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. 

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. ...

Humana borrows UnitedHealth’s Medicare Advantage playbookModern Healthcare; by Nona Tepper; 8/25/25Humana's stock price is up 16.5% so far this year, a notable contrast to the [11.6%] declines the larger Medicare Advantage sector and industry leader UnitedHealth Group report. Humana's secret to success is its transparency into its focused business, experts say.

HHS launches committee to shape Medicare, MedicaidBecker's Payer Issues; by Andrew Cass; 8/22/25HHS and CMS are establishing a panel of experts tasked with providing recommendations on how to “improve how care is financed and delivered” across Medicare, Medicaid, the Children’s Health Insurance Program and the ACA’s exchanges... “This committee will help us cut waste, reduce paperwork, expand preventive care, and modernize CMS programs with real-time data and accountability, all while keeping patients at the center,” Dr. Oz said in the release.Publisher's note: Click here for additional information or to apply to particiate on this Technical Expert Panel.

Navigating the Wage Index: Insights from industry experts Teleios Collaborative Network (TCN); podcast by Chris Comeaux with Annette Kiser and Judi Lund Person; 8/20/25 The healthcare landscape is transforming before our eyes, shifting away from hospital-centered care toward home-based models.  This fundamental change raises urgent questions about Medicare's outdated reimbursement systems, particularly for Hospice providers facing a mere 2.6% rate increase while battling significant inflation. Join us in this illuminating conversation and in-depth discussion with industry experts Annette Kiser, Chief Compliance Officer with Teleios, and Judi Lund Person, Principal, Lund Person & Associates LLC, as they sit down with Chris and explore the complexities of the final 2026 Hospice Wage Index and its impact on Hospice organizations.

The Medicare Advantage, ACA and No Surprises Act lawsuits to watch Modern Healthcare; by Bridget Early; 8/18/25 Legal challenges to Medicare Advantage marketing, health insurance exchange regulations and the No Surprises Act are working their way through the courts with major implications for the healthcare sector. Here are some key cases that could change how health insurance companies sell Medicare plans, how insurers and providers resolve out-of-network billing disputes, how consumers sign up for health insurance exchange plans, and how preventive healthcare is covered. 

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. 

HHS sets its sights on $50b in cost savings: Medicare payments to nonhospice providers potentially under fire JD Supra; by Taylor Henderson, Callan Stein, Rebecca Younker; 7/31/25 In May 2025, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) published a review, titled " Potential Cost Savings HHS Programs – HHS Actions," which provided some insight into the OIG's direction to accomplish the Trump administration's stated goal of cutting federal spending. This review spans 35 reports, adding up to $50 billion in potential cost savings — including a reported $6.6 billion in potential savings by preventing Medicare payments for nonhospice items or services furnished to active hospice beneficiaries (nonhospice payments). When a beneficiary qualifies for and elects hospice benefits, the beneficiary signs a statement choosing hospice care over other Medicare-covered treatments for their terminal illness, and the hospice provider is paid a daily, per diem rate to provide these comprehensive services. With nonhospice payments accounting for a significant portion of HHS's potential savings, providers across the health care industry — including nursing and long-term care facilities, hospice and home health agencies, hospitals, individual providers, pharmacies, and medical equipment distributors — will need to be ready for the OIG's possible next steps.

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. 

Hospice | CMS.gov/Fraud Fast FactsCMS.gov/Fraud; by CMS; July 2025 ... Medicare hospice utilization has increased in recent years. In Fiscal Year 2024, Medicare payments for hospice reached over $27 billion, with approximately 1.8 million Medicare beneficiaries receiving hospice care. CMS has taken significant action to address likely fraudulent behavior occurring in Medicare-enrolled hospices, including long lengths of stay, co-located hospices, and high rates of beneficiaries discharged alive. [This Fast Facts one-page sheet includes:]