Literature Review

All posts tagged with “Regulatory News | Medicare.”



How Compliance Management Systems help ensure business efficiency

07/24/25 at 03:00 AM

How Compliance Management Systems help ensure business efficiency Enterprise Talk; by Apoorva Kasam; 7/22/25 With changing rules and regulations, businesses can’t afford to leave compliance to chance. A robust compliance management system (CMS) helps meet regulatory, legal, and internal policy requirements.

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Facing new CMS pressure, providers should audit mental health diagnoses, prescriptions: expert

07/24/25 at 03:00 AM

Facing new CMS pressure, providers should audit mental health diagnoses, prescriptions: expert McKnights Long-Term Care News; by Kimberly Marselas; 7/22/25 As reported in McKnight’s Long-Term Care News on July 23, “Nursing homes should be auditing documentation for all residents with mental health disorders to ensure their diagnoses are compliant with new federal guidance, a well-known clinical reimbursement recommended Tuesday. Leigh Ann Frick, president of Care Navigation Consulting, made that suggestion while reviewing updated Long-Term Care Surveyor Guidance that went into effect in late April. At over 900 pages, the new manual and appendixes have left many providers still navigating the changes and how best to respond to them. When it comes to giving antipsychotic medications, diagnosing patients with disorders that require them, or identifying and responding to any other patient needs, the guidance puts new emphasis on the use of professional standards, Frisk explained. Guest Editor’s Note, Judi Lund Person:  For nursing home residents who have elected the Medicare hospice benefit, this information may apply. Diagnosing mental health issues, prescribing, and documenting based on professional standards is an important component in the updated Long-Term Care Surveyor guidance issued in April.

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Rural hospitals eye service expansions to weather federal cuts

07/23/25 at 03:00 AM

Rural hospitals eye service expansions to weather federal cuts Modern Healthcare; by Alex Kacik; 7/14/25 Rural hospitals are hopeful they can add rather than reduce services to help soften the blow from looming Medicaid and Medicare cuts. ...  If rural providers cannot recruit physicians, lean more heavily on philanthropic donors or find other ways to reduce their reliance on Medicaid and Medicare reimbursement to get ahead of cuts in the law, hospitals will be forced to pare back services or close their doors, industry observers said. ... In response, rural providers have accelerated ongoing operational adjustments, including renegotiating vendor contracts, beefing up their coding and billing processes, freezing new hires and standardizing daily tasks to reduce administrative waste. But those tweaks alone cannot sustain rural hospitals, so some providers are aiming to grow surgeries, infusions and other services to boost their bottom lines, executives said.

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Perform detail-oriented internal audits to avoid common denials

07/22/25 at 03:00 AM

Perform detail-oriented internal audits to avoid common denials DecisionHealth - Home Health Line; by MaryKent Wolff; 7/18/25 The most common reason for hospice denials in the first quarter of 2025 was that the claim was not hospice appropriate, according to Palmetto GBA, a Medicare Administrative Contractor (MAC) servicing 16 states. Palmetto released its list of the top 10 hospice medical review denial reasons from January to March 2025 on May 16. [Subscription required.]

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A look at nursing facility characteristics between 2015 and 2024 - KFF

07/21/25 at 03:00 AM

A look at nursing facility characteristics between 2015 and 2024 - KFF KFF; by Priya Chidambaram and Alice Burns; 12/6/24 In a KFF Issue Brief on nursing facility characteristics over time, KFF has described nursing homes and the people living in them. Data is pulled from Care Compare (Nursing Homes) and CASPER (Certification and Survey Provider Enhanced Reports). Data includes the number of certified nursing facilities, hours of care by nurse staff type over years, survey deficiencies in nursing homes, and the share of residents by primary payer. The study confirms that Medicaid is the primary payer for 63% of nursing facility residents in 2024, followed by 24% for private and other payers, and 13% by Medicare. As reported by KFF,  “KFF polling shows that four in ten adults overall incorrectly believe that Medicare is the primary source of insurance coverage for low-income people who need nursing facility care.” Guest Editor's Note, Judi Lund Person: As we think about the impact of Medicaid cuts on nursing home residents, it is important to note that Medicaid is the primary payer for 63% of nursing home residents as of 2024. In some states, that percentage may be higher. See the KFF article.

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51 healthcare leaders’ takes on doing more with less

07/21/25 at 03:00 AM

51 healthcare leaders’ takes on doing more with less Becker's Hospital Review; by Allie Woldenberg, Kelly Gooch, Mariah Taylor, Giles Bruce, Kristin Kuchno, and  Andrew Cass; 7/17/25 It’s a directive that hospitals and health systems of every size know well — whether sprawling academic medical centers, multistate nonprofit systems or rural, independent 25-bed hospitals. While the phrase isn’t new, the urgency behind it is intensifying. The nation’s healthcare workforce remains fragile, forcing leaders to distinguish between staffing gaps that are temporary hurdles or structural limitations. Revenue projections for health systems have shifted dramatically ... Against this backdrop, Becker’s set out to understand how health system leaders across the U.S. are interpreting and enacting the mandate to “do more with less” today. From June 9 to July 15, we spoke with executives across the country, in every type of market, hospital, and health system, to hear how they are navigating this evolving landscape. ...Editor's Note: Scan through these with a sharp eye toward improving the quality of patient care while "doing more with less." I applaud many of these leaders for not just focusing on cutting costs, but for using these crucial changes as a vehicle to improve patient care.

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How PACE is jockeying for position amid Medicaid cuts

07/21/25 at 03:00 AM

How PACE is jockeying for position amid Medicaid cuts Modern Healthcare; by Diane Eastabrook; 7/16/25 A federal-state program aimed at keeping older adults out of nursing homes could come out awinner under the new federal tax law. Nevada was the latest state to approve a Program of All-Inclusive Care for the Elderly last month before President Donald Trump signed the tax law. South Dakota is considering PACE as well. The program can save states money by caring for adults at home, rather than in nursing homes. However, PACE is a relatively small and not widely known initiative, which could make it a low priority for states weighing the best way to spend fewer Medicaid dollars.

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Medicare telehealth trends: Information on telehealth use by Medicare Fee-for-Service beneficiaries

07/18/25 at 03:00 AM

Medicare telehealth trends: Information on telehealth use by Medicare Fee-for-Service beneficiaries Data.CMS.gov; Centers for Medicaree & Medicaid Services; 7/16/25 Data update frequency: Quarterly Latest data available: Q4 2025The Medicare Telehealth Trends dataset provides information about people with Medicare who used telehealth services between January 1, 2020 and December 31, 2024. The data were used to generate the Medicare Telehealth Trends Report.

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HOPE Blog Part III – Navigating change with confidence

07/17/25 at 03:00 AM

HOPE Blog Part III – Navigating change with confidence Teleios Collaborative Network (TCN); by Melissa Colkins; 7/16/25 The HOPE tool arrives October 1, ready or not. While some teams will stumble through implementation, others will use this moment to demonstrate what effective change management actually looks like. The question isn't whether change is hard - it's whether your organization will emerge stronger because of how you handle it. Here's the reality: every meaningful change follows a predictable pattern. Teams don't just flip a switch and suddenly excel with new systems. They move through distinct phases - each with its own challenges and opportunities for growth. Understanding this journey is what separates organizations that merely survive change from those that leverage it for lasting improvement.

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Medicare fraud has gone global. It’ll take a nationwide effort to stop it

07/16/25 at 03:00 AM

Medicare fraud has gone global. It’ll take a nationwide effort to stop itLos Angeles Times; by Mehmet Oz, Kim Brandt; 7/15/25Federal law enforcement recently announced a $14-billion fraud takedown — the largest healthcare fraud action in U.S. history, involving many crimes orchestrated by foreign nationals. Every American taxpayer should be alarmed not just because of the dollars at stake, but also because it reveals how vulnerable Medicare and Medicaid have become to large-scale, international exploitation... Fraud is a national problem, but it starts locally. Drive around certain neighborhoods in Los Angeles and you’ll pass what appear to be empty office buildings, which unbeknownst to neighbors could serve as hubs of criminal activity. There are more than 1,000 potentially fraudulent hospice operations identified in Los Angeles.Publisher's note: Medicare fraud is tragic - and that hospice is the highighted provider in this story is also tragic. This article includes steps that can be taken to stop this fraud. Also, thanks to Sheila Clark, President-CEO of the California Hospice & Palliative Care Association (CHAPCA) for forwarding this article.

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Tracking the Medicare Provisions in the 2025 Reconciliation Bill | KFF

07/15/25 at 03:20 AM

Tracking the Medicare Provisions in the 2025 Reconciliation Bill | KFF KFF; updated 7/8/25 Similar to the chart for Medicaid provisions in the 2025 Reconciliation Bill, KFF also provides details on the changes for Medicare. Topics include eligibility policies, physician payment, prescription drugs, rules for Pharmacy Benefit Managers (PBMs), nursing homes – including the prohibition of implementation, administration, or enforcement of the minimum staffing levels requirement until October 1, 2034, and funding for HHS to “contract with AI contractors and data scientists to identify and reduce Medicare improper payments and recoup overpayments.Guest Editor’s Note, Judi Lund Person: The chart of Medicare provisions confirms that implementation of the Medicare eligibility and enrollment final rule will be delayed until October 1, 2034, except for those provisions that have already taken effect. The Senate version enacted into law also has a temporary one-year increase of 2.5% in the Physician Fee Schedule conversion factor for all services furnished between January 1, 2026 and January 1, 2027 and a delay of the nursing home staffing final rule until October 1, 2034. It is helpful to have the chart in a usable form for reference on the final bill enacted into law.

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AAPA asks CMS to remove regulatory restrictions on PAs providing hospice care

07/15/25 at 03:00 AM

AAPA asks CMS to remove regulatory restrictions on PAs providing hospice care American Academy of Physician Associates (AAPA); by Trevor Simon; 7/9/25 In June 2025, AAPA submitted comments to the Centers for Medicare and Medicaid Services (CMS) regarding the topics of hospice, skilled nursing facilities, inpatient rehabilitation facilities, and inpatient psychiatric facilities. These comments, in response to annually released proposed rules that make adjustments to the hospice wage index and respective fee schedules, responded directly to inquiries made within the rules, as well as identified policy obstacles faced by PAs in these settings. [Continue reading for] a brief summary of the topics AAPA discussed in each, with links to the full letters.

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DOJ & HHS announce reinvigoration of False Claims Act Working Group and Healthcare Fraud Enforcement Priorities

07/11/25 at 03:00 AM

DOJ & HHS announce reinvigoration of False Claims Act Working Group and Healthcare Fraud Enforcement Priorities Dorsey & Whitney LLP; Press Release; 7/9/25 The Department of Justice and the Department of Health and Human Services announced the reinvigoration of a False Claims Act (“FCA”) Working Group, a joint effort between the two agencies.  The announcement was made on July 2 during remarks at the American Health Law Association (“AHLA”) Annual Meeting by Brenna Jenny, the new Deputy Assistant Attorney General of DOJ’s Commercial Litigation Branch, and in a press release that same day. This working group underscores that healthcare fraud is a priority for the Administration, despite recent staff changes and recent policy announcements about enforcement priorities in civil rights and DEI. It also underscores that robust compliance programs should continue to be a priority for healthcare-industry stakeholders.

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Health care attorneys: Hospice investigations coming from all sides

07/10/25 at 03:00 AM

Health care attorneys: Hospice investigations coming from all sides Hospice News; by Jim Parker; 7/8/25 Hospices are subject to a rising number of investigations and audits from Medicare contractors, the U.S. Department of Health and Human Services Office of the Inspector General and, in some cases, the U.S. Justice Department, among others. Hospices need to understand the various types of investigations they may encounter and how to respond to them. Key factors are completely and accurately documenting the medical necessity of the care they receive. Hospice News sat down with Guillermo Beades and Todd Brower, partners with the law firm Frier Levitt to discuss the ins-and-outs of hospice investigations and how providers should respond.

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Medicaid provisions threaten home and community-based services for millions of vulnerable Americans

07/07/25 at 03:00 AM

Medicaid provisions threaten home and community-based services for millions of vulnerable Americans National Alliance for Care at Home, Alexandria, VA and Washington, DC; Press Release; 7/3/25The National Alliance for Care at Home (the Alliance) issued the following statement today in response to the House’s passage of the “One Big Beautiful Bill Act,” also known as the Reconciliation bill, which now heads to President Trump’s desk for his signature. “The Alliance is deeply troubled by the Medicaid provisions within the One Big Beautiful Bill Act, which has passed both chambers of Congress and now awaits President Trump’s signature,” said Alliance CEO Dr. Steve Landers. “These provisions—including work requirements, reduced provider taxes, and new cost-sharing mandates—prioritize short-sighted budget savings over the health and wellbeing of our most vulnerable citizens who rely on home and community-based services (HCBS).” The home care community advocated throughout the legislative process for Congress to mitigate these harmful Medicaid provisions.

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Center for Acute Hospice Care to close in August

07/07/25 at 03:00 AM

Center for Acute Hospice Care to close in August 29 News, Charlottesville, VA; by Jacob Phillips; 7/1/25 After nearly a decade of offering around-the-clock end-of-life care, Hospice of the Piedmont is closing their Center for Acute Hospice Care (CAHC) on Ivy Road in Charlottesville in August. “It gives us an opportunity to concentrate more on where patients want to be, which is home, and those services will still be provided,” Hospice of the Piedmont President and CEO Nancy Littlefield said. “[CAHC] is a 10-bed unit that we lease...and it’s for patients who might be having needs of a higher level of hospice care.” Littlefield says the main reason for closing the center is the lease is coming to an end and with uncertainty surrounding federal budget cuts of hospice care, continuing in this location is not sustainable. “Our hospice, as well as all hospices across the state, are having to be very cautious about what Medicaid and other reimbursement changes may occur under the current administration,” Littlefield said, “and I think the worst thing we can do for families and patients is to not be prepared.”

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Alliance Statement on House passage of Reconciliation Bill: Medicaid provisions threaten home and community-based services for millions of vulnerable Americans

07/07/25 at 02:00 AM

Alliance Statement on House passage of Reconciliation Bill: Medicaid provisions threaten home and community-based services for millions of vulnerable Americans National Alliance for Care at Home, Alexandira, VA and Washington DC; Press Release; 7/3/25 The National Alliance for Care at Home (the Alliance) issued the following statement today in response to the House’s passage of the “One Big Beautiful Bill Act,” also known as the Reconciliation bill, which now heads to President Trump’s desk for his signature. “The Alliance is deeply troubled by the Medicaid provisions within the One Big Beautiful Bill Act, which has passed both chambers of Congress and now awaits President Trump’s signature,” said Alliance CEO Dr. Steve Landers. “These provisions—including work requirements, reduced provider taxes, and new cost-sharing mandates—prioritize short-sighted budget savings over the health and wellbeing of our most vulnerable citizens who rely on home and community-based services (HCBS).”

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CMS Age-Friendly Measure: Overview for hospitals and health systems

07/03/25 at 03:00 AM

CMS Age-Friendly Measure: Overview for hospitals and health systems Institute for Healthcare Improvement; retrieved from the internet 7/2/25 Starting with the 2025 reporting period, hospitals will attest to providing age-friendly care through a new measure introduced by the Centers for Medicare & Medicaid Services (CMS). The CMS Age Friendly Hospital Measure advances the Age-Friendly Health Systems movement’s vision to ensure that all older adults receive age-friendly care that is evidence-based and aligns with what matters most to the older adult and their family caregivers. To date, nearly 5,000 sites of care have been recognized as Age-Friendly Health Systems — Participants and celebrated by IHI and The John A. Hartford Foundation. The measure has five domains that cover all four elements of age-friendly care, known as the 4Ms: What Matters, Medication, Mentation, and Mobility.

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Older adults spending excess time in ED, putting hospitals at risk of failing to meet new guideline, analysis finds

07/03/25 at 03:00 AM

Older adults spending excess time in ED, putting hospitals at risk of failing to meet new guideline, analysis finds McKnights Long-Term Care News; by Donna Shryer; 7/1/25 A new national analysis of hospital data shows that older adults in the United States increasingly are spending more time in emergency departments (EDs) than federal guidelines recommend — delays that can be harmful to aging patients. The findings come as hospitals prepare to comply with new Medicare rules aimed at improving emergency care for older adults. ... Among patients who were admitted to the hospital, more than one-third (36%) waited more than three hours after the decision was made to admit them, a delay known as boarding. These benchmarks — eight hours in the ED and three hours to admission — are part of the new Age-Friendly Hospital Measure introduced by the Centers for Medicare & Medicaid Services (CMS). As of January 2025, hospitals are required to confirm they have procedures in place to meet these time goals.

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The Alliance responds to Senate passage of Reconciliation Bill

07/03/25 at 03:00 AM

The Alliance responds to Senate passage of Reconciliation Bill National Alliance for Care at Home, Alexandira, VA and Washington, DC; Press Release; 7/1/25 The National Alliance for Care at Home (the Alliance) issued the following statement today in response to the Senate’s passage of the “One Big Beautiful Bill Act,” also known as the Reconciliation bill. “The Alliance is alarmed by the Senate’s passage of the One Big Beautiful Bill Act, which prioritizes misplaced budget cuts over the health and wellbeing of our most vulnerable. The legislation will reduce access to care and support for the millions of Americans who rely on home and community-based services (HCBS),” said Alliance CEO Dr. Steve Landers. ... “The Alliance continues to maintain that the complexity of the Medicaid program makes it nearly impossible to reduce expenditures by the amounts contemplated by this legislation – potentially exceeding $1 trillion over ten years – without impacting services to older adults and people with disabilities. The Alliance will advocate on behalf of Medicaid enrollees, families, and providers nationwide ...

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United Palliative & Hospice Care accused of $87M hospice scam

07/03/25 at 02:00 AM

United Palliative & Hospice Care accused of $87M hospice scam Hospice News; by Jim Parker; 7/2/25 Three women associated with Houston-based United Hospice & Palliative Care (UPHC) have been charged with Medicaid and Medicare fraud after allegedly bilking more than $87 million in federal health care funds. The trio includes UPHC owner Dera Ogudo, an UPHC employee Victoria Martinez and a psychiatric hospital employee, Evelyn Shaw, ABC-13 Houston reported. The prosecutor’s indictment also includes an unnamed physician who allegedly received kickbacks for referrals to UPHC. “Ogudo and her co-conspirators preyed on the vulnerable residents of those group homes by enrolling them in hospice services with UPHC when they were not terminally ill,” the indictment indicated.

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Nearly 50 charged in Southern District of Texas as part of national health care fraud takedown

07/02/25 at 03:00 AM

Nearly 50 charged in Southern District of Texas as part of national health care fraud takedown United States Attorney's Office - Southern District of Texas, Houston, TX; 6/30/25 A total of 22 cases are being announced as part of local efforts targeting health care fraud and include various schemes alleging unlawful distribution of controlled substances, some of which were diverted onto the black market, hospice fraud, kickbacks and other Medicare/Medicaid fraud schemes involving medically unnecessary genetic tests, durable medical equipment and more.  The charges filed in Southern District of Texas (SDTX) federal court are part of the Department of Justice’s 2025 national health care fraud takedown. ... One of the largest cases include three individuals for their alleged roles in a $110 million hospice fraud and kickback scheme. The charges allege Dera Ogudo, 39, and Victoria Martinez, 35, both of Richmond, operated hospice company United Palliative & Hospice Company (UPHC) that misled vulnerable elderly adults about what services were being billed to their Medicare and Medicaid plans.

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HOPE Tool Anxiety, Part II: From planning to practice

07/02/25 at 03:00 AM

HOPE Tool Anxiety, Part II: From planning to practice Teleios Collaborative Network (TCN); podcast by Melissa Calkins; 6/30/25The countdown has begun. With October 1 on the horizon, hospice teams across the country are deep into training and testing—but preparation alone won’t guarantee success. The shift to HOPE isn’t just operational; it’s cultural. And real readiness goes far beyond timelines and task completion. It demands that every clinician, across every shift and care setting, understands what’s changing and feels confident in how to respond. This is the critical moment when planning must translate into practice—because once HOPE is live, the margin for error disappears.

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CMS to test prior authorization model in traditional Medicare

07/02/25 at 02:15 AM

CMS to test prior authorization model in traditional Medicare MedPageToday; by Joyce Frieden; 6/30/25 The Centers for Medicare & Medicaid Services (CMS) announced a new experimental model late last week to streamline some prior authorizations under the traditional Medicare program, but some politicians and experts are concerned that it could result in more delays in care. Under the model, known as the Wasteful and Inappropriate Service Reduction (WISeR) Model, "CMS will partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process" under traditional Medicare, the agency said Friday [6/27] in a press release ...

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Provider payment incentives: Evidence from the U.S. hospice industry

07/02/25 at 02:00 AM

Provider payment incentives: Evidence from the U.S. hospice industry ScienceDirect - Journal of Public Public Economics; by Norma B. Coe and David A. Rosenkranz; online ahead of print for August 2025 (retrieved from the internet 7/1/25) Highlights

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