Literature Review

Frailty in Medicare Advantage beneficiaries and Traditional Medicare beneficiariesJAMA Network Open; Sandra M. Shi, MD, MPH; Brianne Olivieri-Mui, PhD, MPH; Chan Mi Park, MD, MPH; Stephanie Sison, MD, MBA; Ellen P. McCarthy, PhD, MPH; Dae H. Kim, MD, ScD; 8/24In this nationally representative cohort study of 7063 community-dwelling individuals aged 65 years and older, compared with traditional fee-for-service Medicare beneficiaries, Medicare Advantage beneficiaries had higher levels of frailty at baseline but similar levels of frailty change over 1 year. These findings suggest that enrollment in Medicare Advantage plans is not associated with altered frailty trajectories compared with Traditional Medicare, and more work is needed to better understand the health services needs of older adults with frailty.

Medicare Advantage bonus payments decline for first time since 2015Becker's Payer Issues; by Rylee Wilson; 9/11/24Bonus payments to Medicare Advantage plans will decline by around 8% in 2024 compared to 2023, according to a report from KFF. The analysis, published Sept. 11, found bonus payments to MA plans will decline by around $1 billion to $11.8 billion in 2024. Although this was the first decline since 2015, the $11.8 billion in payments will still exceed amounts for every year from 2015 to 2022. The number of bonus payments will decline because of temporary policies in place during the COVID-19 pandemic increased star ratings for some plans, according to KFF. When the policies ended, some plans took a hit in bonus payments. CMS pays Medicare Advantage plans bonus payments for achieving a star rating of four or higher.

Hospice Insights Podcast: What’s the latest on UPICs? Highlights from recent audit activity, part I JD Supra; podcast by Husch Blackwell, LLP; 9/11/24 [UPIC stands for Unified Program Integrity Contractor audits.] UPIC activity is picking up, and the UPICs are reviving some old tactics. In this episode, Husch Blackwell’s Meg Pekarske and Bryan Nowicki discuss these trends which include extrapolation, Medicaid nursing home room and board payments, patient interviews, and more. Meg and Bryan also describe some handouts they’ve developed to help hospices stay prepared for the inevitable audit. 

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.” 

Prepping for the hospice HOPE tool: Starting the journeyCHAP email; by Jennifer Kennedy; 9/6/24The Centers for Medicare and Medicaid Services (CMS) recently finalized the implementation date of the hospice HOPE assessment tool in the FY 2025 Hospice Payment Update final rule. This quality requirement signals a new beginning for hospice providers related to quality measurement and future payment reform. Implementation is scheduled for October 1, 2025, so the clock is ticking, and the interval is short for provider and software vendor preparation for compliance.Publisher's note: Excellent article with helpful resource links.

Report: More than one-third of nursing homes don’t have required medical director McKnights Long-Term Care News; by Kristen Fischer; 9/3/24Though all nursing homes must have a medical director under federal law, a new study shows that some nursing homes don’t meet the requirement. Facilities that do have a medical director report that the medical director spends just a few hours per week on site, according to the study. Medical directors are charged with overseeing medical care. They manage resident care policies and procedures to align with current standards of practice, including infection control protocols, educational programs and performance reviews for healthcare workers. The report was published on [9/2/24] in the Journal of the American Geriatrics Society. The authors reviewed the practices of nearly 15,000 nursing homes in the United States, using federal Payroll-Based Journal (PBJ) data on staffing positions for the period of 2017–2023, as well as federal nursing home ownership data and deficiencies data for 2023.

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.]

State seeks input on Columbia Gorge hospital, Gentiva hospice care The Lund Report, Oregon and SW Washington; by Nick Budnick; 8/29/24 State officials are checking in on two health care acquisitions that have occurred since August of 2022, the absorption of Mid-Columbia Medical Center into California-based Adventist Health as well as a private equity firm's acquisition of Kindred Hospice. Now the state wants to hear how the renamed entities are doing: Adventist Health Columbia Gorge and Kindred Hospice Care. “OHA wants to understand how ownership changes may have affected health care services at AHCG and Gentiva hospice agencies,” according to a state announcement. “We’d like to hear from patients, health care providers, employees, and community members who have interacted with AHCG or Gentiva in the past year.”

Southern California doctor sentenced in $2.8 million hospice fraud schemeLos Angeles Daily News; by Sydney Barragan; 8/27/24A Southern California doctor was sentenced Tuesday to 37 months in prison for his role in a $2.8 million fraud scheme in which Medicare was billed for unneeded services, the U.S. Department of Justice announced. John Thropay, 75, of Arcadia was the medical director for several hospice companies, including Blue Sky Hospice Inc. in Van Nuys. From October 2014 to March 2016, Thropay certified terminal illnesses that patients did not have in order to bill Medicare for hospice services, officials said. According to the indictment, the owners of Blue Sky paid recruiters illegal kickbacks in exchange for referring “beneficiaries,” or patients. These recruiters paid the patients approximately $300 to $400 of the kickbacks for every month they remained on hospice care with Blue Sky. 

CMS is taking action to address benefit integrity issues related to hospice care CMS Newsroom; by Dara A. Corrigan and Dora L. Hughes, MD, MPH; 8/22/24... Unfortunately, hospices are profiting from fraud at the expense of beneficiaries far too often. Recent media reporting, and research by CMS, have identified instances of hospices certifying patients for hospice care when they were not terminally ill and providing little to no services to patients. The media reports identified that these activities led to a rapid growth in potentially fraudulent hospices, particularly in Arizona, California, Nevada, and Texas. Some of the addresses listed for these hospices also appeared to be non-operational. ... In response to these findings, CMS revisited and revitalized our hospice program integrity strategy, focusing on identifying bad actors and addressing fraudulent activity to minimize impacts to beneficiaries in the Medicare program. As part of this strategy, CMS embarked on a nationwide hospice site visit project, making unannounced site visits to every Medicare-enrolled hospice. [Click here to continue reading this significant information from CMS.]

Hospice’s post-VBID value-based outlook Hospice News; by Holly Vossel; 8/15/24 The post-Medicare Advantage hospice carve-in landscape could include wider value-based reimbursement avenues in the hospice space, leading providers to pivot into MA payer relationships. The forthcoming end of the hospice component of the value-based insurance design (VBID) demonstrative takes effect Dec. 31. Launched in 2021, the carve-in was designed to test coverage of hospice care through Medicare Advantage, as well as coverage of palliative and transitional care. Hospices will need a strong value-based payment negotiation strategy to prepare for the unknowns that lie ahead, according to Melinda Gaboury, co-owner and CEO of Healthcare Provider Solutions Inc., a hospice and home care consulting company. 

Humana will pay $90 million in Medicare drug fraud settlement Bloomberg Law; by Daniel Seiden; 8/16/24 Humana Inc. agreed to pay $90 million to the federal government to settle a whistleblower’s False Claims Act suit alleging that the company submitted fraudulent bids for Medicare Part D prescription drug contracts. Whistleblower Steven Scott alleged that, since 2011, Humana began offering its Medicare Part D prescription drug plan, known as the basic Walmart Plan, and “knowingly provided benefits under that plan that have been significantly less valuable than Humana promised in its bids,” according to Scott’s suit filed in 2016 in the US District Court for the Central District of California. ... This suit was among several in 2016, including suits against Humana, United Health, Cigna Corp., and Optum RX Inc., accusing health insurers of secretly overcharging for prescription drugs.

Stay ahead of Medicare fraudsters ... Watch out for Medicare fraudsters The Times of Noblesville, Indiana; Information provided by the U.S. Department of HEalth & Human Services 8/16/24 (Family Features) ... Watch Out for Medicare Hospice Fraud: Beware of scammers offering older Americans in-home perks, like free cooking, cleaning and home health services, while they are unknowingly being signed up for hospice services. The scammers then unlawfully bill Medicare for these services in your name. Remember this advice to avoid hospice scams: [practical tips for the public] ... Report Medicare Fraud ...Editor's Note: This information for the public--provided by the U.S. Department of Health & Human Services--provides an important resource for your community outreach, marketing, and admissions employees.