Literature Review
All posts tagged with “Regulatory News | Medicare.”
Medicare's AI prior authorization pilot sparks backlash over incentives to deny care
12/10/25 at 03:00 AMMedicare's AI prior authorization pilot sparks backlash over incentives to deny care Complete AI Training | Insurance; by Joren Erne; 12/7/25 CMS will pilot AI prior auth in traditional Medicare across AZ, NJ, OH, OK, TX, WA through 2031. Expect tougher reviews, vendor incentives, and pushback on denials and delays. ... For insurance professionals, this is a signal: CMS is importing private-plan utilization tactics into fee-for-service Medicare, with financial incentives tied to denial-driven cost savings. Expect policy, operations, and provider relations to feel it.
Healthcare fraud enforcement trends to expect in 2026
12/09/25 at 02:30 AMHealthcare fraud enforcement trends to expect in 2026 JD Supra; by Arnall Golden Gregory; 12/8/25Key Takeaways
MedPAC to recommend 7% cut to 2027 home health payment rate
12/09/25 at 02:00 AMMedPAC to recommend 7% cut to 2027 home health payment rate Home Health Care News; by Morgan Gonzales; 12/8/25 Just over a week after home health providers were hit with the announcement that their 2026 Medicare payment rates would be reduced by a 1.3% aggregate cut, the Medicare Payment Advisory Commission (MedPAC) agreed to recommend a significantly more drastic cut for the following year. On Friday, MedPAC released a draft report recommending that Congress reduce the Medicare base payment rate for home health care services for calendar year 2027 by 7%.
The alphabet soup of laboratory compliance
12/08/25 at 03:00 AMThe alphabet soup of laboratory compliance Parkview Health; by Amy Stiles; 12/4/25 Every fall, Medicare beneficiaries can review their healthcare coverage and choose to enroll in or switch between Original (Traditional) Medicare and Medicare Advantage plans for the upcoming year. However, many people may not realize that the type of plan they choose can affect how certain laboratory tests are processed and billed. In this post, we aim to unscramble the letters and bring clarity to common Medicare terminology, helping you better understand what your plan offers and how to maximize the value of your benefits.
The complex quandary over hospice relatedness
12/08/25 at 02:00 AMThe complex quandary over hospice relatedness Hospice News; by Jim Parker; 12/5/25 Questions over which services are deemed related to patients’ terminal diagnosis in hospice care are crucial, and physicians’ determinations of those factors may be growing more complex. ... CMS has taken a stance that essentially all the care needed by a terminally ill patient should be covered through the benefit. However, that is not always what happens in practice. ... When considering relatedness, physicians must take a holistic approach, according to Dr. Lauren Templeton, hospice physician consultant at Weatherbee Resources and Physician Council member at The Pennant Group. ... In most cases, hospices should err on the side of considering conditions related, when possible, for the sake of their patients, Templeton indicated. “If it’s impacting the plan of care for our patients, that would make it related for us,” Templeton said.
Racial disparities in premature mortality and unrealized Medicare benefits across US states
12/06/25 at 03:25 AMGUIDE and beyond: Strategies for comprehensive dementia care integration
12/06/25 at 03:05 AMGUIDE and beyond: Strategies for comprehensive dementia care integrationJournal of the American Geriatrics Society; by Kristin Lees Haggerty, David B Reuben, Rebecca Stoeckle, David Bass, Malaz Boustani, Carolyn Clevenger, Ian Kremer, David R Lee, Madelyn Johnson, Morgan J Minyo, Katherine L Possin, Quincy M Samus, Lynn Spragens, Lee A Jennings, Gary Epstein-Lubow; 10/25The Centers for Medicare & Medicaid Services' (CMS) Guiding an Improved Dementia Experience (GUIDE) Model represents a landmark opportunity to improve outcomes for persons with dementia and their caregivers and scale comprehensive dementia care through a structured service delivery and alternative payment approach. Drawing from the experiences of six previously tested programs ... we describe a four-step approach to enable successful adoption and implementation: identifying key leaders and partners, preparing a tailored value proposition, initiating program start-up, and ensuring sustainable implementation. We highlight practical tools and resources to address operational challenges, including electronic health record integration, reimbursement strategies, and staff training. By focusing on evidence-based models, health systems and other providers can accelerate implementation, reduce costly emergency and institutional care, and deliver high-quality, person-centered support. This approach can help to empower GUIDE participants and others to build effective, durable, scalable comprehensive dementia care systems, ultimately advancing the goal of establishing such care as a permanent Medicare benefit.
Data book: Beneficiaries dually eligible for Medicare and Medicaid
12/04/25 at 03:00 AMData book: Beneficiaries dually eligible for Medicare and Medicaid MEDPAC (Medicare Payment Advisory Commision) and MACPAC (Medicaid and CHIP Payment and Access Commission); December 2025 This data book is a joint project of the Medicaid and CHIP Payment and Access Commission (MACPAC) and the Medicare Payment Advisory Commission (MedPAC). The data book presents information on the demographic and other personal characteristics, expenditures, and health care utilization of individuals who are dually eligible for Medicare and Medicaid coverage. Dually eligible beneficiaries receive both Medicare and Medicaid benefits by virtue of their age or disability and low income. This population is diverse and includes individuals with multiple chronic conditions, physical disabilities, and cognitive impairments such as dementia, developmental disabilities, and mental illness. It also includes some individuals who are relatively healthy.
Bulletin: HHS repeals nursing home staffing rule provisions
12/03/25 at 03:00 AMBULLETIN: HHS repeals nursing home staffing rule provisions McKNights Long-Term Care News; by Kimberly Marselas; 12/2/25 The Department of Health and Human Services today repealed key provisions of the minimum staffing standards for long-term care facilities finalized in 2024. The move follows months of legal and legislative challenges, which had already rendered hourly staffing and registered nurse requirements moot. HHS said it was repealing provisions in alignment with the One Big Beautiful Bill Act, which imposed a nine-year moratorium on the rule’s staffing measures. ... Notice of the appeal was posted in the Federal Register Tuesday morning. Editor's Note: Click here for the official publication of this repeal, scheduled to be published on 12/3/25.
Bipartisan senators: Keep hospice out of Medicare Advantage
12/02/25 at 03:00 AMBipartisan senators: Keep hospice out of Medicare Advantage Hospice News; by Jim Parker; 11/21/25 Two U.S. Senators have penned a letter to congressional leadership urging them to oppose any measures to bring hospice reimbursement into Medicare Advantage. Sens. Dr. Roger Marshall (R-Kan.) and Sheldon Whitehouse (D-R.I.) circulated the letter on Thursday, addressed to Senate leaders from both major political parties, as well as the chair and ranking member of the Senate Finance Committee.
'It has made my life a lot easier': New Ohio program pays people to care for their loved ones at home
12/01/25 at 03:00 AM'It has made my life a lot easier': New Ohio program pays people to care for their loved ones at homeWTOL-11, Columbus, OH; by Kevin Landers; 11/24/25 Mark Straub, of Delaware County, started caring for his 93-year-old mother about two years ago. As much as he loves to have his mother at home instead of a nursing home, caring for a loved one 24/7 brings with it stress, both emotional and financial. ... The average cost of in-home care in Ohio is $60,238, according to CareScout. The average cost of nursing home care is $108,500 a year, or about $9,000 per month. Thanks to a new program in Ohio, those who care for a loved one at home are about to get financially easier. It’s called Structured Family Caregiving, or SFC. Currently, at least 11 states have formal Medicaid SFC programs that pay family members. “I didn’t believe it at first, until I got that first paycheck and I really wanted to cry, “ said Tsavaris.
National Alliance for Care at Home: CMS modifies Final Payment Rule based on stakeholder feedback, but 1.3% cut still undermines access
12/01/25 at 02:00 AMNational Alliance for Care at Home: CMS modifies Final Payment Rule based on stakeholder feedback, but 1.3% cut still undermines access National Alliance for Care at Home, Alexandria, VA and Washington, DC; Press Release; 11/28/25 The National Alliance for Care at Home (the Alliance) today acknowledged that the Centers for Medicare & Medicaid Services (CMS) made significant adjustments in the Home Health Perspective Payment System (HH PPS) Final Rule for CY 2026 in response to community concerns regarding patient access and data integrity. However, the Alliance remains concerned that any payment cut for home health providers will continue to compromise access for the millions of Medicare beneficiaries who rely on these services to age and recover from illness or injury safely at home.
New from MedPAC: 2025 Payment Basics series
12/01/25 at 02:00 AMNew from MedPAC: 2025 Payment Basics series MedPAC - Medicare Payment Advisory Commission; 11/24/25 MedPAC announces the release of the updated 2025 Medicare Payment Basics series. MedPAC's mission is to advise the Congress on Medicare issues, and part of that mission is providing clear and accessible information about how Medicare works. Payment Basics is a series of explainers on how Medicare's payment systems function. These "basics" are typically no more than 5 pages long and feature handy diagrams that visually depict how the payment systems calculate providers' payments. MedPAC produces "basics" for the major payment systems (20 in all), and updates the series once a year in the fall. The updated versions are now available here.
Alliance ready to go ‘full bore’ on legislative strategy if CMS Rule falls short
11/28/25 at 03:00 AMAlliance ready to go ‘full bore’ on legislative strategy if CMS Rule falls short Home Health News; by Morgan Gonzales; 11/24/25 The National Alliance for Care at Home (the Alliance) is prepared to take a "full bore" approach to its legislative strategy if the Centers for Medicare & Medicaid Services (CMS) rule falls short. This includes scrutinizing CMS's methodologies and implementation plans once the final rule is issued. The Alliance is ready to push the Home Health Stabilization Act of 2025 if the final rule includes a massive cut to the home health Medicare rate. ... The Alliance's docket for the new year includes pushing for key deregulations, most top of mind: the 80/20 rule.
Calendar Year (CY) 2026 End-Stage Renal Disease (ESRD) Prospective Payment System Final Rule
11/25/25 at 03:00 AMCalendar Year (CY) 2026 End-Stage Renal Disease (ESRD) Prospective Payment System Final Rule CMS Newsroom - Fact Sheets; by CMS; 11/20/25 Key points:
CMS' TEAM model leaves hospitals scrambling before 2026 launch
11/25/25 at 03:00 AMCMS' TEAM model leaves hospitals scrambling before 2026 launch Modern Healthcare; by Bridget Early; 11/21/25 On January 1, 2026, Medicare will launch the Medicare Transforming Episode Accountability Model (TEAM), a mandatory fee-for-service model with bundled payments for five common procedures. ... More than 700 hospitals are required to participate and develop partnerships for post-acute care. Detailed information on the model and a list of participating hospitals can be found here.
He built a nursing home empire despite state investigations. Now, lawsuits are piling up
11/24/25 at 03:10 AMHe built a nursing home empire despite state investigations. Now, lawsuits are piling upCal Matters; by Jocelyn Wiener; 11/20/25California nursing homes affiliated with Shlomo Rechnitz are facing lawsuits alleging that patients were raped, ignored and unnecessarily exposed to COVID-19. His companies deny the allegations. In February 2024, a Los Angeles County jury awarded $2.34 million to an 84-year-old nursing home resident named Betsy Jentz, finding that the facility had violated her rights on 132 occasions, at times leading to serious injuries. [Three more equally offensive cases.] All of these facilities have one thing in common: state records list Shlomo Rechnitz as an owner. Court documents show Rechnitz and his companies have denied all allegations in all of the cases.
AGG Files Amicus Brief on Behalf of the National Alliance for Care at Home and AAHPM
11/24/25 at 03:05 AMAGG Files Amicus Brief on Behalf of the National Alliance for Care at Home and AAHPM JD Supra; by Jason Bring, Bill Dombi, and T. Chase Ogletree; 11/20/25 AGG Healthcare attorneys Bill Dombi and Jason Bring and Litigation & Dispute Resolution attorney TC Ogletree filed an amicus (or “friend of the court”) brief on behalf of the National Alliance for Care at Home (the “Alliance”) and the American Academy of Hospice and Palliative Medicine (the “AAHPM”) with the United States Court of Appeals for the Sixth Circuit. The case involves a hospice audit that proceeded through the administrative appeals process to an administrative law judge (“ALJ”) hearing, in which the ALJ denied the hospice’s Medicare reimbursement claims.
Three Palmetto GBA hospice reports
11/24/25 at 03:00 AMThree Palmetto GBA ReportsPalmetto press release; 11/21/25
Telehealth survives again: What the most recent flexibility extension means for providers
11/19/25 at 03:00 AMTelehealth survives again: What the most recent flexibility extension means for providers JD Supra; by Conor Duffy and Danielle Tangorre; 11/17/25 On November 12, 2025, President Trump signed H.R. 5371 the “Continuing Appropriations, Agriculture, Legislative Branch, Military Construction, and Veterans Affairs and Extensions Act, 2026” (the Act). The Act ended the federal government shutdown by providing necessary funding; it also extends key Medicare telehealth flexibilities to January 30, 2026. ... This represents another short-term extension of Medicare telehealth flexibilities that will again need to be revisited in January 2026. ... Medicare Telehealth Flexibilities Extended by the Act [include]:
When Medicare sent patients home sooner, Mary Naylor built the safety net
11/19/25 at 03:00 AMWhen Medicare sent patients home sooner, Mary Naylor built the safety net Penn LDI - Leonard Davis Institute of Health Economics; by Liz Seegert; 11/17/25 When Medicare’s diagnosis-related group (DRG) payment system took effect in October 1983, hospitals adapted quickly, discharging patients faster to manage fixed reimbursement rates. Heart failure patients who once stayed eight to 10 days were going home in three to four days. But LDI Senior Fellow Mary Naylor, then a fellow with what was then known as the U.S. Senate Committee on Aging and Finance, realized no one had thought about what happened after discharge. She saw how these shifts created new risks for older adults, as hospitals lacked the infrastructure to support care continuity. ...
Four California residents sentenced to prison in connection with $16m Hospice fraud and money laundering scheme
11/19/25 at 03:00 AMFour California residents sentenced to prison in connection with $16m Hospice fraud and money laundering scheme Office of Public Affairs - U.S. Department of Justice; Press Release; 11/18/25 Four California residents were sentenced to prison for their roles in defrauding Medicare of nearly $16 million through sham hospice companies and laundering the fraudulent proceeds.
Hospice: Track errors, payment caps to avoid facing costly penalties
11/18/25 at 03:00 AMHospice: Track errors, payment caps to avoid facing costly penalties Home Health Line, DecisionHealth; by MaryKent Wolff; 11/13/25 Keep a close eye on possible claim and billing mistakes that could lead to issues related to your payment cap. While increased revenue may seem like a good thing for providers, overpayments could lead to heightened scrutiny and financial hardships for your agency. [May require subscription for additional information]
Hospital-at-home programs gripped by uncertainty
11/18/25 at 03:00 AMHospital-at-home programs gripped by uncertainty Modern Healthcare; by Diane Eastabrook; 11/17/25 ... Stopgap legislation signed into law last week continues the Centers for Medicare and Medicaid Services Acute Hospital Care at Home waiver until the end of January. The short extension is creating more confusion and uncertainty for health systems hoping to start or scale hospital-at-home, said Dr. Stephen Dorner, chief of clinical operations and medical affairs at Mass General Brigham’s Healthcare at Home program. Guest Editor’s Note, by Judi Lund-Person: Health systems who had Hospital-at-Home programs are rethinking their plans to reopen their programs, largely due to the very short waiver extension until January 30, 2026. According to Modern Healthcare, a bill has been introduced, titled the “Hospital Inpatient Services Modernization Act.” The waiver for Hospital-at- Home would be extended for five years, through the end of 2030.
Federal government re-opens
11/14/25 at 03:00 AMFederal government re-opens CHAP; Press Release; 11/13/25 On November 12, the U.S. House passed the Senate Amendment to H.R. 5371, ending the 43-day government shutdown. The continuing resolution (CR) provides funding for most agencies through January 30, 2026, at current levels, and grants full-year 2026 funding to select departments, including Agriculture, FDA, Legislative Branch, military construction, and Veterans Affairs. It also contains measures relevant to the home care community.