Literature Review

CMS proposes expanded authority to revoke Medicare privileges TechTarget; by Jacqueline LaPointe; 7/6/26 CMS proposes expanding its authority to revoke Medicare providers in fraud crackdown, while updating home health payments with a 2.4% increase and continued PDGM adjustments. The Trump administration wants to double down on its healthcare fraud, waste and abuse crackdown. This time, policymakers are seeking to expand CMS' powers to remove providers from Medicare -- a move that the agency says will save taxpayers about $82 million a year. The added capabilities are part of the Calendar Year 2027 Home Health Prospective Payment System Proposed Rule (CMS-1844-P), which CMS released ahead of the July 4th weekend.

Investigation revealing $6.5B in healthcare fraud signals more oversight of wound care Nurse.com; by Zelda Meeker; 7/6/26 ... Why skin substitutes have become a fraud target: The heightened focus surrounding wound care reflects a dramatic increase in Medicare spending on skin substitute products over the past several years. According to the HHS-OIG, Medicare Part B spending on skin substitutes grew from approximately $256 million in 2019 to more than $10 billion by the end of 2024. The OIG has warned that this rapid increase far outpaced expected utilization and identified significant vulnerabilities for fraud, waste, and abuse under the current reimbursement system. ... In terms of wound care fraud, alleged schemes have included:

Errors in billing in the United States may result in severe civil or even criminal penalties Spilman Thomas & Battle; by Christopher R. Arthur, William S. Thompson; 7/1/26 The United States Department of Justice (DOJ) has ratcheted up its efforts to pursue actions against corporations, healthcare entities, and individuals, including physicians, for false Medicare or Medicaid billing and COVID-19-related loans. ... As part of this announcement, the Centers for Medicare and Medicaid Services (CMS) suspended 1,079 providers and revoked billing privileges for 1,403 providers. ... In addition to allowing the United States to pursue perpetrators of fraud on its own, the FCA allows private citizens to file suits on behalf of the government (called “qui tam” suits) against those who have defrauded the government. In the healthcare realm, these suits are often filed by disgruntled employees and patients, but can also be brought by competitors. ...

Hospice in the spotlight – audits, PEPPER, and patient autonomy RACmonitor; by Ronald Hirsch, MD, FACP, ACPA-C, CHCQM, CHRI; 7/1/26 .. why talk hospice now? Because it seems to be hospice’s time to be in the spotlight. ... Last week you likely heard about a big U.S. Department of Justice (DOJ) $6.5 billion fraud takedown. Included in that was another hospice fraud scheme that included a funeral home employee who sold information on recently deceased people to a fraudster who then submitted claims for hospice services that were never provided. ...Then, the Centers for Medicare & Medicaid Services (CMS) has released the Program for Evaluating Payment Patterns Electronic Report (PEPPER) for hospice organizations. And to top it off, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) released an audit of hospice claims finding that Medicare paid over $255 million for patients who were not eligible for hospice care. ...

CMS mulls tougher Medicare enrollment rules to combat fraud as part of 2027 home health payment rule Fierce Healthcare; by Heather Landi; 7/1/26 The Centers for Medicare and Medicaid Services released on Wednesday afternoon its 2027 proposed payment rule for home health agencies. The rule includes an aggregate payment increase of $420 million, or 2.4%, based on a proposed 2.1% payment update and an estimated 0.3% increase related to the fixed dollar loss ratio. That 2.1% payment update represents $370 million, according to a CMS fact sheet. The proposal also includes updates to payment methodologies, case-mix weights, outlier payments and quality reporting requirements, while seeking feedback on expanding access to home-based palliative care. Beyond payment policy, CMS is proposing a series of anti-fraud measures that would make all Medicare enrollment revocations retroactive and broaden the agency’s authority to deny or revoke enrollment for providers and suppliers linked to compliance violations. 

Hospice sues Medicare over denied claims worth over $1 million Bloomberg Law; by Ganny Belloni; 7/1/26 An Arizona hospice group is suing Medicare alleging the program arbitrarily denied hundreds of claims for palliative care services. The lawsuit filed Tuesday in the US District Court for the Northern District of Texas by Infinity Hospice Care claims that the Centers for Medicare & Medicaid Services, through its private claims processor, denied over 200 claims for hospice services worth over $1 million after audits found the services didn’t meet the Medicare Administrative Contractor’s payment criteria. [Full access may be limited by a paywall.]

Medicare pushes end-of-life discussions in hospitalsAXIOS; by Maya Goldman; 6/29/26The Trump administration wants to formalize the process for recording whether Medicare patients want to be kept alive if they become incapacitated. Why it matters: Health providers have been required to ask about living wills and other "advance directives" since the early 1990s. But the questions are often skipped - or become a box-check in the admissions process. Only about a third of U.S. adults have documented their end-of-life care wishes. More consultations could reduce costly life-extending treatments that patients don't really want.Driving the news: The administration is proposing that hospitals begin reporting adult patients' preferences for end-of-life care in electronic health records starting in 2028.

Solace Hospice suspends opening amid Medicare moratorium Hospice News; by Holly Vossel; 6/25/26 The launch of Solace Hospice of Southwest Virginia has paused due to a nationwide temporary moratoria on hospice and home health Medicare enrollment. The hospice’s operations will be suspended for an indeterminate time. The U.S. Centers for Medicare & Medicaid Services’ (CMS) six-month moratoria took effect on May 13, a move to halt new providers amid fraudulent activity in the hospice space. The program’s cessation is a direct result of the moratorium, said Shanna Western, founder and executive director of Solace Hospice of Southwest Virginia.

National health care fraud takedown results in 455 defendants charged in connection with over $6.5 billion in alleged fraud Office of Public Affairs - U.S. Department of Justice, Washington, DC; Press Release; 6/23/26Record Medicaid Fraud Charges Largest Number of States Participating in Health Care Fraud Takedown History: The Justice Department today announced the 2026 National Health Care Fraud Takedown, which resulted in charges against 455 defendants, including 90 doctors and other licensed medical professionals, for their alleged participation in health care fraud and opioid abuse schemes involving over $6.5 billion in false claims and significant patient harm, including death. Today’s Takedown represents a new era in federal, state, and international cooperation to combat health care fraud: cases in 56 federal districts and 45 U.S. states and territories, with 50 state Medicaid Fraud Control Units participating, the most in Department history.

California hospice providers laud state’s newly proposed emergency regulationsMcKnights Home Care; by Suzy Frisch; 6/22/26 The California Hospice and Palliative Care Association (CHAPCA) has praised proposed emergency regulations for hospices issued June 1 that aim to provide more oversight of operators and establish stronger guardrails against scammers. “This is a significant moment for hospice in California,” CHAPCA President and CEO Sheila Clark said in a statement. “CHAPCA welcomes the California Department of Public Health’s proposed emergency regulations for hospice agencies, which we have long called for.” 

Somerset hospice opening delayed by Medicare move The Tribune-Democrat, Somerset, PA; by Kelly Urban; 6/20/26 Following a ribbon-cutting in May for the reopening of the Somerset inpatient hospice facility, Windber Hospice at Chan Soon-Shiong Medical Center at Windber has provided an update regarding the facility’s opening timeline. While the facility remains on track to reopen, the opening has been delayed by a recently announced nationwide Medicare enrollment moratorium affecting new hospice enrollments and hospice locations. ... “We know many families have been eagerly anticipating the return of inpatient hospice care in Somerset County, and we share their disappointment in this unexpected delay,” said Richard Sukenik, CEO of Chan Soon-Shiong Medical Center at Windber. “We are actively working with local, state and federal legislators to seek assistance and ensure they understand the importance of bringing this service back to Somerset County. We will continue pursuing every available avenue to move this project forward while preparing to welcome patients as soon as approval is granted.” [Access to the full article may be limited by a paywall.]

CMS proposed rule locks in lower prices and fosters innovation for the Medicare Drug Price Negotiation Program CMS.gov; Press Release; 6/12/26 A new proposal from the Centers for Medicare & Medicaid Services (CMS) would establish a permanent framework for the Medicare Drug Price Negotiation Program (“Negotiation Program”), creating a more transparent and sustainable process for lowering drug costs for millions of Medicare beneficiaries. The proposed rule would also create greater long-term certainty for drug manufacturers that participate in negotiations. It includes policies for negotiating and renegotiating high-cost, single-source drugs beginning with initial price applicability year 2029, while continuing to support innovation and strengthen the program.