Literature Review

CMS’s Special Focus Facility Program for Nursing Homes has not yielded lasting improvementsOIG press release; 10/29/25This report evaluated the effectiveness of the Centers for Medicare & Medicaid Services’ (CMS) Special Focus Facility (SFF) program, the agency’s flagship effort to address quality problems at the nation’s poorest-performing nursing homes. OIG found nearly two-thirds of facilities that graduated from the SFF program between 2013 and 2022 later exhibited recurring quality issues. Among nursing homes that received a serious deficiency in the three years after graduating, 38% put residents at risk of serious injury, harm, impairment or death. For program improvement, OIG recommended that CMS use more nonfinancial remedies, assess enforcement effectiveness—especially for staffing deficiencies—and incorporate ownership data.Publisher's note: It's interesting to see what works - and what doesn't work - from the CMS / OIG perspective.

Hospice chain settles fraud claims for $3 million Law.com; 10/7/25 Guardian Hospice of Georgia and affiliated firms Guardian Home Care Holdings and AccentCare have agreed to pay $3 million to settle whistleblower claims that they submitted false claims to Medicare and Medicaid for hospice patients that were not terminally ill, the acting U.S. attorney in Atlanta announced Oct. 2.

Landmark verdict awards over $510 million to Saint Mary’s Health Network Business Wire, Reno, NV; by Noel True and Mark Reece; 10/2/25 In a historic decision with national implications for healthcare, a Washoe County jury awarded Saint Mary’s Health Network, affiliate of Prime Healthcare, over $510 million in damages, including punitive damages, after finding Universal Health Services of Delaware, Inc. (UHS) and affiliated defendants liable for fraud, malice, and oppression in a coordinated scheme against Saint Mary’s Health Network during the height of the COVID-19 pandemic. ... “This verdict delivers a resounding message for all of healthcare: integrity and compassion must guide every decision we make,” said Sunny Bhatia, M.D., President of Prime Healthcare. 

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. 

70% of Americans oppose Medicare home health cuts, national poll finds National Alliance for Care at Home, Alexandria, VA and Washington, DC; Press Release; 9/4/25A new national poll by Fabrizio Ward, commissioned by the National Alliance for Care at Home (the Alliance), finds that seven in ten Americans oppose the Centers for Medicare & Medicaid Services’ (CMS) 2026 Medicare home health proposed rule, which would slash Medicare home health funding by an additional 9%, or $1.1 billion, next year. These cuts would put lifesaving home health care for millions of Americans at risk, particularly seniors and those with disabilities, while doing nothing to address fraud, waste, and abuse occurring in the home health payment system.  

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.

Governor creates new LTC oversight board, pledges to fill surveyor openings by year’s end McKnights Long-Term Care News; by Jessica R. Towhey; 8/12/25 A new politically appointed Nursing Home Oversight and Accountability Advisory Board is being proposed as a way to strengthen facility oversight in a state that has a 42% vacancy rate among its public inspectors. Gov. Glenn Youngkin (R) called for the board, which will consist of members appointed by the state Secretary of Health, in an executive order issued Monday. Both LeadingAge Virginia and the Virginia Health Care Association / Virginia Center for Assisted Living applauded the overall goals of the executive order but cautioned that resources to implement the directives are needed. Guest Editor's Note, Judi Lund Person: The Virginia governor, Glenn Youngkin, has taken steps to address surveyor vacancies and strengthen oversight for nursing homes in the state, calling on partnerships with other states for training. Advocates cited the state, as in many other states, is hampered by flatline funding from federal partners and the lack of clinical staff willing to fill surveyor roles.  

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. 

Aveanna SVP: Hospice providers fed up with fraud Hospice News; by JIm Parker; 7/29/25 Issues surrounding Medicare fraud are “top of mind” for hospice providers, according to Jim Melancon, senior vice president of government affairs at Aveanna Healthcare Holdings (Nasdaq: AVAH). Reports of hospice fraud have proliferated in recent years, particularly in the four hotbed states of California, Arizona, Nevada and Texas. Fraudulent operators have used a slew of illegal or unethical tactics, such as enrolling Medicare beneficiaries in hospice care without their knowledge or without providing services. ... One principal tactic among fraudulent hospices is maintaining multiple provider numbers, hospice leaders told Hospice News on background. This enables perpetrators of fraud to move patients between the various hospices they own. Another common practice is transferring patients who have reached the payment cap to avoid recoupment.

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.]