Literature Review

Medicare Administrative Contractors [MACs] did not consistently meet Medicare Cost Report Oversight Requirements HHS-OIG; Issued on 3/18/25, posted on 3/19/25 ... What OIG Found: MACs did not consistently meet Medicare cost report oversight requirements.

Ohio payer beats UnitedHealthcare in racketeering lawsuit, awarded $50M Becker's Payer Issues; by Jakob Emerson; 3/19/25 An Ohio jury awarded Medical Mutual of Ohio over $50 million in damages on March 12 after the payer prevailed in its lawsuit against FrontPath Health Coalition and HealthScope Benefits, a subsidiary of UnitedHealthcare. FrontPath offers employee benefits solutions, and HealthScope is a third-party administrator. .. The defendants were found to have committed federal wire fraud, telecommunications fraud, tampered with records, and obstructed justice by submitting false bid information. The jury found that the conspiracy resulted in significant damages to Medical Mutual and ultimately caused taxpayers to pay higher healthcare costs than necessary.

CMS will not resume implementation of Hospice SFP in 2025 Hospice News; by Jim Parker; 3/25/25 A federal court has ordered a stay on litigation intended to block the hospice Special Focus Program (SFP) after the U.S. Centers for Medicare & Medicaid Services (CMS) pledged that it would not resume implementation during 2025. The crux of a lawsuit filed by hospice organizations against the U.S. Department of Health and Human Services (HHS) is the criteria that the agency uses to select hospices for the new Special Focus Program (SFP). [Continue reading ...]

Lancaster woman convicted in hospice fraud schemeNBC-4 News, Los Angeles, CA; by City News Service; 3/21/25 A Lancaster [California] woman was found guilty Friday of receiving more than $330,000 in illegal kickbacks for patient referrals to two hospice companies in a fraud scheme that bilked Medicare out of more than $3.2 million through claims for medically unnecessary services. Callie Jean Black, 66, was convicted at the conclusion of a four-day bench trial in Los Angeles federal court of four counts of soliciting and receiving remunerations for patient referrals, according to the U.S. Attorney's Office. U.S. District Judge André Birotte Jr. scheduled sentencing for July 25. [Continue reading ...] 

‘Disturbing’ outlook: Hospices’ top regulatory concerns in 2025 Hospice News; by Holly Vossel; 3/20/25 Telehealth policies and program integrity concerns represent two of the leading regulatory issues on hospices’ radar this year. Regulatory changes and increasing oversight were the second-most cited concerns among nearly a quarter (21%) of 112 hospice professionals who participated in this year’s Outlook Survey by Hospice News and Homecare Homebase. Challenges around staffing and improved public awareness also topped the list of providers’ concerns. This is the third piece of this three-part Hospice News series that explores the significant regulatory challenges facing hospice providers in 2025. 

13th Annual Healthcare Fraud & Abuse Review - 2024 JD Supra; by Bass, Berry & Sims PLC; 3/7/25 Bass, Berry & Sims is pleased to announce the release of the 13th annual Healthcare Fraud & Abuse Review examining important healthcare fraud developments in 2024. Compiled by the firm's Healthcare Fraud & Abuse Task Force, the Review provides a comprehensive analysis of enforcement developments affecting the healthcare industry, significant court decisions involving the False Claims Act, and an overview of settlements involving healthcare fraud and abuse issues.We began the Review over a decade ago with the intention of providing comprehensive coverage of the most significant civil and criminal enforcement issues facing healthcare providers each year. Over that time, the challenges facing the healthcare industry have been significant. ...

DOJ launches probe into UnitedHealth’s Medicare billing practices after investigative reports MSN; by Taylor Herzlich; 3/22/25 The Department of Justice has reportedly launched an investigation into UnitedHealth Group’s Medicare billing practices as scrutiny over the health insurance industry intensifies — sending the company’s stock plummeting.The probe is analyzing the company’s practice of frequently logging diagnoses that trigger larger payments to its Medicare Advantage plans, according to The Wall Street Journal. UnitedHealth shares plunged nearly 9% Friday. A series of Wall Street Journal reports last year found that Medicare paid UnitedHealth billions of dollars for questionable diagnoses.

Saad Healthcare agrees to pay $3M to settle False Claims Act allegations that it billed Medicare for ineligible hospice patientsU.S. Department of Justice - Office of Public Affairs; Press Release; 2/21/25Saad Enterprises Inc., doing business as Saad Healthcare, has agreed to pay $3 million to resolve allegations that it violated the False Claims Act by knowingly submitting false claims for the care of hospice patients in Alabama who were ineligible for the Medicare hospice benefit because they were not terminally ill. ... The settlement resolves allegations that between 2013 and 2020 Saad submitted, or caused the submission of, false claims to Medicare for 21 patients who did not meet the eligibility requirements for the Medicare hospice benefit as defined by statute and regulation, despite Saad knowing the patients were ineligible for the Medicare hospice benefit.

Hospice - The time is now for additional integrity oversightJAMA Forum; by Joan M. Teno; 4/23...Leading hospice organizations are calling for more oversight. The National Partnership for Healthcare and Hospice Innovation, LeadingAge, the National Association for Home Care & Hospice, and the National Hospice and Palliative Care Organization provided a comprehensive set of recommendations to preserve the integrity of hospice. These organizations are returning to the historic mission of hospice: to improve care for dying persons and support for their family members... The recommendations put forth by the 4 hospice organizations are important. Further reforms also are needed.

DOGE probes CMS for Medicare, Medicaid fraud: WSJ Becker's Hospital Review; by Rylee Wilson; 2/5/25Members of Elon Musk's Department of Government Efficiency have been granted access to payment and contracting systems at CMS, The Wall Street Journal reported Feb. 5. Department representatives have been on-site at CMS' offices this week, examining spending data for potential fraud or waste and reviewing the agency's organization and staffing, unnamed sources told the Journal. ... DOGE aims to cut federal spending by $1 trillion, with Medicaid emerging as a likely target, according to The New York Times. CMS spent more than $1.5 trillion on healthcare programs in fiscal year 2024, accounting for 22% of total federal spending, according to the agency's 2024 annual report. "Yeah, this [CMS] is where the big money fraud is happening," Mr. Musk wrote on X in response to the Journal's article.  

Home health operator sentenced to 12 years in prison for $100M fraud schemeHome Health Care News; by Audrie Martin; 1/27/25A Westford, Massachusetts woman was sentenced to 12 years in prison after being convicted of a $100 million home health care fraud. Faith Newton, former operator of Chelmsford, Massachusetts-based Arbor Homecare Services LLC, was sentenced in federal court to 12 years in prison to be followed by three years of supervised release. She was also ordered to pay a fine of $250,000 and restitution of more than $99.7 million. In July 2024, Newton was convicted of one count of conspiracy to commit health care fraud, one count of health care fraud and three counts of money laundering. The jury found the defendant not guilty on one count of money laundering conspiracy. Newton was arrested and charged along with co-defendant Winnie Waruru in February 2021.

Arizona couple pleads guilty to $1.2B health care fraud Office of Public Affairs - U.S. Department of Justice; Press Release; 1/31/25 An Arizona couple pleaded guilty for causing over $1.2 billion of false and fraudulent claims to be submitted to Medicare and other health insurance programs for expensive, medically unnecessary wound grafts that were applied to elderly and terminally ill patients. According to court documents, Alexandra Gehrke, 39, and her husband, Jeffrey King, 46, both of Phoenix, conspired with others to orchestrate the massive scheme. Gehrke ran two companies, Apex Medical LLC and Viking Medical Consultants LLC, that contracted with medically untrained “sales representatives” to locate elderly patients, including hospice patients, who had wounds at any stage and order amniotic wound grafts from a specific graft distributor. 

Former hospice physician alleges retaliation against nonprofit healthcare provider Northern California Record; by Northern California Record State Court; 1/23/25 In a gripping legal battle that raises questions about medical ethics and employee rights, a former hospice physician has filed a lawsuit against his previous employer, alleging wrongful termination and retaliation. The complaint was lodged by Kamaldip Ghei in the Superior Court of California, County of San Francisco, on January 10, 2025, targeting Sutter Visiting Nurse Association and Hospice dba Sutter Care at Home. ... Ghei claims he was wrongfully terminated after raising concerns about the organization's practices regarding patient care. Specifically, he alleges that he was pressured to keep patients in hospice care even when it was not medically justified. ...