Literature Review

Coverage denials in Medicare Advantage—Balancing access and efficiencyJAMA Health Forum; by Suhas Gondi, MD, MBA; Kushal T. Kadakia, MSc; and Thomas C. Tsai, MD, MPH; 3/1/24 Each year, millions of claims for medical services are denied by health insurance plans. Many denials may be justified as a necessary strategy to reduce wasteful spending from low-value care. However, denials may also delay diagnosis and/or treatment for patients, and appealing denials contributes to clinician workload and burnout. This tension is apparent in the Medicare program, where denials affect millions of beneficiaries who enroll in Medicare Advantage (MA). 

Veterans’ care new battleground in nursing home staffing mandate McKnights Long-Term Care News, by Kimberly Marselas; 3/5/24Two senators have introduced a bill to determine exactly what “unintended circumstances” could result for elderly veterans if a federal rule mandating staffing levels at all US nursing homes is allowed to proceed. ... The bill would require the VA to study potential risks associated with the proposed Center for Medicare and Medicaid Services rule — especially as they pertain to rural providers. The senators said the proposal would “unsustainably change staffing ratios at nursing homes.”

Congress floats Medicare physician pay bump: 4 notes Becker's Hospital CFO Report, by Mackenzie Bean; 3/4/24 Physicians are set to receive a 1.7% increase in Medicare pay effective March 9 as part of a $460 billion spending package congressional leaders released this weekend. Four things to know: ... [click on the title's link for more]

Home health disparities: Medicare Advantage patients receive fewer visits, worse outcomes Home Health Care News, by Patirck Filbin; 3/1/24Home health patients under Medicare Advantage (MA) plans have worse functional outcomes compared to traditional Medicare patients, likely as a result of receiving fewer visits, according to a new study.

What the UnitedHealth Group Antitrust Investigation means for Amedisys, home health industry Home Health Care News, by Andrew Donlan; 3/1/24 Since the news surfaced Tuesday that the Department of Justice had opened an antitrust investigation into UnitedHealth Group (NYSE: UNH), additional questions have bubbled up. Namely, those questions surround the home health provider Amedisys Inc. (Nasdaq: AMED), which agreed to be acquired by UnitedHealth Group’s Optum in June of last year.

CMS upends Medicare Advantage supplemental benefits data reporting for payers DLA Piper, by Daivd Kopans and Sua Yoon; 2/27/24 On February 21, 2024, the Centers for Medicare & Medicaid Services (CMS) issued new guidance via a memorandum to Medicare Advantage (MA) organizations, Program of All-Inclusive Care for the Elderly (PACE) organizations, and Demonstration Organizations (collectively, Plans) that upends how these Plans have been reporting (or not reporting) encounter information for their covered supplemental benefits. The guidance in the memorandum is effective retroactively to January 1, 2024. [In this article] is a Q&A explaining the top points of the guidance and highlight its impact on companies across industries.

The Medicare Care Choices Model was associated with reductions in disparities in the use of hospice care for Medicare beneficiaries with terminal illnessHealth Serv Res by Matthew J Niedzwiecki, Lauren Vollmer Forrow, Jonathan Gellar, R Vincent Pohl, Arnold Chen, Lynn Miescier, Keith Kranker; 2/29/24 Conclusions: Medicare Choices Model (MCCM) increased hospice use and quality of end-of-life care for model enrollees from underserved groups and reduced disparities in hospice use and having multiple emergency department visits.

Untangling the history, causes behind the precipitous home health aide utilization drop Home Health Care News, by Patrick Filbin; 2/28/24In the last home health proposed rule from the Centers for Medicare & Medicaid Services (CMS), the federal agency in charge of reimbursement rates sent out a request for information on home health aide utilization. Specifically, the agency wondered why Medicare-covered home health aide visits and utilization had fallen off a cliff over the last few decades. According to the Center for Medicare Advocacy, home health aide visits declined by 90% from 1998 to 2019. 

CMS finalizes important changes to Medicare enrollment requirements for hospice, home health providersJDSupra; 2/28/24The US Centers for Medicare & Medicaid Services (CMS) finalized important changes to the Medicare enrollment regulations applicable to hospices and home health agencies (HHAs), including increasing the level of screening that hospice providers are subject to and limiting a Medicare-enrolled hospice’s ability to change majority ownership to once every 36 months.

HCA Mission Hospital regains CMS complianceBecker's Hospital Review, by Mariah Taylor; 2/26/24CMS found Asheville, N.C.-based HCA Mission Hospital in compliance with its plan of correction and recommended removing the immediate jeopardy designation, Blue Ridge Public Radio reported Feb. 23. The hospital's plan of correction to address serious deficiencies it was cited for in January focuses on improving policies and educating staff.

[Updated] CMS crackdown on fraudulent hospice providers in full effect in 2024, expert says McKnights Product Theater, by Adam Healy; 2/22/24In recent years, unscrupulous hospice providers have cropped up in California and other states. In response, the Centers for Medicare & Medicaid Services has prepared a slew of tools to curtail the fraud. States continue to feel the effects. As an example, a California hospice operator last week was convicted in a Medicare fraud scheme for billing nearly $3 million for services that patients did not need, according to the Department of Justice. 

Providers urge CMS to use caution in midst of hospice VBID implementationMcKnights Home Care, by Adam Healy; 2/23/24With the Medicare Advantage Value-Based Insurance Design (MA VBID) model, which allows MA organizations to participate in the hospice benefit, underway, advocates have voiced concerns that critical safeguards be put in place.

Centers for Medicare & Medicaid Services corrects rule involving 2024 home health prospective payment system rate updateCMS Federal Register; 2/21/24This document corrects technical errors in the final rule that appeared in the November 13, 2023 Federal Register titled “Medicare Program; Calendar Year (CY) 2024 Home Health (HH) Prospective Payment System Rate Update; HH Quality Reporting Program Requirements; HH Value-Based Purchasing Expanded Model Requirements; Home Intravenous Immune Globulin Items and Services; Hospice Informal Dispute Resolution and Special Focus Program Requirements, Certain Requirements for Durable Medical Equipment Prosthetics and Orthotics Supplies; and Provider and Supplier Enrollment Requirements” (referred to hereafter as the “CY 2024 HH PPS final rule”).