Literature Review

In-home care providers await updates on CMS Medicaid proposal, begin preparing for 80/20 ruleHome Health Care News, by Patrick Filbin; 1/23/24Drawing parallels between the intentions of the Centers for Medicare & Medicaid Services (CMS) and the narrative of a Charles Dickens novel is an uncommon venture. ...  “When the 80/20 rule came out, many of us saw this as a ‘Tale of Two Cities’ situation,” Dave Totaro, chief government affairs officer at Bayada Home Health Care, recently said during a Home Health Care News webinar. 

CMS confirms nursing home staffing ratios to finalize this yearBecker's Hospital Review, by Mariah Taylor; 1/24/24CMS said it will finalize the nursing home minimum staffing proposal in 2024, officials said in a national stakeholder call Jan. 23. The CMS team said they received more than 46,000 comments on the proposal, which was used to inform the final rule.

Historic 21.3 million people choose ACA Marketplace coverageCMS.gov Press Release; 1/24/24Marketplace enrollment climbs nearly 5 million higher than previous year. ... Total plan selections include more than five million people — about a fourth — who are new to the Marketplaces and 16 million people who renewed their coverage. Notably, open enrollment continues in four states and Washington, D.C., through January 31. 

Number of Georgians dropped from Medicaid nears 500,000 The Atlanta-Journal Constitution, by Ariel Hart; 1/22/24Georgia has dropped at least 488,000 from Medicaid, the government health insurance for the poor, as part of a federally mandated project to ensure those covered by the program qualify to remain on it.

$15 billion win for physicians on prior authorizationAMA, by Kevin B. O'Reilly; 1/18/24Under the leadership of Administrator Chiquita Brooks-LaSure, the Centers for Medicare & Medicaid Services (CMS) has released a final rule making important reforms to prior authorization to cut patient care delays and electronically streamline the process for physicians. Together, the changes will save physician practices an estimated $15 billion over 10 years, according to the U.S. Department of Health and Human Services (HHS).

Owner of defunct Skyline chain pleads guilty in $39M fraud caseMcKnight's Long-Term Care News, by Kimberly Marselas; 1/18/24Joseph Schwartz, former owner of Skyline Management and a 90-plus nursing home empire whose collapse sent patients and workers scrambling in 2018, pleaded guilty Wednesday to his role in a $39 million fraud scheme.

OIG report has clues for 2024 healthcare fraud enforcementLAW360, by Mackenzie Wortley, Elizabeth Nevins and Megan Miller; 1/16/24In late 2023, the U.S. Department of Health and Human Services and the U.S. Department of Justice released the Health Care Fraud and Abuse Control Program Annual Report for fiscal year 2022, highlighting continued enforcement and recovery actions under the program.

Acute hospital care at home data release fact sheetCMS.gov, Newsroom; 1/16/24A public release of the data submitted to CMS as part of the Acute Hospital Care at Home initiative will be available beginning on January 16, 2024. CMS plans to release data through the Research and Data Assistance Center (ResDAC), collected from November 27, 2020, through March 30, 2023.

CMS terminates 2 Centene Medicare Advantage plansModern Healthcare, by Nona Tepper; 1/8/24A pair of Centene Medicare Advantage plans must suspend enrollment and marketing because of poor star ratings, the Centers for Medicare and Medicaid Services notified the company.

Nurse pleads guilty to federal charge for stealing pain medications at Baxter clinicBrainerd Dispatch; 1/9/24A registered nurse pleaded guilty to fraudulently obtaining prescription opioid pain medications from a hospice clinic, United States Attorney Andrew M. Luger announced Tuesday, Jan. 9. ... Cambie Elizabeth Broker, 33, was a registered nurse case manager at a hospice clinic in Baxter. Broker used her position to fraudulently obtain controlled substances from the clinic. Broker entered false prescription requests into the clinic’s e-prescribing software to fraudulently obtain oxycodone, hydromorphone, and fentanyl for illegal sale and personal use. 

Home healthcare company agrees to pay nearly $10 million to resolve false claims act allegations relating to its participation in the energy employees occupational illness compensation programOffice of Public Affairs; 1/5/24Atlantic Home Health Care LLC (AHH), a home health care agency operating in Arizona and eight other states, has agreed to pay $9,990,944 to resolve allegations that it violated the False Claims Act by submitting false claims to the Energy Employees Occupational Illness Compensation Program (EEOICP or the Energy Program), a healthcare program administered by the Department of Labor (DOL) for the benefit of Department of Energy employees and contractors with occupational illnesses.

Evaluation of Phase II of the Medicare Advantage Value-Based Insurance Design Model Test: First three years of implementation (2020–2022)CMS Report; 12/29/23Year Two Evaluation Report - Key Takeaways: The Medicare Advantage (MA) Value-Based Insurance Design (VBID) model test enables MA insurers to offer one or more innovative benefit design options in eligible MA plans. The model aims to encourage the use of high-value care and promote healthy behavior, with goals of enhancing care quality, improving beneficiary health, and reducing spending. Most VBID benefits can be targeted based on beneficiaries’ chronic conditions or socioeconomic status (SES). A separate Hospice Benefit component is also included in the model. 

The 10 biggest Medicare Advantage stories in 2023Becker's Payer Issues, by Rylee Wilson; 12/21/232023 was an eventful year for Medicare Advantage. As the program continued to grow, with enrollment surpassing 30 million in 2023, some hospitals are beginning to push back on private Medicare plans. CMS also introduced new rates and regulations in 2023 that are taking effect in 2024. Here are 10 of the biggest Medicare Advantage stories Becker's reported in 2024...