Literature Review

Home health agency sues HHS over $34m Medicare payment recoupment Home Health Care News; by Morgan Gonzales; 9/8/25 Infinity Home Care of Lakeland, a Florida-based home health provider and affiliate of Amedisys, has sued the U.S. Department of Health and Human Services over Medicare recoupments. The Florida-based home health agency alleged that HHS completed “shoddy expert work” that led the agency to conclude that Medicare overpaid Infinity by $34 million for services from 2014 to 2016. According to the lawsuit, a contractor, Zone Program Integrity Contractors (ZPIC), reviewed 72 of the agency’s claims in 2017 and denied all 72 on the basis of errors with the face-to-face encounter documentation, that home health services were not medically reasonable and necessary or a lack of medical records. 

Hospice Insights Podcast - Where’s the line: When does poor quality create false claims liability JDSupra; by Meg Pekarske and Jonathan Porter; 8/27/25 Substandard quality care is the subject of survey citations and lawsuits, but it has also been used by the Justice Department to support false claim liability. While historically these cases were rare, a recent multi-million dollar settlement puts “worthless services” on the radar. Join Husch Blackwell’s Meg Pekarske and Jonathan Porter as they explore what the “worthless services” theory of liability is, when it has been used, and whether the recent settlement could signal a resurgence of these types of cases. 

Protecting Florida's seniors: Fighting fraud and financial exploitation Targeted News Service; 8/29/25 The Senate Special Committee on Aging released the following testimony by Brandy Bauer, director of the Senior Medicare Patrol Resource Center, from an Aug. 7, 2025, field hearing entitled "Protecting Florida's Seniors: Fighting Fraud and Financial Exploitation": Chairman Scott, thank you for inviting me here today on behalf of the Senior Medicare Patrol program. The nation's 54 Senior Medicare Patrol, or SMP, programs are managed by the U.S. Administration for Community Living, with the mission to help empower and assist people to prevent, detect, and report Medicare fraud, errors, and abuse. ...

DOJ probing UnitedHealth’s Optum Rx, alongside Medicare practicesModern Healthcare; by Chris Strohm, John Tozzi; 8/26/25The U.S. Justice Department’s criminal division is digging into UnitedHealth Group Inc.’s prescription management services as well as how it reimburses its own doctors under an ongoing probe into the firm’s operations, according to people familiar with the matter. The previously unreported areas of the probe show the scrutiny is broader than was known and goes beyond an inquiry into possible Medicare fraud. Investigators are looking into business practices at the company’s pharmacy benefit manager Optum Rx, in addition to the physician payments, said the people, who asked not to be identified discussing a confidential matter.

Amedisys pays $1.1 million for HSR compliance lapse amid pending UnitedHealth deal Lexology - Triage Health Law Blog; by Squire Patton Boggs; 8/12/25 Amedisys, a major provider of home health and hospice care, has agreed to pay a $1.1 million civil penalty to settle allegations that it violated the Hart-Scott-Rodino (HSR) Act during the antitrust review of its pending $3.3 billion acquisition by UnitedHealth’s Optum division. ... In December 2023, while responding to a DOJ “Second Request” for information, a mandatory step in large merger reviews, Amedisys filed a sworn certification that its production was “true, correct, and complete.” In reality, the company knew that its email archiving system had malfunctioned, causing the loss of a month’s worth of emails from May–June 2023, a critical period in the merger negotiations. ... The DOJ emphasized that this was not a “minor paperwork glitch” but a material omission in a sworn filing.

Merging clinical and legal: How home health providers achieve medical appeals success Home Health Care News; by Joyce Famakinwa; 7/31/25 For home-based care providers, medical appeals can be extremely costly. When navigating the medical appeals process, home health clinical and legal teams must operate in lockstep in order to achieve successful results and avoid financial blowback, ... ROI should be the biggest determining factor when deciding to appeal, according to Bill Dombi, senior counsel for Arnall Golden Gregory law firm. He formerly served as the president of the National Alliance for Care at Home. ... Despite the hefty costs that medical appeals can potentially rack up, sometimes figuring out the ROI can go beyond dollars and cents. For example, if a provider is going through the Medicare Targeted Probe and Educate (TPE) audit process.

Glendale woman sentenced to 9 years in federal prison for $10.6 million hospice fraud scheme involving kickbacks for patients United States Attorney's Office - Central District of California, Los Angeles, CA; Press Release; 8/5/25 A Glendale woman was sentenced today to 108 months in federal prison for participating in a scheme in which hundreds of thousands of dollars in illegal kickbacks were paid and received for patient referrals that resulted in the submission of approximately $10.6 million in fraudulent claims to Medicare for purported hospice care. Nita Almuete Paddit Palma, 75, of Glendale, was sentenced by United States District Judge Dolly M. Gee, who also ordered her to pay $8,270,032 in restitution. 

Georgia may be next for enhanced hospice oversight, regulatory affairs expert predicts McKnights Home Care; by Adam Healy; 7/29/25 Warning, hospice providers in Georgia. Your state may be the next target for the Centers for Medicare & Medicaid Services’ Provisional Period of Enhanced Oversight (PPEO). “If you are from Georgia, do not be surprised if something like this comes to your town soon,” Katie Wehri, vice president of regulatory affairs, quality and compliance for the National Alliance for Care at Home, said on the closing day of the Alliance’s Financial Management Summit Tuesday. “The reason is that the Medicare Payment Advisory Commission and CMS have both mentioned Georgia as an area where there’s a high number of new hospices.” Four states are currently the subject of PPEO: California, Arizona, Nevada and Texas. California — and specifically Los Angeles County — has been a hotbed of hospice fraud in recent years. 

Be on the lookout for this new Medicare scam Las Vegas Review-Journal; by Toni King; 7/24/25 Dear Toni: A hospice agent recently came knocking on the doors in my neighborhood saying he represented Medicare. He was giving away hospice gifts and told me that I could receive these Medicare services at no charge for me and my husband. I told him that I did not give out personal information to anyone that I do not know. Now, I’m concerned that I could have made a mistake. Should I call and ask if this Medicare service is still available? —Deidre, Katy, Texas Dear Deidre: Medicare is not giving away anything free! This is a new scam that is targeting America’s Medicare population.  ...Editor's Note: Though we’ve addressed this topic repeatedly in recent months, ongoing awareness and community education remain essential. Please continue seeking opportunities to collaborate with media outlets in your service areas to help inform and protect vulnerable populations. Use the following articles—previously featured in our newsletter—as reference points:

Perform detail-oriented internal audits to avoid common denials DecisionHealth - Home Health Line; by MaryKent Wolff; 7/18/25 The most common reason for hospice denials in the first quarter of 2025 was that the claim was not hospice appropriate, according to Palmetto GBA, a Medicare Administrative Contractor (MAC) servicing 16 states. Palmetto released its list of the top 10 hospice medical review denial reasons from January to March 2025 on May 16. [Subscription required.]

DOJ & HHS announce reinvigoration of False Claims Act Working Group and Healthcare Fraud Enforcement Priorities Dorsey & Whitney LLP; Press Release; 7/9/25 The Department of Justice and the Department of Health and Human Services announced the reinvigoration of a False Claims Act (“FCA”) Working Group, a joint effort between the two agencies.  The announcement was made on July 2 during remarks at the American Health Law Association (“AHLA”) Annual Meeting by Brenna Jenny, the new Deputy Assistant Attorney General of DOJ’s Commercial Litigation Branch, and in a press release that same day. This working group underscores that healthcare fraud is a priority for the Administration, despite recent staff changes and recent policy announcements about enforcement priorities in civil rights and DEI. It also underscores that robust compliance programs should continue to be a priority for healthcare-industry stakeholders.

Two California residents plead guilty in connection with $16M hospice fraud scheme and money laundering schemeDOJ press release; 7/8/25Two California residents pleaded guilty yesterday in connection with their roles in defrauding Medicare of nearly $16 million through sham hospice companies and to laundering the proceeds of the fraud as part of a multi-year scheme. According to court documents, Karpis Srapyan, 35, of Winnetka, California, conspired with others, including co-defendants Petros Fichidzhyan and Juan Carlos Esparza, to bill Medicare for hospice services that were not medically necessary and never provided. To conduct their fraudulent scheme, they used a series of four sham hospice companies: one owned by Esparza and the other three owned by foreign nationals but controlled by the defendants. Srapyan and his co-defendants concealed the scheme by using foreign nationals’ personal identifying information to open bank accounts, submit information to Medicare, and sign property leases. They also misappropriated names and other identifying information of several doctors, two of whom were deceased, to fraudulently bill Medicare for purported hospice services. In total, Medicare paid the fake hospice companies nearly $16 million.

CMS launches new model to target wasteful, inappropriate services in original Medicare CMS Newsroom; 6/27/25 The Centers for Medicare & Medicaid Services (CMS) is announcing a new Innovation Center model aimed at helping ensure people with Original Medicare receive safe, effective, and necessary care. Through the Wasteful and Inappropriate Service Reduction (WISeR) Model, CMS will partner with companies specializing in enhanced technologies to test ways to provide an improved and expedited prior authorization process relative to Original Medicare’s existing processes, helping patients and providers avoid unnecessary or inappropriate care and safeguarding federal taxpayer dollars. This model builds on other changes being made to prior authorization as announced by the U.S. Department of Health and Human Services and CMS on [6/23].