Literature Review

Unlicensed Saratoga County nursing home operator to pay $650,000Times Union (Albany, NY)December 21, 2023Ballston Spa, NY—The unlicensed operator of a now shuttered Saratoga County nursing home is set to repay Medicaid $656,000 after an investigation by the state attorney general’s office and U.S. attorney for the Northern District of New York found years’ worth of fraud and resident neglect at the facility. 

Steward Health Care hit with False Claims Act lawsuitHealthcare DiveDecember 20, 2023The federal government is suing Dallas-based Steward Health Care and its facilities, Steward Medical Group and Boston-based St. Elizabeth’s Medical Center, for violating the False Claims Act and a physician self-referral law, according to a Monday announcement. The complaint, filed in Massachusetts District Court, alleges Steward Medical Group improperly linked a lead cardiologist’s compensation with his referrals, leading the group to award him nearly $5 million in incentive-based pay—and violating physician self-referral rules, known as the Stark Law. 

The Backbone of Better Care: Compliance in Home-Based HealthcareBy Jennifer Kennedy, 12/15/23In the realm of home-based healthcare, the distinction between good and great care is often defined by the role of compliance. This invisible backbone extends beyond immediate healthcare services, forming a critical framework that upholds every action and procedure to the highest standards of legal and ethical conduct.

NAHC President Bill Dombi—History Repeating Itself on Hospice Program IntegrityHospice NewsDecember 14, 2023Issues of fraud in the hospice industry echo events that previously affected the home health space, and providers can learn from that prior experience. This is according to Bill Dombi, president of the National Association for Home Care and Hospice, who spoke Thursday in a Relias webinar. ... “What I’m seeing is history repeating itself. Back in the 1990s, the microscope ended up focusing on the Medicare Home Health Program. 

US Supreme Court refuses to hear fraud appeal for South Florida health care executive pardoned by TrumpSouth Florida Sun-SentinelDecember 11, 2023The U.S. Supreme Court on Monday refused to take up an appeal by a South Florida nursing-home operator whose 20-year prison sentence was commuted by former President Donald Trump after being convicted in what prosecutors called a “massive health care fraud scheme.” The Supreme Court rejected a petition by attorneys for Philip Esformes, who was found guilty in 2019 on 20 counts related to kickbacks, money laundering, obstruction of justice and conspiracy, according to court documents. 

In letter to CMS, lawmakers call for more MA transparencyMcKnight’s Home Care DailyDecember 11, 2023Four senators demanded the Centers for Medicare & Medicaid Services make more data surrounding prior authorizations in Medicare Advantage publicly available. “In the last few years, federal watchdogs have released numerous reports examining concerning trends in MA,” Sens. Bill Cassidy, MD (R-LA), Elizabeth Warren (D-MA), Marsha Blackburn (R-TN) and Catherine Cortez Masto (D-NV), the letter’s signees, said in a statement. “Without publicly available plan-level data ... policymakers and regulators are unable to adequately oversee the program and legislate potential reforms.” The senators specifically requested CMS gather and publish data regarding prior authorization requests, denials and appeals, justifications for denials and the timeliness of prior authorization decisions. 

UnitedHealth hit with Medicare Advantage marketing complaintModern HealthcareDecember 7, 2023Advocates for people with disabilities are calling on regulators [to] halt what they describe as misleading Medicare Advantage marketing by UnitedHealth Group. The Center for Medicare Advocacy, National Health Law Program, Disability Rights Connecticut and National Disability Rights Network wrote the Centers for Medicare and Medicaid Services, the Federal Trade Commission and other state and federal officials Thursday to protest UnitedHealthcare advertisements for Dual Eligible Special Needs Plans appearing in Connecticut. The ads target people with both Medicare and Medicaid and spotlight extra benefits from Medicare Advantage plans that state and federal laws already require, the groups wrote. “Unquestionably, this misleading advertising is intended to induce, and has induced, thousands if not tens of thousands of older adults and disabled low-income individuals we are charged with representing to sign up for UnitedHealthcare’s plan, having been led to believe this means they can get extra benefits,” the letter says. UnitedHealth Group did not immediately respond to an interview request.

OIG’s Audit of Nursing Home Workers in Louisiana Finds Flaws in Background Check ProcessSkilled Nursing NewsDecember 6, 2023A federally commissioned report released Wednesday found that nursing homes in Louisiana failed to complete background checks on a portion of their non-licensed employees. In conducting the audit to examine whether Louisiana nursing homes complied with federal requirements for backgrounds checks, the Office of Inspector General chose a sample of 9 Louisiana nursing homes out of a total of 276 licensed facilities in the state, basing its sample size on a variety of risk factors and on the need to select nursing homes in urban and rural settings, the agency said. ... The OIG report states. “Although Federal requirements do not specify the methods or types of information that should be considered for a background check to be regarded as having been satisfactorily completed, we identified potential limitations in the nursing homes’ background check searches and adjudication methods for 49 of the 209 non-licensed employees we reviewed.” In response to OIG’s findings and recommendations, Louisiana has agreed to update its standard survey process to ensure routine monitoring of nursing homes’ compliance with background check requirements by reviewing a sample of 5% of current non-licensed staff and by directing nursing homes to conduct self-audits of current personnel files. ... Among the findings, some disturbing practices emerged. Of the 9 nursing homes closely investigated, six nursing homes, and some of the staffing companies with which they contracted, had employee background check searches conducted that did not include a statewide search of State police records.

The Medicare Gold Rush Is Slowing DownWall Street JournalDecember 6, 2023The popularity of private Medicare plans has been a huge driver of profits for insurance companies in recent years. There are signs the gold rush isn’t quite what it once was. ... The most immediate red flag came from the industry leader, UnitedHealth. During an investor day last week, it predicted its Medicare Advantage enrollment would grow by 450,000 to 550,000 seniors in 2024. That translates to around 5% growth next year, a significant slowdown from the 11% it grew so far this year, according to TD Cowen analyst Gary Taylor. As UnitedHealth executives were presenting in New York, The Wall Street Journal reported that the second-largest Medicare plan provider, Humana, was in merger talks with Cigna. While Cigna’s interest in Humana surely attests to insurers’ continued desire to expand into the Medicare market, some investors took it as a sign that Humana isn’t so sure about the strength of the business going forward. 

Government expects to recover more than $3B from healthcare fraud, misspent funds in fiscal year 2023Healthcare DiveDecember 4, 2023The HHS’ Office of the Inspector General is expected to recover more than $3.44 billion in fiscal year 2023 as a result of investigations into fraud and misspent funds in Medicare, Medicaid and other government health programs, according to the agency’s latest report.

Hospices Seek Special Focus CONs to Reach Underserved PopulationsHospice NewsDecember 1, 2023Some states with certificate of need regulations have special focus policies that allow hospice providers to expand services among underserved communities. But navigating these CON processes can be a challenge. ... A difficulty in seeking these types of special focus CONs is proving an unmet need among specific populations, according to André Lee, co-founder and administrator of Nashville-based Heart’n Soul Hospice.

MedPAC Meeting 12/7-8/23.Register for the Thursday, December 7 afternoon session (1:30PM to 5:00PM) by clicking here. Topics covered include: Assessing payment adequacy and updating payments: Hospice services.Notable Mentions: Kim Neuman.