Literature Review

Home-based hospice operators welcome CMS anti-fraud efforts Home Health Care News; by Joyce Famakinwa; 7/24/25 In an effort to combat fraud, the hospice industry may see increased scrutiny from the U.S. Centers for Medicare & Medicaid Services (CMS). Home-based care providers that offer hospice services, including AccentCare and Elara Caring, told Home Health Care News they hope that CMS will act on their statements about bad actors in the industry – and that a crackdown would protect “high-integrity” providers. ... Companies like AccentCare, which offer both home health and hospice services, welcome CMS’s active approach to rooting out fraud. “We hope it materializes,” Dr. Balu Natarajan, chief medical officer at AccentCare, told HHCN. ... Similar to AccentCare, Elara Caring believes that this would be a step in the right direction. “We fully support CMS’s efforts to crack down on fraud in hospice and home health,” an Elara Caring spokesperson told HHCN in an email.  

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].

Nearly 50 charged in Southern District of Texas as part of national health care fraud takedown United States Attorney's Office - Southern District of Texas, Houston, TX; 6/30/25 A total of 22 cases are being announced as part of local efforts targeting health care fraud and include various schemes alleging unlawful distribution of controlled substances, some of which were diverted onto the black market, hospice fraud, kickbacks and other Medicare/Medicaid fraud schemes involving medically unnecessary genetic tests, durable medical equipment and more.  The charges filed in Southern District of Texas (SDTX) federal court are part of the Department of Justice’s 2025 national health care fraud takedown. ... One of the largest cases include three individuals for their alleged roles in a $110 million hospice fraud and kickback scheme. The charges allege Dera Ogudo, 39, and Victoria Martinez, 35, both of Richmond, operated hospice company United Palliative & Hospice Company (UPHC) that misled vulnerable elderly adults about what services were being billed to their Medicare and Medicaid plans.

Artificial intelligence and health care waste—Promise or peril?JAMA Health Forum; William H. Shrank, MD, MSHS; Suhas Gondi, MD, MBA; David J. Brailer, MD, PhD; 6/25One obvious target of AI [artificial intelligence] tools in health care is the reduction of waste. While LLM [large language model] applications to health care are still nascent—many still make errors, and more rigorous evaluations are needed—most agree that the long-term opportunity for AI in health care is tremendous. A recent study estimated that widespread adoption of AI could lead to savings of 5% to 10% of total US health care spending. Realizing even a fraction of this potential would increase the affordability of care for people in the US and free substantial societal resources to make other valuable investments. But getting there will require deliberate choices from leaders and policymakers and careful attention to risks that could set back progress.

Whistleblowers receive $1.5 million for exposing alleged hospice kickback schemeWhistleblower Network News; by Geoff Schweller; 6/18/25On June 11, the U.S. Attorney for the Northern District of Georgia announced that Creative Hospice Care, Inc., and affiliated companies paid $9.2 million to settle whistleblower allegations that the entities violated the False Claims Act by entering into kickback arrangements with medical directors in exchange for referrals of hospice patients to Creative Hospice.

CMS budget proposal would shift nursing facility oversight Becker's Hospital Review; by Elizabeth Gregerson; 6/4/25 Key changes put forth in President Donald Trump’s proposed fiscal year 2026 budget may have downstream effects on the survey and certification of skilled nursing facilities. ... Here are three things to know about the proposed changes:

Experts warn of scams during Medicare Fraud Prevention Week Public News Service; by Suzanne Potter; 6/4/25 Medicare loses $60 billion to $80 billion a year to fraud and this year, for Medicare Fraud Prevention Week, your local Senior Medicare Patrol has good advice on how to spot a con. There are plenty of scams to be aware of. Karen Joy Fletcher, communications director with the nonprofit California Health Advocates, said beware if a caller asks to verify your Medicare number, claiming the program needs to send out a new type of card. ... ... Caregivers can be on the lookout for medical equipment arriving at the house even though the beneficiary never ordered it. Another red flag? A stranger may approach you in a parking lot asking you to sign up for new, free Medicare services like house cleaning or meals, which are then fraudulently billed to the government. ... Another scam involves tricking people into unknowingly signing up for hospice care. It is especially dangerous, because once a person is on hospice, Medicare will only approve palliative care and could mistakenly deny an essential surgery or medication.

TCN/HPC Today: Storm clouds on the horizon for reimbursement - Top news stories, May 2025 Teleios Collaborative Network (TCN); podcast by Chris Comeaux with Cordt Kassner, 6/4/25 What happens when artificial intelligence meets end-of-life care?  How do we reconcile private equity's profit motives with hospice's mission-driven ethos?  These questions took center stage in this month's roundup of hospice news with host Chris Comeaux and guest Cordt Kassner. The May edition of TCNtalks' top news stories reveals a healthcare sector at a fascinating crossroads.  AI has emerged as both a tantalizing promise and a practical challenge for hospice providers.  ... In this episode of TCN Talks, hosts Chris Comeaux and Cord Kassner reflect on Memorial Day and discuss significant news stories from May, including the complexities of thanking veterans for their service, the role of artificial intelligence in hospice care, and the importance of honest conversations about racism in healthcare.Editor's note: This monthly podcast combines quantitative data and qualitative discussion from articles gleaned from the 400+ posts we provide each month. Do you seek to make sense of it all? Tune in and learn. We welcome your feedback via our newsletter's Contact page. 

Saugus nurse arrested in FBI raid for alleged part in $2.5 million Medicare [hospice] fraud KHTS - Santa Clarita News, Santa Clarita, CA; by Jade Aubuchon; 5/30/25 Jessa Zayas, aka Jessa Contreras, a vocational nurse, is believed to have committed medicare fraud through two different hospice providers, submitting more than $2,500,000 in fraudulent claims to Medicare. Zayas is the Chief Executive Officer of two hospice providers, Healing Hands Hospice Inc. and Humane Love Hospice. From June 2023 through February 2025, she caused Healing Hands and Humane Love to bill Medicare for millions of dollars’ worth of hospice services that were not medically necessary, not authorized by a physician, and were not actually provided to the patients. ...