Literature Review

Owner of defunct Skyline chain pleads guilty in $39M fraud caseMcKnight's Long-Term Care News, by Kimberly Marselas; 1/18/24Joseph Schwartz, former owner of Skyline Management and a 90-plus nursing home empire whose collapse sent patients and workers scrambling in 2018, pleaded guilty Wednesday to his role in a $39 million fraud scheme.

OIG report has clues for 2024 healthcare fraud enforcementLAW360, by Mackenzie Wortley, Elizabeth Nevins and Megan Miller; 1/16/24In late 2023, the U.S. Department of Health and Human Services and the U.S. Department of Justice released the Health Care Fraud and Abuse Control Program Annual Report for fiscal year 2022, highlighting continued enforcement and recovery actions under the program.

Acute hospital care at home data release fact sheetCMS.gov, Newsroom; 1/16/24A public release of the data submitted to CMS as part of the Acute Hospital Care at Home initiative will be available beginning on January 16, 2024. CMS plans to release data through the Research and Data Assistance Center (ResDAC), collected from November 27, 2020, through March 30, 2023.

CMS terminates 2 Centene Medicare Advantage plansModern Healthcare, by Nona Tepper; 1/8/24A pair of Centene Medicare Advantage plans must suspend enrollment and marketing because of poor star ratings, the Centers for Medicare and Medicaid Services notified the company.

Nurse pleads guilty to federal charge for stealing pain medications at Baxter clinicBrainerd Dispatch; 1/9/24A registered nurse pleaded guilty to fraudulently obtaining prescription opioid pain medications from a hospice clinic, United States Attorney Andrew M. Luger announced Tuesday, Jan. 9. ... Cambie Elizabeth Broker, 33, was a registered nurse case manager at a hospice clinic in Baxter. Broker used her position to fraudulently obtain controlled substances from the clinic. Broker entered false prescription requests into the clinic’s e-prescribing software to fraudulently obtain oxycodone, hydromorphone, and fentanyl for illegal sale and personal use. 

Home healthcare company agrees to pay nearly $10 million to resolve false claims act allegations relating to its participation in the energy employees occupational illness compensation programOffice of Public Affairs; 1/5/24Atlantic Home Health Care LLC (AHH), a home health care agency operating in Arizona and eight other states, has agreed to pay $9,990,944 to resolve allegations that it violated the False Claims Act by submitting false claims to the Energy Employees Occupational Illness Compensation Program (EEOICP or the Energy Program), a healthcare program administered by the Department of Labor (DOL) for the benefit of Department of Energy employees and contractors with occupational illnesses.

Evaluation of Phase II of the Medicare Advantage Value-Based Insurance Design Model Test: First three years of implementation (2020–2022)CMS Report; 12/29/23Year Two Evaluation Report - Key Takeaways: The Medicare Advantage (MA) Value-Based Insurance Design (VBID) model test enables MA insurers to offer one or more innovative benefit design options in eligible MA plans. The model aims to encourage the use of high-value care and promote healthy behavior, with goals of enhancing care quality, improving beneficiary health, and reducing spending. Most VBID benefits can be targeted based on beneficiaries’ chronic conditions or socioeconomic status (SES). A separate Hospice Benefit component is also included in the model. 

The 10 biggest Medicare Advantage stories in 2023Becker's Payer Issues, by Rylee Wilson; 12/21/232023 was an eventful year for Medicare Advantage. As the program continued to grow, with enrollment surpassing 30 million in 2023, some hospitals are beginning to push back on private Medicare plans. CMS also introduced new rates and regulations in 2023 that are taking effect in 2024. Here are 10 of the biggest Medicare Advantage stories Becker's reported in 2024...

Unlicensed Saratoga County nursing home operator to pay $650,000Times Union (Albany, NY)December 21, 2023Ballston Spa, NY—The unlicensed operator of a now shuttered Saratoga County nursing home is set to repay Medicaid $656,000 after an investigation by the state attorney general’s office and U.S. attorney for the Northern District of New York found years’ worth of fraud and resident neglect at the facility. 

Steward Health Care hit with False Claims Act lawsuitHealthcare DiveDecember 20, 2023The federal government is suing Dallas-based Steward Health Care and its facilities, Steward Medical Group and Boston-based St. Elizabeth’s Medical Center, for violating the False Claims Act and a physician self-referral law, according to a Monday announcement. The complaint, filed in Massachusetts District Court, alleges Steward Medical Group improperly linked a lead cardiologist’s compensation with his referrals, leading the group to award him nearly $5 million in incentive-based pay—and violating physician self-referral rules, known as the Stark Law. 

The Backbone of Better Care: Compliance in Home-Based HealthcareBy Jennifer Kennedy, 12/15/23In the realm of home-based healthcare, the distinction between good and great care is often defined by the role of compliance. This invisible backbone extends beyond immediate healthcare services, forming a critical framework that upholds every action and procedure to the highest standards of legal and ethical conduct.

NAHC President Bill Dombi—History Repeating Itself on Hospice Program IntegrityHospice NewsDecember 14, 2023Issues of fraud in the hospice industry echo events that previously affected the home health space, and providers can learn from that prior experience. This is according to Bill Dombi, president of the National Association for Home Care and Hospice, who spoke Thursday in a Relias webinar. ... “What I’m seeing is history repeating itself. Back in the 1990s, the microscope ended up focusing on the Medicare Home Health Program.