Literature Review

Killing of UnitedHealthcare CEO brings resentment of the health care system to the fore STAT Business, Boston, MA; by Bob Herman and Tara Bell; 12/6/24 The targeted killing of UnitedHealthcare CEO Brian Thompson has become a defining moment in the zeitgeist of American health care. The attack was a tragedy that adds to the country’s grim tally of gun deaths. But instead of eliciting sympathy, it opened the floodgates for an outpouring of rage, captured across social media and online forums, over the health care system — one that charges people the highest prices in the world, erects financial and bureaucratic barriers to getting care, and has plunged millions of people into debt. Social media posts have ranged from mournful to apathetic to joyful, including morbid celebrations of Thompson’s death. That deluge has forced people across the country to grapple with two heavy subjects at once: the callousness of a slaying, and an undercurrent of deep-seated anger at a health care industry that makes a lot of money by exploiting Americans. ... [Click on the title's link to continue reading.]

HHS OIG's Fall 2024 Semiannual Report to CongressU.S. Department of Health and Human Services [HHS] - Office of Inspector General [OIG]; by OIG; issued on 12/4/24, posted on 12/4/24 The Fall 2024 Semiannual Report to Congress highlights OIG's work focusing on the most significant and high-risk issues in health care and human services related to HHS programs and operations during the semiannual reporting period of April 1 through September 30, 2024. The semiannual reports are intended to keep the HHS Secretary and Congress informed of OIG’s crucial findings and recommendations.  ...

Hospice Oversight: 2024’s most impactful regulatory action Hospice News; by Jim Parker; 11/27/24 The past year has seen a slew of regulatory developments aimed at improving quality and combatting fraud in the hospice industry. The drive by regulators and members of Congress to strengthen oversight is fueled by two main factors. The first was two July 2019 reports on hospice quality from the Office of the Inspector General (OIG) in the U.S. Department of Health and Human Services (HHS). These spurred passage of the Helping Our Senior Population in Comfort Environments (HOSPICE) Act, which mandated the establishment of a hospice Special Focus Program (SFP), among other actions. The second driving force was the emergence of fraudulent actors in the space in relatively large numbers, particularly concentrated in California, Nevada, Arizona and Texas. [Click on the title's link to continue reading this important information.]

Seven of thirty hospices reviewed did not comply or may not have complied with terms and conditions and federal requirements for Provider Relief Fund payments HHS Office of Inspector General; issued on 11/8/24, posted on 11/14/24Why OIG Did This Audit: The Provider Relief Fund (PRF), a $178 billion program, provided funds to eligible providers for health care-related expenses or lost revenue attributable to COVID-19. ... This audit is part of a series reviewing PRF payments to various provider types. Specifically, this audit assessed whether 30 selected hospices expended taxpayer funds in accordance with Federal and program requirements. ... What OIG Found: ... Of the 30 selected hospices, 23 hospices used PRF funds for allowable expenditures and lost revenues attributable to COVID-19; however, 7 hospices did not comply with or may not have complied with Federal requirements. Of these seven hospices, which received $98.1 million in PRF payments, six hospices claimed a total of $8.3 million of unallowable PRF expenditures and inaccurately reported $1.5 million of lost revenues, and one hospice claimed $4 million in expenditures that may not have been allowable. ... What OIG Recommends: We made two recommendations to HRSA, including that it require the selected hospices to return any unallowable expenditures to the Federal Government or ensure that the hospices properly account for these expenditures. ...

CMS to surveyors: Keep eyes open for hospice fraud Hospice News; by Jim Parker; 11/14/24 The U.S. Centers for Medicare & Medicaid Services (CMS) has issued a memo to accreditation bodies and state agencies advising surveyors to watch out for potential hospice fraud. The memo directs surveyors to refer issues to CMS if they suspect fraudulent activity. These actions were spurred by a rash of fraudulent hospices that have emerged primarily in California, Texas, Nevada and Arizona. “While the primary purpose of [state agencies and accreditation organization] surveys is to determine compliance with the Medicare Hospice CoPs, there are several elements of the survey process that can uncover concerns that would necessitate a referral to CMS for potential fraud,” CMS indicated in the memo. 

Quality hospice researchers seek to untangle possible relationships between tax status and outcomes Hospice News; by Holly Vossel; 11/8/24 ... More private equity (PE) investors have stepped into the hospice and home health space in recent years. This trend extends across the broader health care continuum, as certain types of owners — notably private equity entities — have come under scrutiny from lawmakers. Providers’ tax status may be among the potential risk factors of fraudulent hospice spending. For-profit business and operational infrastructures can differ from nonprofit hospices, which have historically represented much of the providers in the industry. But research has found that the tide is shifting. Private equity transactions represented half of all home health and hospice deals in 2018 and 2019, resulting in a 300% increase in patients enrolled under PE-backed providers, according to research published in the Journal of Palliative Medicine. ... Live discharges occur in less than 10% of patients at nonprofit hospices, study author Lauren Hunt indicated. This compared to an overall 20% of live discharge rates among patients of for-profit hospices. 

Reps. Van Duyne, Panetta introduce bill to reform hospice Special Focus Program Hospice News; by Jim Parker; 11/6/24 Reps. Beth Van Duyne (R-Texas) and Jimmy Panetta (D-California) have introduced a bill that would reform aspects of the hospice Special Focus Program (SFP). If enacted, the Enhancing Hospice Oversight and Transparency Act also would increase the penalty for hospices that do not report quality measure data to 10% by 2027, up from 4% currently. The SFP has the authority to impose enforcement remedies against hospices with poor performance based on its algorithm. Hospices flagged by the SFP also will be surveyed every six months rather than the current three-year cycle and could face monetary penalties or expulsion from the Medicare program. 

How today’s hospice fraud could warp tomorrow’s reimbursement outlook Hospice News; by Holly Vossel; 10/28/24 This is the second of a two-part Hospice News series that explores how fraud, waste and abuse in the hospice space could create headwinds for the industry at large. Fraudsters misspend millions of Medicare dollars annually, though the actual hospice-specific amounts are difficult to determine, regulators previously told Hospice News. Industry stakeholders have questioned whether the malfeasance will stymie the U.S. Centers for Medicare & Medicaid Services’ (CMS) ability to justify future reimbursement rate increases, which many hospice providers already consider insufficient to support the full range of their interdisciplinary services in today’s economic climate.

3 strategies for hospice GIP compliance Hospice News; by Jim Parker; 10/21/24 Utilization of the general inpatient level of care (GIP) is frequently the subject of audits by Medicare Administrative Contractors (MACs), and avoiding or responding to that scrutiny requires strict compliance to a complex web of rules. Audits are becoming more frequent in the hospice space, and GIP is an increasing focus, including ​for the most common types — Supplemental Medical Review Contractor (SMRC) and Targeted Probe and Educate (TPE). In a survey earlier this year, more than half of hospice providers reported having undergone multiple types of audits within a six-month period. ... In addition to these routine MAC audits, the U.S. Department of Health and Human Services Office of the Inspector General (GIP) has been performing a national audit of GIP utilization, as well as an additional investigation into management of the associated payment cap. The inpatient cap limits the number of days of inpatient care for which Medicare will pay to 20% of a hospice’s total Medicare patient care days, according to OIG. If GIP billing exceeds that metric, the hospice must refund those payments to Medicare.

Hospice fraud casts lengthening shadow over future of industryHospice News; by Holly Vossel; 10/11/24Fraudulent operators in the hospice space have misspent millions of Medicare dollars in recent years. This problem has become so severe that it is one of the defining issues facing the hospice industry, with providers and other industry stakeholders expressing concern about significant impacts to future payment, access, sustainability and utilization. This is the first of a two-part Hospice News series that examines the financial and operational pressures weighing on the minds of hospice providers amid instances of fraud, waste and abuse occurring in the industry.Notable mentions: Patrick Harrison, Senator Elizabeth Warren, MedPAC, Lauren Hunt.

CMS memo hints at what hospices can expect under Special Focus ProgramMcKnight's Home Care; by Adam Healy; 10/8/24Hospices subjected to Special Focus Program (SFP) scrutiny will undergo frequent surveys, and noncompliant providers may face termination from the Medicare program, according to the Centers for Medicare & Medicaid Services. Under the SFP, hospices will receive surveys no less than every six months, and follow-ups may be needed, CMS said in a memo to state hospice survey agencies. Hospices that are found to have condition-level deficiencies will be required to complete appropriate enforcement remedies, which include suspension of payment, civil money penalties, directed plans of correction, directed in-service training or termination, according to CMS’ state operations manual. Hospices that have completed two SFP surveys within 18 months, have zero uncorrected condition-level deficiencies and zero pending immediate jeopardy or condition-level complaints may graduate from the SFP, CMS said. However, any hospice that does not comply with all of CMS’ requirements within the necessary timeframes may be considered for termination.

Hospice ‘license flipping’ still plagues sector, though regulations help Hospice News; by Jim Parker; 10/3/24  “Shady” brokers allegedly continue to facilitate “license flipping” among fraudulent hospices, though new regulations have started bearing down on the practice. Soon after obtaining them, or before regulators can act on alleged malfeasance, according to several industry sources who spoke with Hospice News. The practice appears to stem from a rash of newly licensed hospices that have emerged in California, Nevada, Texas and Arizona – states identified by federal watchdogs as hotspots for hospice fraud. Many of these sales involve certain brokers who move the licenses between owners. “There’s a lot of shady people out there, and they put a high value on their agencies. Right now they’re selling like hot tamales from anywhere between $300,000 to $500,000 per license,” one former hospice leader told Hospice News on condition of anonymity. “They’re all done through the same brokers and the same people.”  

SNF, home health [and hospice] CEOs could be jailed over cybersecurity issues under new billMcKnight's Senior Living; by Kathleen Steele Gaivin; 9/30/24New legislation aimed at improving cybersecurity in healthcare could see leaders at skilled nursing facilities, home health agencies and hospices jailed if they lie about their cybersecurity precautions, according to one of its sponsors. Senate Finance Committee Chair Ron Wyden (D-OR) and Sen. Mark Warner (D-VA) announced the Health Infrastructure Security and Accountability Act on Thursday. The bill also covers other types of healthcare businesses. “The healthcare industry has some of the worst cybersecurity practices in the nation despite its critical importance to Americans’ well-being and privacy,” Wyden said. “These commonsense reforms, which include jail time for CEOs that lie to the government about their cybersecurity, will set a course to beef up cybersecurity among healthcare companies across the nation and stem the tide of cyberattacks that threaten to cripple the American healthcare system.”