Literature Review

New red flags emerge in hospice UPIC auditing Hospice News; by Holly Vossel; 9/20/24 Unified Program Integrity Contractor (UPIC) auditors are taking a sharper look at nursing home room-and-board for hospice patients. Hospices have increasingly faced more regulatory scrutiny in recent years amid rising program integrity concerns, including ramped up UPIC audits, among various others. These audits are designed to instill oversight measures aimed at safeguarding against bad actors in the hospice industry. Regulators have been zeroing in around hospices’ data when it comes to patient interviews and Medicaid skilled nursing room-and-board payments, among other aspects of care delivery. These data could give UPIC auditors clues as to potential malfeasance. However, auditors’ data extrapolation methodology is flawed and poses risks for quality hospice providers, according to Bryan Nowicki, partner at the law firm Husch Blackwell.

How palliative care-ACO partnerships could reduce health disparities Hospice News; by Holly Vossel; 9/18/24 Palliative care providers engaging in Accountable Care Organization (ACO) relationships have the potential to make significant strides in bridging inequitable gaps of access. Groups of physicians, hospitals and other health care providers voluntarily join forces in ACOs, which are designed to offer high-quality, coordinated care to Medicare patients. Collaborating or contracting with ACO networks can help palliative care providers better understand and address the leading barriers among underserved populations as they move across the continuum, said Empath Health CEO Jonathan Fleece. The ACO reimbursement landscape includes incentives and quality measures designed to improve outcomes based on population needs. Providing palliative care through ACO relationships can result in greater potential to address patients’ full scope of medical, non-medical and psychosocial needs further upstream in their illness trajectories, Fleece stated, speaking at the recent Hospice News Palliative Care Virtual Summit.

CMS updates guidance for rural emergency hospitals: 16 things to know Becker's Hospital CFO Report; by Alan Condon; 9/17/24 CMS has updated guidance for hospitals interested in converting to a rural emergency hospital, a Medicare designation that was made available Jan. 1, 2023. REHs are a provider type established by the Consolidated Appropriations Act, 2021, to address concerns over rural hospital closures and provide rural facilities a potential alternative to closure.  Since 2005, 106 rural hospitals have shut down, with another 86 facilities no longer providing inpatient services, according to data compiled by the University of North Carolina's Cecil G. Sheps Center for Health Services Research. Of those, 37 closures have occurred since 2020. Here are 16 things to know about REHs, including designation requirements, qualifying facilities, conditions of participation and how many hospitals have converted to REHs.  

CMS submits 75,000 pages to federal court to justify nursing home staffing mandate McKnights Long-Term Care News; by Kimberly Marselas; 9/15/24 The Department of Health and Human Services filed more than 75,000 pages of rule-making records with a federal court Friday, beginning its formal defense of its controversial nursing home staffing mandate. The submission of the administrative record is the first significant advance in the case since the American Health Care Association brought its challenge to the minimum staffing standard in late May. The Texas Health Care Association, three Texas providers and LeadingAge are also part of the case. In another development, District Court for the Northern District of Texas Judge Matthew Kacsmaryk on Sept. 10 agreed to fold in a separate federal challenge against the staffing mandate filed by the state of Texas. He noted that the two cases “share common questions of law or fact, consist of similar parties, the same claims, and [have] the same relief sought.”

Phoenix Home Care and Hospice shares Medicare Mondays on Silver Notes NBC KSNF-16,  Joplin, MO; byWendi Douglas; 9/12/24 News segment for community education about Medicare for seniors, provided by a local hospice nurse.

CMS teases new cybersecurity policies for third-party vendors Modern Healthcare; by Bridget Early; 9/13/24 The Centers for Medicare and Medicaid Services is planning oversight of third-party healthcare vendors in the wake of the Change Healthcare cyberattack, said Jonathan Blum, the agency's principal deputy administrator. Blum, who also serves as chief operating officer for CMS, said at Modern Healthcare's Leadership Symposium Thursday that the agency is working to determine what levers it can pull to ensure severe disruptions in care like those linked to the cyberattack on the UnitedHealth Group subsidiary aren’t repeated. ... Almost 133 million individuals were affected by healthcare data breaches last year, more than double the number of those affected in 2022 and a number equivalent to about 40% of the U.S. population.

Medicare Advantage bonus payments decline for first time since 2015Becker's Payer Issues; by Rylee Wilson; 9/11/24Bonus payments to Medicare Advantage plans will decline by around 8% in 2024 compared to 2023, according to a report from KFF. The analysis, published Sept. 11, found bonus payments to MA plans will decline by around $1 billion to $11.8 billion in 2024. Although this was the first decline since 2015, the $11.8 billion in payments will still exceed amounts for every year from 2015 to 2022. The number of bonus payments will decline because of temporary policies in place during the COVID-19 pandemic increased star ratings for some plans, according to KFF. When the policies ended, some plans took a hit in bonus payments. CMS pays Medicare Advantage plans bonus payments for achieving a star rating of four or higher.

Hospitals target Medicare Advantage in DSH payment lawsuitModern Healthcare; by Alex Kacik; 9/11/24Hospitals allege in a new lawsuit that the federal government unlawfully changed Medicare disproportionate share hospital payment calculations to include care provided to Medicare Advantage patients, and facilities lost billions of dollars in the process. Eighty hospitals on Monday sued the Health and Human Services Department over how the agency factors inpatient care for Medicare Advantage patients into DSH payments, which are meant to bolster providers that treat many low-income patients. Hospitals from states including California, Ohio, Pennsylvania and Texas allege HHS violated the Administrative Procedure Act by not following the typical rulemaking process when it finalized a rule in June 2023 on how Medicare Advantage influences DSH calculations.

Medicare administrative contractor news includes a data breach and potential consolidation HFMA, Downers Grove, IL; by Nick Hut; 9/9/24 Recent happenings involving Medicare administrative contractors (MACs) include a notice of a data breach and a request for feedback on possible consolidation. CMS sent out word that nearly 950,000 Medicare beneficiaries whose claims go through Wisconsin Physicians Service Insurance Corporation (WPS) are being informed that their protected health information or other personally identifiable information may have been compromised due to a security vulnerability in third-party software. The breach also could have affected those with other insurance if their information was collected to support CMS’s audits of healthcare providers, according to a news release. Belying its name, WPS handles Medicare Parts A and B claims spanning Indiana, Iowa, Kansas, Michigan, Missouri and Nebraska (not Wisconsin). 

CMS to expand ‘enhanced oversight’ to combat hospice fraud in 4 states Hospice News; by Jim Parker; 9/10/24 The U.S. Centers for Medicare & Medicaid Services (CMS) is expanding its enhanced oversight for new hospices in fraud-ridden states, including California, Nevada, Arizona and Texas. The agency in July 2023 first announced a “provisional period of enhanced oversight” for new hospices in those states. A key component of the enhanced oversight includes a medical review of claims before a Medicare Administrative Contractor (MAC) will pay them. “To combat fraud, waste, and abuse under the hospice benefit, CMS will expand prepayment medical review this September in Arizona, California, Nevada and Texas,” the agency indicated in a statement. “To help reduce burden on compliant providers, initial review volumes will be low and adjusted based on results. If you’re noncompliant, we may implement extended review or take additional administrative actions.” 

Norfolk woman celebrates 106th birthday after hospice discharge for being too healthy CBS WTKR 3, Norfolk, VA; by Vashti Moore; 9/6/24 A local woman not only celebrated good health on Thursday, but she also celebrated 106 years of life. Dorothy Southall was born in Whaleyville — a small neighborhood in Suffolk on Sept. 5, 1918. That’s two years before women received the right to vote and two months before the end of World War I. ... During the Civil Rights Movement, Dorothy worked as a licensed practical nurse at Bellevue Hospital Center in New York. She served her community as a healthcare worker for 20 years before moving back to Virginia in the late 1980s where she would live on her own and manage her own finances until she was 103. ... In August 2023, while living with her family, Dorothy was discharged from hospice because she deemed too healthy and no longer met the requirements. When admitted into residential care this summer in Norfolk, Dorothy said she “felt like she was home” when she arrived.

22 health systems dropping Medicare Advantage plans | 2024Becker's Hospital CFO Report; by Jakob Emerson; 9/4/24Medicare Advantage provides health coverage to more than half of the nation's older adults, but some hospitals and health systems are opting to end their contracts with MA plans over administrative challenges. Among the most commonly cited reasons are excessive prior authorization denial rates and slow payments from insurers. [See article for list of 22 health systems dropping Medicare Advantage plans - including KS, ME, SD, NE, NV, MI, MN, OH, NY, IN, OK, TX, PA, DE, NC, OR, MO, KY, and CA.]

Humana to depart 13 Medicare Advantage markets Modern Healthcare; by Lauren Berryman; 9/4/24 Humana previewed its Medicare Advantage strategy for the coming plan year, including a decision to quit 13 counties where performance has been unsatisfactory, at the Wells Fargo Healthcare Conference on Wednesday. The Medicare Advantage heavyweight, which had 6.2 million members in those plans as of the second quarter, expects to lose a few hundred thousand enrollees in 2025 as it prioritizes profitable markets, Chief Financial Officer Susan Diamond told investors at the event in Everett, Massachusetts. In addition to leaving those 13 counties, Humana will offer fewer plans in some other areas, Diamond said. About 560,000 members will have to choose new policies for 2025, most of whom will have other Humana plans available to them, she said. ... Diamond did not specify what markets will be affected, but Humana will continue selling Medicare Advantage plans in every state. The company is committed to a presence in certain favorable regions, including south Florida, she said.