Literature Review

Cigna considers Humana acquisition – What it means for the stocks MarketBeat; by Jea Yu; 10/29/24 There has been speculation of a massive merger in the medical sector between two massive health insurers. Specifically, the rumor is The Cigna Group NYSE: CI is interested in acquiring Humana Inc. NYSE: HUM. The conjecture caused both stocks to react, as Cigna stock fell 10% as the rumored surfaced on Oct. 18, 2024, and Humana stock remained relatively flat. Based on the reactions, the market doesn't see this as a favorable merger, and for good reason. While there are many potential synergies in a merger, assuming it passes the regulatory antitrust sniff test (which is a big "if"), there is also a major sticking point that sinks any possibility of it coming to fruition called Medicare Advantage (MA). 

How today’s hospice fraud could warp tomorrow’s reimbursement outlook Hospice News; by Holly Vossel; 10/28/24 This is the second of a two-part Hospice News series that explores how fraud, waste and abuse in the hospice space could create headwinds for the industry at large. Fraudsters misspend millions of Medicare dollars annually, though the actual hospice-specific amounts are difficult to determine, regulators previously told Hospice News. Industry stakeholders have questioned whether the malfeasance will stymie the U.S. Centers for Medicare & Medicaid Services’ (CMS) ability to justify future reimbursement rate increases, which many hospice providers already consider insufficient to support the full range of their interdisciplinary services in today’s economic climate.

Medicare Part D paid millions for drugs for which payment was available under the Medicare Part A Skilled Nursing Facility Benefit HHS Office of Inspector General; Report Highlights; 10/27/24 What OIG Found: ... On the basis of our sample results, for 2018 through 2020, we estimated that up to the entire Part D total cost of $465.1 million was improperly paid for drugs for which payment was available under the Part A SNF benefit. Of that amount, we estimated that approximately $245.4 million was for drugs that the medical records showed were administered to Part D enrollees during their Part A SNF stays.What OIG Recommends: We made five recommendations, including that CMS work with its plan sponsors to adjust or delete PDEs, as necessary, and determine the impact to the Federal Government related to the Part D total costs of $953,370 for drugs associated with our sample items for which payment was available under the Part A SNF benefit; work with its plan sponsors to identify similar instances of noncompliance that occurred during our audit period and determine the impact to the Federal Government, which could have amounted up to an estimated $465.1 million in Part D total cost; and provide plan sponsors with timely and accurate information, such as dates of covered Part A SNF stays, to reduce instances of inappropriate Part D payment for drugs for which payment is available under the Part A SNF benefit. ... CMS concurred with all five recommendations.

Doctor sues to save Medicare billing rights over hospice role Bloomberg Law; by Ganny Belloni; 10/24/24 A medical director designee at a California hospice sued the US Department of Health and Human Services to prevent the termination of his physician billing privileges after an independent contractor found his affiliation with the facility posed a fraud risk to the Medicare program. The lawsuit filed Wednesday by internal medicine physician Rami Shaarawy seeks injunctive relief from the US District Court for the Central District of California preventing the HHS’ Centers for Medicare & Medicaid Services from sanctioning the doctor until his dispute is resolved through Medicare’s internal appeals process.

Hospice executives laser-focused on regulation, see change on horizon Hospice News; by Holly Vossel; 10/24/24 ... Hospice News spoke with c-suite executives who have recently stepped into their roles to learn more about what led them to the space and their top priorities. Regulatory challenges are among hospice leaders’ most significant concerns. They also envision opportunities to reform the Medicare Hospice Benefit and diversify their scope of services.

New hospice special focus programAmerican Health Association / National Center for Assisted Living; by Amy Miller; 10/22/23 ​​As required under the Consolidated Appropriations Act of 2021, CMS has established a hospice special focus program (SFP) in the Calendar Year (CY) 2024 Home Health Prospective Payment System (HH PPS) final rule (88 FR 77676). Through increased regulatory oversight and enforcement of the selected poor performing hospice programs, the SFP will address issues that could place hospice beneficiaries at risk of receiving poor quality of care. The hospice SFP is like the current Special Focus Facility (SFF) program in place for nursing homes. As many nursing homes refer residents to hospice programs and may receive questions from residents or their families, it will be important to keep informed if there are noted quality of care issues. 

Customizing a palliative program to patient, payer priorities Hospice News; by Jim Parker; 10/23/24 While some palliative care programs mirror the hospice model, more operators are working to tailor their services to patients’ specific needs, with varying intensity. This is increasingly important as payment shifts towards value-based payment models in which demonstrating cost savings is crucial to success. Providers need to demonstrate strong performance on quality scores as well as a track record of effectively preventing avoidable hospitalizations, readmissions and emergency department visits. This is particularly the case when negotiating contracts with Medicare Advantage plans, Accountable Care Organizations (ACOs) and other value-based payment arrangements, Sue Lynn Schramm, a partner of the hospice and palliative care consulting company Confidis, LLC, said in a presentation at the National Hospice and Palliative Care Organization Annual Leadership Conference. [Click on the title's link to continue reading.]

Leveraging sales strategies in hospice payment cap management Hospice News; by Jim Parker; 10/22/24 Errors or other inconsistencies with the payment cap can have significant consequences for providers, and sales and marketing staff can help hospices achieve a healthy balance. The cap is designed to prevent overuse of hospice, put controls on Medicare spending and foster greater access to care among patients. For Fiscal Year 2024, the U.S. Centers for Medicare & Medicaid Services set the cap at $33,394. In 2025, this will rise to $34,465. If a hospice has a cap liability, they will have to repay that amount to Medicare. In some situations, a hospice might face additional monetary penalties, interest charges or referrals to the U.S. Treasury Department in severe cases.

Home health agencies may soon claim telehealth services during patients’ hospital stays McKnights Home Care; by Adam Healy; 10/17/24 In a recent change, the Centers for Medicare & Medicaid Services announced that it would allow home health providers to submit claims for telehealth while their clients are receiving inpatient care. Currently, Medicare beneficiaries may not be inpatients in a hospital or skilled nursing facility and simultaneously receive home healthcare. CMS rejects any home health service claims that overlap with a patient’s hospital or SNF stay, and providers are responsible for submitting a new claim without any dates for service that coincide with an inpatient stay. In a recent change request, CMS announced that it would modify its rule to allow home health providers to submit telehealth claims even when their clients are in hospital or SNF care. The change specifically applies to telehealth services that fall under the G0320, G0321 or G0322 Healthcare Common Procedure Coding System codes. 

Gentiva reaches $19.4 million False Claims Act Settlement Policy & Medicine; by Thomas Sullivan; 10/15/24 Gentiva – formerly known as Kindred at Home – reached a $19.4 million settlement with the United States, resolving allegations that it violated the False Claims Act by holding on to overpayments for hospice services provided to patients who were ineligible to receive hospice benefits under various federal health care programs. Kindred is made up of entities that were previously part of an enterprise that did business through various subsidiaries as Kindred at Home. Kindred provided health care services, including hospice services, using various business names during the time periods relevant to the settlement. The settlement resolves allegations brought by the United States and the State of Tennessee against certain Kindred entities alleging that from 2010 until February 2020, the entities knowingly submitted (or caused to be submitted) false claims for hospice services to hospice patients in Tennessee and other states who were ineligible for Medicare or Medicaid hospice benefit because they were not terminally ill. The settlement further resolved allegations that the defendants improperly concealed or otherwise avoided the obligation to repay the hospice claims at issue. The settlement also resolves allegations that SouthernCare New Beacon – a subsidiary – allegedly violated the Anti-Kickback Statute by willfully paying remuneration to a consulting physician to induce Medicare beneficiary hospice referrals.

The daily balancing act of value-based cancer care The American Journal of Managed Care (AJMC); by Laura Joszt, MA; 10/14/24 In value-based care, there’s a daily balancing act to achieve quality outcomes, cost reduction, and patient care improvements, explained Stuart Staggs, vice president of transformation, quality, and shared services for The US Oncology Network (Network). At the Institute for Value-Based Medicine event, cohosted by The American Journal of Managed Care (AJMC) and Minnesota Oncology, Staggs kicked it off with what he called a “practical look at value-based care.” He highlighted 4 main areas: quality, improvement, adoption, and cost. ... The area of improvement that the Network wanted to focus on was advanced care planning and better supporting and engaging patients and their families around hospice and life support. During the OCM, the Network better engaged patients and families around hospice care and encouraged practices to have difficult conversations. Not only does this improve patient experience by providing them the end-of-life care that they want, but there is also a cost factor. Patients who don’t receive hospice care spend significantly more in the last 30 to 60 days, Staggs said.

Managing the hospice payment cap by balancing Length of Stay Hospice News; by Jim Parker; 10/15/24 Careful management of the hospice aggregate cap is key to providers’ sustainability as regulatory scrutiny continues to heat up. The cap is designed to prevent overuse of hospice, put controls on Medicare spending and foster greater access to care among patients. For Fiscal Year 2024, the U.S. Centers for Medicare & Medicaid Services set the cap at $33,394. In 2025, this will rise to $34,465. “While the cap is a beneficiary driven cap, meaning the reimbursement allowed per Medicare beneficiary, it is not assessed at the beneficiary level, but rather in the aggregate at the agency provider number level for all beneficiaries served by the agency in the cap,” Rochelle Salinas, vice president of operations for CommonSpirit Health at Home, said. “This allows for greater flexibility in providing care to those in need.” ... [Click on the title's link to continue reading.]

Millions of aging Americans are facing dementia by themselves California Healthline; by Judith Graham; 10/15/24 Sociologist Elena Portacolone was taken aback. Many of the older adults in San Francisco she visited at home for a research project were confused when she came to the door. They’d forgotten the appointment or couldn’t remember speaking to her. It seemed clear they had some type of cognitive impairment. Yet they were living alone. Portacolone, an associate professor at the University of California-San Francisco, wondered how common this was. Had anyone examined this group? How were they managing? ... Portacolone got to work and now leads the Living Alone With Cognitive Impairment Project at UCSF. The project estimates that that at least 4.3 million people 55 or older who have cognitive impairment or dementia live alone in the United States. ... Imagine what this means. ...