Literature Review

The best, worst states for Medicare: ReportBecker's Payer Issues; by Elizabeth Casolo; 10/16/25Vermont, Utah and Minnesota topped the Commonwealth Fund’s Medicare performance scorecard in 2025, whereas Kentucky, Mississippi and Louisiana struggled the most. The healthcare research foundation evaluated states on criteria spanning four domains: access to care, quality of care, costs and affordability, and population health. These performance indicators draw from CMS, federal surveys and other public data sources. The Commonwealth Fund ranked states according to how well Medicare was working based on those indicators. The organization mostly reviewed data from 2023 through 2025.

Lancaster woman sentenced to home detention for role in hospice fraud MSN, Lancaster, CA; 10/16/25 A Lancaster woman was ordered Wednesday [10/15] to serve 12 months of home detention and pay a $100,000 fine for her role in a hospice fraud scheme that netted more than $3.2 million from Medicare. Callie Jean Black, 66, was convicted in March 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. 

The government shutdown’s impact on Medicare Advantage: As clear as mud? JD Supra; by Jeffrey Davis and Lynn Nonnemaker; 10/16/25 Over the last couple of weeks, stakeholders have raised many questions about how the government shutdown will affect different healthcare initiatives and programs, and Medicare Advantage (MA) is no exception. The Centers for Medicare & Medicaid Services (CMS) has provided guidance related to Medicare claims processing, telehealth services, and other operations, but most of that has pertained to Medicare fee-for-service (traditional Medicare). MA plans have been largely responsible for figuring out how the information applies to them. About half of Medicare beneficiaries are in MA, meaning more than 35 million Medicare beneficiaries and the providers who care for them rely on MA plans to communicate how benefits and coverage have, or have not, changed. As the shutdown drags on, CMS’s work to establish future MA policies and payment rates through rulemaking and notices also could be impeded. To discuss some of the ways that the shutdown has impacted MA and may continue to do so, I’m bringing in my colleague Lynn Nonnemaker. ...

Medicare aborts apparent plan to pause all physician payments during shutdown MedPageToday; by Shannon Firth; 10/16/25 Amid the federal government shutdown, the Centers for Medicare & Medicaid Services (CMS) on Wednesday appeared to announce a pause on all Medicare payments to doctors, but then quickly backed off. An initial notice stated that CMS had instructed all Medicare Administrative Contractors to temporarily hold "all claims paid under the Medicare Physician Fee Schedule, ground ambulance transport claims, and all Federally Qualified Health Center claims" with dates of service of Oct. 1 and later. ... But within hours, the agency issued another notice saying it would only stop processing claims related to expired programs such as certain telehealth and hospital-at-home services, both of which had been expected ahead of the shutdown.

The telehealth cliff has arrived: What’s changing and what to watch Healthcare Law Blog; by Sheppard Mullin Richter & Hampton LLP, co-author Joel Dankwa; 10/9/25On October 1st, certain key telehealth flexibilities created during the COVID-19 public health emergency (“PHE”) expired as the government shutdown began. The Centers for Medicare & Medicaid Services (“CMS”) issued a number of telehealth waivers during the PHE, some of which were extended through September 30, 2025 by the Full-Year Continuing Appropriations Act, 2025 (“CAA”). The flexibilities expired as legislative efforts to once again extend the flexibilities, including through the House Committee’s stop-gap government funding Continuing Resolution, failed to pass. The flexibilities that expired on October 1, after being extended by the CAA, are:

Winnetka man gets nearly 5 years for role in $16M Medicare fraud Los Angeles Daily News, Los Angeles, CA; by City News Service; 10/6/25 A San Fernando Valley man was sentenced Monday, Oct. 6, to four years and nine months behind bars for his role in conning Medicare out of nearly $16 million through sham hospice companies and then helping launder the illicit proceeds. Karpis Srapyan, 35, was also ordered to pay restitution of $3.2 million to Medicare, according to the U.S. Department of Justice. 

Busted: The top fraud schemes of Q2 2025 Cotiviti; by Erin Rutzler; 9/25/25As we move through 2025, the pace of fraud, waste, and abuse (FWA) schemes in healthcare show no signs of slowing. This past quarter brought cases involving unlicensed clinics, hospice kickbacks, insider deception, and prescription fraud totaling billions in false claims. Read our breakdown of 10 major healthcare FWA schemes from April through June 2025—and what they reveal about the evolving tactics of bad actors. ...

Serious falls resulting in hospitalization among Medicare-enrolled nursing home residents, July 2022–June 2023HHS Office of the Inspector General; Report number: OEI-05-24-0018; 9/18/25This OIG data snapshot accompanies the report, Nursing Homes Failed To Report 43 Percent of Falls With Major Injury and Hospitalization Among Their Medicare-Enrolled Residents, OEI-05-24-00180. The snapshot found that between July 1, 2022, and June 30, 2023, more than 42,000 Medicare-enrolled nursing home residents experienced serious falls resulting in major injury and hospitalization, and 1,911 died during their hospital stays. The data indicated that most residents had known fall risk factors prior to their injuries, and falls were more common among female, older, and short-stay residents. Nursing homes with lower nurse staffing levels and lower quality ratings had higher fall rates. These preventable events reduced residents’ quality of life and cost Medicare and enrollees over $800 million, underscoring the need for stronger fall prevention and quality improvement efforts in nursing homes. 

The Alliance expresses concerns regarding MACPAC approach to HCBS rate setting National Care at Home, Alexandria, VA and Washington, DC; Press Release; 9/18/25 The National Alliance for Care at Home (the Alliance) released the following statement in response to the Medicaid and CHIP Payment and Access Commission’s (MACPAC) discussion regarding home- and community-based services (HCBS) rate-setting held during today’s September MACPAC meeting. The Alliance appreciates MACPAC’s interest in addressing issues related to worker pay in HCBS. These workers should receive higher wages and benefits as they are the backbone of the long-term care system in our country. ... Unfortunately, we are concerned about the draft recommendation MACPAC discussed during today’s meeting. Rather than seeking to address the root-cause of low worker wages, MACPAC’s recommendation instead focuses on collecting additional information that would further describe the issue. This approach increases administrative burden on states and providers without actually proposing solutions to this problem.

Access to hospice and certain services under the hospice benefit for beneficiaries with end-stage renal disease or cancerMedPAC report; by Kim Neuman, Grace Oh, Nancy Ray; 9/5/25Summary: MedPAC explores policy and payment options for higher cost services that may be covered under the Medicare Hospice Benefit, such as dialysis, radiation, blood transfusions, and chemotherapy. Advantages and disadvantages / complexities of potential policy directions are outlined, including enhanced data reporting, hospice payment policy changes, and a voluntary transitional program.

Hospice Insights Podcast - Where’s the line: When does poor quality create false claims liability JDSupra; by Meg Pekarske and Jonathan Porter; 8/27/25 Substandard quality care is the subject of survey citations and lawsuits, but it has also been used by the Justice Department to support false claim liability. While historically these cases were rare, a recent multi-million dollar settlement puts “worthless services” on the radar. Join Husch Blackwell’s Meg Pekarske and Jonathan Porter as they explore what the “worthless services” theory of liability is, when it has been used, and whether the recent settlement could signal a resurgence of these types of cases. 

CMS updates AHEAD model: 6 things to know Becker's Hospital Review; by Alan Condon; 9/2/25 CMS on Sept. 2 unveiled policy and operational updates to the Achieving Healthcare Efficiency through Accountable Design Model, a state total cost of care initiative launched in 2023 to curb spending, improve population health and advance health equity. Six things to know: 

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.