Literature Review

More home health providers sunset relationships with largest Medicare Advantage players Home Health Care News; by Andrew Donlan; 9/13/24 Essentia Health--a regional nonprofit health system with a substantial home health arm--announced this week that it will no longer serve as an in-network provider for UnitedHealth Group. ... Dr. Cathy Cantor, Essentia’s chief medical officer for population health, said in a statement ... “The frequent denials and associated delays negatively impact our ability to provide the timely and appropriate care our patients deserve. This is the right thing to do for the people we are honored to serve.” Headquartered in Duluth [MN], Essentia Health provides care across Minnesota, Wisconsin and North Dakota. Its network includes about 15,000 employees, 14 hospitals, 78 clinics, six long-term care facilities, six assisted living and independent living facilities, and much more. It also has a robust home health and hospice business. The company has informed patients that it will no longer serve as an in-network provider for the above-mentioned MA payers beginning Jan. 1. ... Sanford Health, a health system based in Sioux Falls, South Dakota, announced a similar plan this week. 

CMS teases new cybersecurity policies for third-party vendors Modern Healthcare; by Bridget Early; 9/13/24 The Centers for Medicare and Medicaid Services is planning oversight of third-party healthcare vendors in the wake of the Change Healthcare cyberattack, said Jonathan Blum, the agency's principal deputy administrator. Blum, who also serves as chief operating officer for CMS, said at Modern Healthcare's Leadership Symposium Thursday that the agency is working to determine what levers it can pull to ensure severe disruptions in care like those linked to the cyberattack on the UnitedHealth Group subsidiary aren’t repeated. ... Almost 133 million individuals were affected by healthcare data breaches last year, more than double the number of those affected in 2022 and a number equivalent to about 40% of the U.S. population.

The ‘Holy Grail’ of palliative care payment through ACOs Hospice News; by Jim Parker; 9/11/24 As opportunities to provide palliative care through Accountable Care Organization (ACO) relationships continue to arise, operators will likely need to understand the varying types of reimbursement that exist in that arena. ACOs are groups of physicians, hospitals and other health care providers who come together voluntarily to give coordinated high-quality care to their Medicare patients. Hospices and palliative care providers can collaborate with ACOs by becoming members of those organizations themselves, or by contracting with them through a preferred provider network. Community-based palliative care’s track record of reducing costs and hospitalizations could make providers of those services attractive to ACOs, according to Edo Banach, partner at Manatt Health, a division of the law firm Manatt, Phelps & Phillips, LLP.

Hospitals target Medicare Advantage in DSH payment lawsuitModern Healthcare; by Alex Kacik; 9/11/24Hospitals allege in a new lawsuit that the federal government unlawfully changed Medicare disproportionate share hospital payment calculations to include care provided to Medicare Advantage patients, and facilities lost billions of dollars in the process. Eighty hospitals on Monday sued the Health and Human Services Department over how the agency factors inpatient care for Medicare Advantage patients into DSH payments, which are meant to bolster providers that treat many low-income patients. Hospitals from states including California, Ohio, Pennsylvania and Texas allege HHS violated the Administrative Procedure Act by not following the typical rulemaking process when it finalized a rule in June 2023 on how Medicare Advantage influences DSH calculations.

Medicare administrative contractor news includes a data breach and potential consolidation HFMA, Downers Grove, IL; by Nick Hut; 9/9/24 Recent happenings involving Medicare administrative contractors (MACs) include a notice of a data breach and a request for feedback on possible consolidation. CMS sent out word that nearly 950,000 Medicare beneficiaries whose claims go through Wisconsin Physicians Service Insurance Corporation (WPS) are being informed that their protected health information or other personally identifiable information may have been compromised due to a security vulnerability in third-party software. The breach also could have affected those with other insurance if their information was collected to support CMS’s audits of healthcare providers, according to a news release. Belying its name, WPS handles Medicare Parts A and B claims spanning Indiana, Iowa, Kansas, Michigan, Missouri and Nebraska (not Wisconsin). 

CMS to expand ‘enhanced oversight’ to combat hospice fraud in 4 states Hospice News; by Jim Parker; 9/10/24 The U.S. Centers for Medicare & Medicaid Services (CMS) is expanding its enhanced oversight for new hospices in fraud-ridden states, including California, Nevada, Arizona and Texas. The agency in July 2023 first announced a “provisional period of enhanced oversight” for new hospices in those states. A key component of the enhanced oversight includes a medical review of claims before a Medicare Administrative Contractor (MAC) will pay them. “To combat fraud, waste, and abuse under the hospice benefit, CMS will expand prepayment medical review this September in Arizona, California, Nevada and Texas,” the agency indicated in a statement. “To help reduce burden on compliant providers, initial review volumes will be low and adjusted based on results. If you’re noncompliant, we may implement extended review or take additional administrative actions.” 

Norfolk woman celebrates 106th birthday after hospice discharge for being too healthy CBS WTKR 3, Norfolk, VA; by Vashti Moore; 9/6/24 A local woman not only celebrated good health on Thursday, but she also celebrated 106 years of life. Dorothy Southall was born in Whaleyville — a small neighborhood in Suffolk on Sept. 5, 1918. That’s two years before women received the right to vote and two months before the end of World War I. ... During the Civil Rights Movement, Dorothy worked as a licensed practical nurse at Bellevue Hospital Center in New York. She served her community as a healthcare worker for 20 years before moving back to Virginia in the late 1980s where she would live on her own and manage her own finances until she was 103. ... In August 2023, while living with her family, Dorothy was discharged from hospice because she deemed too healthy and no longer met the requirements. When admitted into residential care this summer in Norfolk, Dorothy said she “felt like she was home” when she arrived.

22 health systems dropping Medicare Advantage plans | 2024Becker's Hospital CFO Report; by Jakob Emerson; 9/4/24Medicare Advantage provides health coverage to more than half of the nation's older adults, but some hospitals and health systems are opting to end their contracts with MA plans over administrative challenges. Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers. [See article for list of 22 health systems dropping Medicare Advantage plans - including KS, ME, SD, NE, NV, MI, MN, OH, NY, IN, OK, TX, PA, DE, NC, OR, MO, KY, and CA.]

Medicare Advantage vendors brace for supplemental benefits cutsModern Healthcare; by Lauren Berryman; 9/4/24Companies that have profited from the largesse of Medicare Advantage insurers seeking to lure customers with generous perks are looking ahead to a tough 2025. Humana and CVS Health subsidiary Aetna are among those signaling that curtailing supplemental benefits such as transportation, fitness memberships, in-home support services, and vision, dental and hearing coverage will be a key part of their strategies to restore margins in a business troubled by high costs and a more restrictive regulatory environment.

Hospice care standards are important. Congress must be careful tinkering with them. NorthJersey.com, Special to the USA TODAY Network; by Patrick Maron; 8/28/24... As hospice care grows, real attention needs to be paid to the differences between nonprofit and for-profit centers.  [A] staggering  73%  of hospice programs today are for-profit and are driven by financial motives, ... Rep. Earl Blumenauer, D-Oregon, is drafting legislation that, if enacted, would represent the most significant reforms to date for hospice payment and oversight. Though Blumenauer’s bill, the Hospice Care Accountability, Reform, and Enforcement — or Hospice CARE — Act, is still in development, key provisions will likely include a new payment mechanism for high-acuity palliative services, changes to the per-diem payment process and actions to improve quality and combat fraud. The bill would also implement a temporary, national moratorium on the enrollment of new hospices into Medicare, to help stem the tide of fraudulent activities ... However, there are significant challenges for nonprofit freestanding inpatient hospice facilities like Villa Marie Claire in Saddle River. Most important, the proposed five-year moratorium on enrolling new hospice programs into Medicare could limit our ability to expand services, straining resources of the Villa ... What’s more, the legislation mandates more frequent inspections and enhanced oversight, which could lead to operational stress and higher costs. [Click on the title's link to continue reading.]

[CMS] Disparities impact statementCMS press release; 8/20/24This tool can be used by health care stakeholders to promote efforts to identify and address health disparities while improving the health of all people, including those from racial and ethnic minorities; people with disabilities; members of lesbian, gay, bisexual, and transgender communities; individuals with limited English proficiency; and rural, Tribal, and geographically isolated communities. This worksheet has 5 steps to be completed over time...

TCN podcast: The need to know on the 2025 Hospice Wage Index Telios Collaborative Network (TCN); podcast hosted by Chris Comeaux; 8/21/24 In this episode of TCN Talks, Chris interviews Annette Kiser, Chief Compliance Officer with Teleios and Judi Lund Person, Principal with Lund Person & Associates LLC.  The conversation covers the need to know around the final published 2025 Wage Index for Hospices.  Some of the key points discussed are: