Literature Review

Medicaid Access Rule review completed by White House McKnights Senior Living, by Lois A. Bowers; 4/16/24A proposed federal rule establishing mandatory quality measures for home- and community-based services and requiring providers to allocate 80% of HCBS payments to direct care worker pay is one step closer to being finalized. The White House Office of Management and Budget’s Office of Information and Regulatory Affairs has completed its review of the Centers for Medicare & Medicaid Services’s so-called Medicaid Access Rule, according to the agency’s website.

 Health Care Fraud and Abuse 2023 Year in ReviewJD Supra; by Kevin Coffey, Meredith Eng, Haley Essner, Rebecca Hsu, Christopher Kim, Tessa Lancaster, Dayna LaPlante, Logan Moore, Angela Powers; 4/12/24 Polsinelli proudly introduces the Health Care Fraud and Abuse 2023 Year in Review, a comprehensive examination of the evolving landscape surrounding the False Claims Act (“FCA”) and fraud & abuse enforcement efforts in the United States. Since its significant amendments in 1986, the FCA has stood as a formidable tool in combating health care fraud, with the Department of Justice reclaiming over $75 billion in allegedly fraudulent proceeds. 

$1 billion Medicaid shortfall leads to waiting list for HCBS McKnights Senior Living, by Kimberly Bonivssuto; 4/12/24An almost $1 billion shortfall in Indiana’s Medicaid program is fueling the implementation of a waitlist for the state’s home- and community-based services waiver program.  ... Last week, the [Family and Social Services Administration] FSSA announced that it was implementing a waiting list after the A&D waiver program reached maximum capacity. Overall, strategies the agency outlined to reign in spending are expected to have a $300 million impact over the biennium.

New patient safety measures imminent as risk of harm evolves: CMS McKnights Long-Term Care News, by Kimberly Marselas; 4/10/24 The Centers for Medicare & Medicaid Services remains acutely focused on patient harm and will introduce new measures addressing patient safety later this year, agency leaders said at an event in Baltimore Tuesday. ... Agency officials are working with other Health and Human Services branches and meeting internally to develop a 10-point patient safety strategy to be unveiled later this year. 

How MA Plan design affects utilization, health equity MedCity News, by Marissa Pescia; 4/8/24 A new study found that enrollees with zero-premium MA plans are three times as likely to be non-White compared to other MA enrollees and traditional Medicare enrollees. ... The study was published by Harvard Medical School and Inovalon, a provider of cloud-based software solutions. It used Inovalon’s Medical Outcomes Research for Effectiveness and Economics Registry dataset, which “tracks demographic characteristics and outcomes for about 30% of all MA members at any given point in time,” according to the report.

CMS provides first look at shorter, Risk-Based Survey process McKnights Long-Term Care News, by Kimberly Marselas; 4/4/24 The Centers for Medicare & Medicaid Services on Wednesday revealed initial information about a potential “Risk-Based Survey” option that could be available to some of the nation’s best performing nursing homes. ... CMS said in an update to its nursing home provider enrollment page Wednesday that it is working with states to test this process over the next several months. ... CMS said the proposed risk-based survey, or RBS, approach would allow “consistently higher-quality facilities” to receive a more focused survey, while still ensuring compliance with health and safety standards. 

What home health providers need to know about the Medicare TPE Audit ProcessHome Health Care News, by Joyce Famakinwa;  4/2/24... TPE is a medical review program that began for the home health and hospice settings in December 2017. The goal of the program is to weed out improper payments by zeroing-in on providers with high claims denial rates or unusual billing practices. ... TPE has three pillars. Target refers to errors or mistakes that are identified through data in comparison to providers or peers. Probe is the examination of 20 to 40 claims. ... Education means helping providers reduce claim denials and appeals through one-on-one individualized education.

EnforceMintz - False Claims Act statistical year in review Mondaq - Mintz; by Kevin M. McGinty, Laurence Freedman, Karen Lovitch and Brian Dunphy; 3/27/24 Mintz's annual report on False Claims Act case activity analyzes data from the DOJ and the firm's Health Care Qui Tam Database, and explores the 2023 spike in FCA case activity, the ongoing moderate decline in health care–related activity, and continuing robust recoveries in health care cases. ... Also interesting is the absence of hospice care facilities from this year's table. In a number of recent years, those entities had been a growing category of FCA defendants in our internal data.

Improving the Quality Of Quality Metrics Health Affairs; by Aditya Narayan, Bob Kocher, and Nirav R. Shah; 3/19/24... The landscape of health care quality measures is dynamic, reflecting efforts to enhance patient care, safety, and outcomes. These measures are developed and reimbursed by a variety of stakeholders, including government agencies such as the Centers for Medicare and Medicaid Services (CMS), health care organizations, and independent bodies such as the National Quality Forum and the Agency for Healthcare Research and Quality (AHRQ). The development process involves rigorous research, stakeholder engagement, and consensus-building to ensure measures are evidence-based, applicable across different health care settings, and meaningful to patient care.Editor's Note: Read and share this informative, big-picture article about the evolution of healthcare's quality metrics, its tools, and best practices. 

New legislation proposes national expansion of integrated care modelsHealth Affairs, by Laura M. Keohane; 3/20, 24 This article is the latest in the Health Affairs Forefront major series, Medicare and Medicaid Integration. The series features analysis, proposals, and commentary that will inform policies on the state and federal levels to advance integrated care for those dually eligible for Medicare and Medicaid.  ... On March 14, a bipartisan group of senators—members of the Senate Duals Working Group—released legislation (The DUALS Act: Delivering Unified Access to Lifesaving Services Act of 2024) that commits to ambitious goals for aligning Medicare and Medicaid coverage ... Would the integration measures proposed in this bill be more successful [than previous programs] in achieving these goals? This Forefront article highlights the key components of the legislation and assesses its ability to advance better outcomes for dual-eligible beneficiaries.

New ACO model paves way for innovative home-based primary care services: CMS McKnights Home Care, by Adam Healy; 3/20/24 The Centers for Medicare & Medicaid Services on Tuesday unveiled a new person-centered care payment model that expands how and where beneficiaries can receive primary care. “People whose primary care provider participates in the ACO PC Flex Model may get care in more convenient ways, like care based at home or through virtual means, extra help managing chronic diseases, and more preventive health services to keep them healthy,” CMS Administrator Chiquita Brooks-LaSure said in a statement. “Not only will people with Medicare receive more coordinated, seamless care that addresses their unique needs, but CMS is supporting primary care clinicians and giving them more flexibility to provide person-centered care.”

Medi-Cal Update - Hospice Care Program BulletinMedi-Cal, March Bulletin[Topics include:]