by Jim Parker; 5/31/24 The senior care advocacy group LeadingAge has praised the U.S. Centers for Medicare & Medicaid Services (CMS) inquiries into high-acuity palliative care, but expressed concern over reimbursement and staffing issues. The agency’s 2025 proposed hospice rule featured a series of requests for information (RFI) on issues like health equity, social determinants of health and future quality measures. The RFIs contain further questions about the utilization of higher-cost palliative treatments under the Medicare Hospice Benefit. The agency posed similar queries in its proposed rule for 2024. The new proposal seeks greater clarity on the financial risks and costs that providers say represent barriers to providing those services, such as palliative chemotherapy, radiation blood transfusions or dialysis, among others.

To guard themselves from sanctions, home health agencies need to invest in QAPI programs, NAHC experts say McKnights Home Care; by Adam Healy; 5/22/24 To protect themselves against the Centers for Medicare & Medicaid Services’ compliance enforcement mechanisms, home care providers must focus on quality assessment and performance improvement (QAPI) programs, experts at the National Association for Home Care & Hospice said during a webinar. ... Earlier this month, the Centers for Medicare & Medicaid Services released updates to its enforcement remedies and alternative sanctions for home health and hospice agencies. These remedies and sanctions may be imposed in lieu of termination for providers with condition-level deficiencies. They include civil money penalties, payment suspensions, temporarily-appointed management, directed plans of correction or in-service training.

Owner of home health services agency and parent of disabled child arrested for Medicaid provider fraudFL Office of the Attorney General; 5/15/24Tallahassee, FL - Attorney General Ashley Moody’s Medicaid Fraud Control Unit announced the arrest of the owner of a home health services agency and a parent of a disabled child for Medicaid provider fraud. Latrena Marie Thomas is the owner of A River’s Journey, a home health care agency with residential home care facilities located in Yulee and Jacksonville. Thomas is accused of hiring non-licensed individuals to provide hands-on personal care services to Medicaid recipients. In addition, Thomas paid Donald Ray Adams II, a parent of a disabled Medicaid recipient, to provide medically licensed care for his own child. In total, Thomas fraudulently billed Medicaid claims for 30 distinct medically needy Medicaid recipients, which caused a total loss of more than $1.6 million.

Humana, Aetna likely to lose Medicare Advantage members Modern Healthcare; by Nona Tepper and Lauren Berryman; 5/14/24 Industry heavyweights CVS Health Aetna and Humana foresee Medicare Advantage membership losses next year. Anticipated changes to health plan offerings and benefit design to achieve long-term business profitability could mean losing a significant portion of their Medicare Advantage membership, executives told investors at the Bank of America Securities Healthcare Conference on Tuesday. ... Headed into next year, Aetna may adjust benefits, tighten its prior authorization policies, reassess its provider networks and exit markets, CVS Health Chief Financial Officer Tom Cowhey told investors.  ... [Humana Chief Financial Officer Susan Diamond] anticipates losing about 5% of its 6.1 million Medicare Advantage members, ... Conversely, UnitedHealth Group’s UnitedHealthcare insurance business appears to be better positioned for growth heading into 2025 ... , executives said. UnitedHealth Group CEO Andrew Witty said, ... “The thing we don't want is unsustainable ups and downs in our performance in any particular regard. ... You should just expect more of the same from us in terms of what we’re doing.” 

CMS extends Medicaid waivers to 2025 Becker's Payer Issues; by Rylee Wilson; 5/13/24 CMS will extend flexibilities designed to help states keep more eligible individuals enrolled in Medicaid through June 2025. The waivers, previously set to expire at the end of 2024, will be extended for six more months, Daniel Tsai, deputy CMS administrator and director of the Center for Medicaid and CHIP services, wrote in a May 9 memo to states. Nearly all states were expected to complete the unwinding process by June 2024, Mr. Tsai wrote, but because several states took extension waivers from CMS, several states will continue renewals past June. 

Planning ahead: How Medicare services at home differ from at-home Medicaid The Mercury; by Janet Colliton; 5/10/24 When asked how they would like to receive long-term care services many consumers, probably most, indicate they would like to receive them at home. Expectations for extensive help at home with government support often exceed what is available and this, considering shortages in available health care workers and limited funding is likely to continue. However, knowing the differences between what is offered under Medicare versus Medicaid is extremely helpful. ... [Click on the title's link for practical, user-friendly descriptions of Medicare versus Medicaid at home, for short term rehab, hospice, and more.] 

Baptist Health settles False Claims allegations for $1.5MBecker's Hospital Review; by Naomi Diaz; 5/7/24Jacksonville, FL-based Baptist Health has agreed to pay $1.5 million to address accusations of breaching the False Claims Act. The health system allegedly prompted its subsidiaries to provide discounts up to 50% or more to patients, aiming to incentivize them to acquire or recommend Baptist Health services covered by federal healthcare programs, according to a May 6 Justice Department news release. ... The Anti-Kickback Statute states that individuals in federal healthcare programs cannot get paid for sending others to receive healthcare for which the government pays. 

Medicare program suddenly ending leaves seniors in limbo Newsweek; by Suzanne Blake; 5/6/24 Some hospice patients on Medicare Advantage are now facing uncertainty after the government ended a pilot program. Medicare Advantage is one of the top programs for seniors looking for health insurance, and more than 50 percent of those eligible now use the privatized Medicare Advantage option instead of just traditional Medicare. ... According to the Medicare Payment Advisory Commission, around half of 1.7 million Medicare Advantage recipients who died in 2022 were in hospice for end of life care.