Literature Review

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.

National Alliance CEO Dr. Steve Landers: Hospice reform should mean more care, not less Hospice News; by Jim Parker; 7/28/25 Hospice reform efforts should focus on allowing for “more care, not less,” according to National Alliance for Care at Home CEO Dr. Steve Landers. Key elements of this should include home-based respite care and a payment system for high-acuity palliative services that hospice patients often lose out on due to the costs. ... “It means innovation in care, home-based respite services, better payment models for people that need things like dialysis or palliative radiation,” Landers said at the Alliance’s Financial Summit in Chicago. “That is that reform we’re talking about.” ... Landers also said that attempts at hospice reform should not “carve-in” hospice into Medicare Advantage. Bringing hospice under Medicare Advantage would undermine patient choice, adversely impact timely access to care and leave providers with lower reimbursement rates, according to the Alliance, the National Partnership for Healthcare and Hospice Innovation (NPHI) and LeadingAge

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:]

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.  

Where UnitedHealthcare, Humana rule the Medicare Advantage market Modern Healthcare; by Tim Broderick; 7/22/25 Medicare Advantage competition was meager in 97% of counties last year, where beneficiaries could choose among just a handful of dominant insurers. The health policy research institution KFF analyzed Centers for Medicare and Medicaid Services data on the plans available across the U.S. and Puerto Rico in 2024. The findings indicate that Medicare enrollees have few options in most areas. Market share was “highly concentrated” in 79% of counties and “very highly concentrated” in another 18%, KFF found, using metrics similar to those the Federal Trade Commission and the Justice Department employ to measure competitiveness. ... Ninety-three percent of Medicare-eligible people lived in “highly concentrated” or “very highly concentrated” counties. ... [Click here and scroll down for the national map with] the level of Medicare Advantage market concentration for each county and the market share for each county's top insurer.

CMS plans hiring spree ahead of new payment models Becker's Hospital Review; by Alan Condon; 7/22/25 The CMS Innovation Center plans to hire a string of new employees as it plans to roll out several new payment models. The move comes four months after HHS, CMS’ parent department, cut about 5% of the agency’s workforce, Politico reported July 21. Four things to know:

How Compliance Management Systems help ensure business efficiency Enterprise Talk; by Apoorva Kasam; 7/22/25 With changing rules and regulations, businesses can’t afford to leave compliance to chance. A robust compliance management system (CMS) helps meet regulatory, legal, and internal policy requirements.

Rural hospitals eye service expansions to weather federal cuts Modern Healthcare; by Alex Kacik; 7/14/25 Rural hospitals are hopeful they can add rather than reduce services to help soften the blow from looming Medicaid and Medicare cuts. ...  If rural providers cannot recruit physicians, lean more heavily on philanthropic donors or find other ways to reduce their reliance on Medicaid and Medicare reimbursement to get ahead of cuts in the law, hospitals will be forced to pare back services or close their doors, industry observers said. ... In response, rural providers have accelerated ongoing operational adjustments, including renegotiating vendor contracts, beefing up their coding and billing processes, freezing new hires and standardizing daily tasks to reduce administrative waste. But those tweaks alone cannot sustain rural hospitals, so some providers are aiming to grow surgeries, infusions and other services to boost their bottom lines, executives said.

A look at nursing facility characteristics between 2015 and 2024 - KFF KFF; by Priya Chidambaram and Alice Burns; 12/6/24 In a KFF Issue Brief on nursing facility characteristics over time, KFF has described nursing homes and the people living in them. Data is pulled from Care Compare (Nursing Homes) and CASPER (Certification and Survey Provider Enhanced Reports). Data includes the number of certified nursing facilities, hours of care by nurse staff type over years, survey deficiencies in nursing homes, and the share of residents by primary payer. The study confirms that Medicaid is the primary payer for 63% of nursing facility residents in 2024, followed by 24% for private and other payers, and 13% by Medicare. As reported by KFF,  “KFF polling shows that four in ten adults overall incorrectly believe that Medicare is the primary source of insurance coverage for low-income people who need nursing facility care.” Guest Editor's Note, Judi Lund Person: As we think about the impact of Medicaid cuts on nursing home residents, it is important to note that Medicaid is the primary payer for 63% of nursing home residents as of 2024. In some states, that percentage may be higher. See the KFF article.

How PACE is jockeying for position amid Medicaid cuts Modern Healthcare; by Diane Eastabrook; 7/16/25 A federal-state program aimed at keeping older adults out of nursing homes could come out awinner under the new federal tax law. Nevada was the latest state to approve a Program of All-Inclusive Care for the Elderly last month before President Donald Trump signed the tax law. South Dakota is considering PACE as well. The program can save states money by caring for adults at home, rather than in nursing homes. However, PACE is a relatively small and not widely known initiative, which could make it a low priority for states weighing the best way to spend fewer Medicaid dollars.

HOPE Blog Part III – Navigating change with confidence Teleios Collaborative Network (TCN); by Melissa Colkins; 7/16/25 The HOPE tool arrives October 1, ready or not. While some teams will stumble through implementation, others will use this moment to demonstrate what effective change management actually looks like. The question isn't whether change is hard - it's whether your organization will emerge stronger because of how you handle it. Here's the reality: every meaningful change follows a predictable pattern. Teams don't just flip a switch and suddenly excel with new systems. They move through distinct phases - each with its own challenges and opportunities for growth. Understanding this journey is what separates organizations that merely survive change from those that leverage it for lasting improvement.

Tracking the Medicare Provisions in the 2025 Reconciliation Bill | KFF KFF; updated 7/8/25 Similar to the chart for Medicaid provisions in the 2025 Reconciliation Bill, KFF also provides details on the changes for Medicare. Topics include eligibility policies, physician payment, prescription drugs, rules for Pharmacy Benefit Managers (PBMs), nursing homes – including the prohibition of implementation, administration, or enforcement of the minimum staffing levels requirement until October 1, 2034, and funding for HHS to “contract with AI contractors and data scientists to identify and reduce Medicare improper payments and recoup overpayments.Guest Editor’s Note, Judi Lund Person: The chart of Medicare provisions confirms that implementation of the Medicare eligibility and enrollment final rule will be delayed until October 1, 2034, except for those provisions that have already taken effect. The Senate version enacted into law also has a temporary one-year increase of 2.5% in the Physician Fee Schedule conversion factor for all services furnished between January 1, 2026 and January 1, 2027 and a delay of the nursing home staffing final rule until October 1, 2034. It is helpful to have the chart in a usable form for reference on the final bill enacted into law.

DOJ & HHS announce reinvigoration of False Claims Act Working Group and Healthcare Fraud Enforcement Priorities Dorsey & Whitney LLP; Press Release; 7/9/25 The Department of Justice and the Department of Health and Human Services announced the reinvigoration of a False Claims Act (“FCA”) Working Group, a joint effort between the two agencies.  The announcement was made on July 2 during remarks at the American Health Law Association (“AHLA”) Annual Meeting by Brenna Jenny, the new Deputy Assistant Attorney General of DOJ’s Commercial Litigation Branch, and in a press release that same day. This working group underscores that healthcare fraud is a priority for the Administration, despite recent staff changes and recent policy announcements about enforcement priorities in civil rights and DEI. It also underscores that robust compliance programs should continue to be a priority for healthcare-industry stakeholders.