Literature Review

Kickbacks and medically unnecessary treatments: Five major qui tam settlements from May 2024 JD Supra; by Geoff Schweller; 6/5/24 Under the FCA’s qui tam provisions, a crucial tool in combating healthcare fraud, whistleblowers have the power to file suits on behalf of the federal government if they possess the knowledge of an individual or company defrauding the government. The government may choose to intervene and take over the suit, but if a qui tam lawsuit results in a successful settlement, the whistleblower is eligible to receive between 15-30% of the monies collected. The settlements announced in May cover a wide range of alleged misconduct that violates the FCA, including cases concerning kickbacks and the billing of federal healthcare programs for medically unnecessary treatments. Each settlement represents a victory in the ongoing battle against fraud. ... [Non-hospice examples followed by this hospice case] $4.2 Million Settlement with Elara Claring for Allegedly Billing Medicare for Ineligible Hospice Patients ...

Leading healthcare transformation: Strategic growth through generative AI Forbes; by Ashu Goel; 6/5/24 When ChatGPT was launched in November 2022, most of us experienced a “wow” moment. Its capabilities seemed magical. Generative AI (GenAI), led by ChatGPT, has taken the industry by storm, emerging as one of the most disruptive technologies of our era. Given the widespread discussion around GenAI, it's clear that its impact is profound and far-reaching. Yet, adopting generative AI has been a significant challenge for many organizations. Gartner's insight highlights this struggle, predicting that at least 30% of generative AI projects will be abandoned throughout the next year due to issues like poor data quality and unclear business value. This prediction alone paints a picture of the adoption hurdles. ... Editor's Note: This is not not a black and white right-wrong, good-bad conflict. Notice in numerous articles we post the valid concerns expressed by hospice and palliative clinical professionals. Practical, effective implementation must reconcile these differences.

NAHC President Bill Dombi reflects on tenure: We Went ‘To War’ on behalf of our providers Home Health News; by Joyce Famakinwa; 6/4/24 For more than 40 years, William A. Dombi has been one of home-based care’s fiercest advocates. He became the National Association for Home Care & Hospice’s (NAHC) vice president for law in 1987, and has been a key player in many of the advancements and milestones that have moved the industry forward. Those include the growth of the home health benefit under Medicare, the implementation of the home health prospective payment system in 2000 and much, much more. ... Home Health Care News recently caught up with Dombi to look back at his time at NAHC, and on what he believes to be the biggest accomplishments during his tenure.

Declared dead at nursing home, 74-year-old was alive at funeral home 2 hours laterNBC News; by Dennis Romero; 6/3/24A 74-year-old woman declared dead at a nursing home was found alive two hours later by funeral home employees attending to what they believed were her remains, a Nebraska sheriff's official said. The employees of the Lincoln funeral home called 911, and the woman was taken to a hospital alive, where she remained Monday, Lancaster County Chief Sheriff’s Deputy Ben Houchin said at a news conference. "At this point, we have not been able to find any criminal intent by the nursing home, but the investigation is ongoing," he said.

Man killed elderly parents, partner and himself in murder-suicide at SW Miami-Dade home NBC 6 South Florida; by Laura Rodriguez; 6/3/24A man shot and killed his elderly parents and partner before turning the gun on himself in a murder-suicide at a home in southwest Miami-Dade Sunday, police and family members said. According to police, [Jesus] Regueira [Jr.] shot and killed his parents, 83-year-old Jesus Regueira Sr. and 84-year-old Mercedes Morato, 61-year-old Kyrsten Stahre, who police identified as his girlfriend but family members said was his wife, before turning the gun on himself. ... The bodies were first discovered by family friend Joanna Cruz, whose mother was bringing food to Morato, who was under hospice care. ... “I think the problem was his mom had a severe stroke and she was in hospice and his mom was his life. Because someone had said that he wasn’t handling it well. The mom was there, but she had hospice coming in. His mom was his favorite person in the world. I don't know about the dad but I just know that’s probably what happened," Carol Miloch said. Editor's Note: Workplace violence in healthcare settings continues to rise, and to be a leading cause for nurse unionization and strikes.

3 keys to hospice oversight preparation Hospice News; by Jack Silverstein; 6/4/24 When hospice providers are being investigated not just by CMS but the FBI, the stakes for compliance are higher than ever. In May of 2024, the federal law enforcement agency placed its spotlight on the rising number of complaints about hospice fraud, in which hospices participate in signing up seniors for care without the seniors’ knowledge. Integrity concerns are in four states: Arizona, California, Nevada and Texas. The mechanics vary but the end result is the same: hospices getting paid for services they either did not provide, provided at a substandard level or had no authority to provide at all. ...

61% of US adults will have cardiovascular disease by 2050, American Heart Association saysBecker's Hospital Review; by Ashleigh Hollowell; 6/4/24A majority of adults in the U.S. — around 61% — are likely to be diagnosed with a form of cardiovascular disease by 2050, according to new American Heart Association data. The increased burden will cost the U.S. health system $1.8 trillion in the time frame. Stroke is anticipated to see the largest increase in prevalence by 2050, according to a June 4 news release from the organization. Projections outlined in AHA data from two reports published in its flagship journal say stroke rates are likely to grow from 3.9% to 6.4%, affecting the health of 20 million adults. Cardiovascular disease, including stroke, is expected to go from affecting 28 million adults to 45 million adults.Publisher's Note: Hospice implications?

Proposed HOPE tool seeks to fill hospice data gaps but needs tweaking, experts sayMcKnight's Home Care; by Adam Healy; 6/3/24Although the proposed Hospice Outcome and Patient Evaluation (HOPE) tool intends to close important data gaps surrounding end-of-life care, there is more work to be done to improve hospice quality reporting. “So much more information needs to be gathered from these patients,” Katy Barnett, director of home care and hospice operations and policy at LeadingAge, the association of nonprofit aging services providers, which include hospices, told McKnight’s Home Care Daily Pulse in an interview. “It’s just not there in the tool right now.”

SCAN wins Medicare Advantage star ratings lawsuit against CMSModern Healthcare; by Nona Tepper; 6/4/24SCAN Health Plan has prevailed in a widely watched federal lawsuit brought last year against the Centers for Medicare and Medicaid Services that alleged regulators did not appropriately calculate the insurer's Medicare Advantage star rating. The decision could have industrywide implications for the star ratings program if regulators decide to recalculate all carriers’ star scores for the 2024 plan year. The ruling could also affect several pending cases filed by other insurers against CMS. It also could be appealed.

Behavioral health patients a challenge to nursing homesModern Healthcare; by Diane Eastabrook; 6/4/24Challenges providing care for nursing home patients with mental health and behavioral health issues are adding to discharge bottlenecks for hospitals, and the demand for such care has led some facilities to set up specialized units with additional staff just for those patients.Publisher's Note: Hospice implications?

Reap what you sowFraud of the Day; by Larry Benson; 6/4/24Newly released Federal Trade Commission data show that consumers reported losing more than $10 billion to fraud in 2023, marking the first time that fraud losses have reached that benchmark. This marks a 14% increase over reported losses in 2022. The short of this report is that there is more opportunity in fraud than ever before. And fraudsters don’t care who they are scheming from. Including the dying. Shiva Akula owned and oversaw the day-to-day operations of Canon Healthcare, LLC, a hospice facility with offices in Louisiana and Mississippi. ... Between January 2013 and December 2019, Akula billed Medicare approximately $84 million in fraudulent claims. He was paid approximately $42 million relating to these fraudulent claims. And leaving the dying to just do that. Die without the extra care he profited from. ... [Akula was sentenced to serve 20 years in prison and to repay $42 million in fraudulent Medicare billing claims.]

Joel Mekler - Medicare Moments: Watch out for these latest scams New Castle News; by Joel Mekler; 6/3/24 ... Across the country, many unscrupulous hospice providers are recruiting and enrolling nonterminally ill patients for end-of-life care they do not need and then billing Medicare for services and items they may never receive. They trick beneficiaries into signing up for hospice by offering freebies, such as additional groceries, nurse visits, durable medical equipment, bus coupons, and more once they enroll. They also make false claims, such as saying “Medicare now covers cooking and cleaning services”. Or they tell beneficiaries they qualify due to age, saying “You’re now old enough to qualify for hospice!” Another tactic is giving money, with some recruiters telling beneficiaries, “You can earn $400/month if you agree to enroll in our program.” ... Tips [to consumers] to avoid hospice fraud: