Patient Data Access

by Kristin Rowan | May 29, 2025 | Artificial Intelligence, Regulatory

by Kristin Rowan, Editor

Access to Patient Data

Tighter than Fort Knox

Access to patient data has always been tricky, even for the patient. Every doctor’s office, hospital, urgent care center, home health agency, and nursing facility uses their own system to house medical records. With concerns over HIPAA violations, that data is secured, sometimes in several ways simultaneously. A breach in that system could spell big trouble for the medical agency and the software company that provided it. Even in the age of electronic medical records, it is difficult to access those records without proof of identity, a signature in triplicate, and an oath punishable by death that you are allowed access to the information. (Okay, I may be exaggerating on that last one just a bit.)

3rd Party Access

Even more difficult than accessing patient data as the patient or the patient’s doctor or caregiver is accessing the data as a service provider:

Consultants who help agencies with operational efficiency, documentation, software implementation, etc.
QAPI advisors who help with reporting and training
Data analytics companies who interpret information and provide meaning behind numbers.

Who Owns the Data?

One of the big questions in these cases is who owns the data. Each party seems to claim some ownership. Medical agencies believe they own the data because the information doesn’t exist without inputing it during a patient visit. Electronic medical records claim ownership based on housing the information in the system they created, designed, and built. I, along with many others I assume, believe the data belongs to the patient. It is being used by the medical agency to perform services and housed by the software company much like a storage facility. But, the information should travel with the patient.

It's a Bot!

Skilled nursing facilities and other providers often hire data analytics companies to help assess their business. One such company, Real Time, provides data analytics services using facility and patient data. Real Time accesses this data using log-in credentials provided by the facilities. Due to the volume of data and the time it takes to sift through a robust EHR system, Real Time uses bots to comb through the system and download the necessary information.

Roadblock

This system works well for analytics companies and consultants to access more data quickly and provide faster, more thorough answers to their clients. The system doesn’t work well when the software housing the data enables CAPTCHA on its log-in page. CAPTCHA is specifically designed to keep bots out. In 2022, PointClickCare started using CAPTCHA on users they thought were bots. In 2023, PointClickCare used images so indecipherable that even humans couldn’t solve.

Request Denied

Real Time was losing access to its accounts. Agencies were losing the data analytics they contracted to receive. Real Time and PointClickCare entered discussion to provide access to the data. Real Time alleges that the solutions PointClickCare agreed to would only allow access to 30% of the data needed. Additional negotiations ended without an agreement. It seems PointClickCare ended the negotiations.

Fight for Your Right to...Data

In January of 2024, Real Time sued PointClickCare claiming unfair competition and tortious interference, among others. A district court issued an injunction to stop PointClickCare from using indecipherable CAPTCHA images and from deactivating Real Time’s accounts. PointClickCare appealed the decision to the Fourth Circuit.

Interpreting the Law

The Fourth Circuit upheld the district court ruling. The significance in the ruling is that the court interpreted some previously ambiguous language in the Cures Act exceptions to the information blocking rules. Specifically, the court interpreted the phrase “cannot reach agreeable terms” to mean that both parties attempt to reach an agreement in “good faith” using “reasonable” and “genuine” effort. The court also stated that the parties must have “articulable reasons why the parties cannot come to an agreement.” While this may seem like a minor ruling, the impact of the interpretation of the exceptions could reach much farther than this law suit.

I Object!

PointClickCare requested a rehearing after the Fourth Circuit decision. The American Hospital Assocition and Electronic Health Record Association filed briefs supporting PointClickCare in the lawsuit and in the petition for a rehearing. On April 23, 2025, The US Court of Appeals for the Fourth Circuit denied the petition for review.

Paving the Way for Interoperability

The Fourth Circuit decision upholds the final rule from HHS implementing the Cures Act disincentives for information blocking. This decision and the denial of the petition for en banc review could have widespread implications. EHR companies must use the same access rules for every user. No more tricky images to stump consultants. No limiting access to 30% of the data.

The use of artificial intelligence-based software that can access EHR data without standard API connectivity could be the next step. Without needing permission to access and download data, switching software companies becomes easier. Sharing patient data with other medical providers is now a simple task. A patient could access their medical records with a single log-in.

Final Thoughts

I anticipate this will not be a decision that is accepted easily. I see more objections, lawsuits, and arguments from the AHA, the EHRA, and individual software providers and consultants. The decision has the potential to reach into other industries. AI will continue to evolve in ways we haven’t even anticipated. This certainly will not solve the issues of access to data or interoperability, but it’s a good first step.

Read the related articles on interoperability from Netsmart. Part 1 | Part 2

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Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.

She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Medicare Advantage Audits

by Kristin Rowan | May 29, 2025 | CMS, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

CMS Strategy for Medicare Advantage Audits

Last week, The Centers for Medicare and Medicaid Services (CMS) rolled out a new, aggressive strategy to enhance and accelerate Medicare Advantage Audits under RADV. CMS will audit all eligible MA contracts in all newly initiated audits. The strategy will also invest additional resources to complete the audits for each payment year (PY) 2018 to 2024.

Falling Behind

CMS is several years behind in completing audits. In fact, the last payment year with any significant recovery was from PY 2007. Completed audits from 2011 to 2013 recovered 5%-8% in overpayments. Federal estimates put current overpayments at $17 billion annually. MedPAC‘s estimate is significantly higher at $43 billion annually.

“We are committed to crushing fraud, waste and abuse across all federal healthcare programs. While the Administration values the work that Medicare Advantage plans do, it is time CMS faithfully executes its duty to audit these plans and ensure they are billing the government accurately for the coverage they provide to Medicare patients.”

Dr. Mehmet Oz

Administrator, CMS

The Plan to Manage Medicare Advantage Audits

According to a press release from CMS, the plan is to complete all outstanding audits from PY 2018 to 2024 by early 2026. Here are key elements from the plan:

Enhanced Technology: CMS will deploy advanced systems to efficiently review medical records and flag unsupported diagnoses.
Workforce Expansion: CMS will increase its team of medical coders from 40 to approximately 2,000 by September 1, 2025. These coders will manually verify flagged diagnoses to ensure accuracy.
Increased Audit Volume: By leveraging technology, CMS will be able to increase its audits from ~60 MA plans a year to all eligible MA plans each year in all newly initiated audits (approximately 550 MA plans). CMS will also be able to increase from auditing 35 records per health plan per year to between 35 and 200 records per health plan per year in all newly initiated audits based on the size of the health plan. This will help ensure CMS’s audit findings are more reliable and can be appropriately extrapolated as allowed under the RADV final rule.

CMS will also reportedly work with the Department of Health and Human Services Office of Inspector General (HHS-OIG) to recover uncollected payments identified in past audits.

Impact of Medicare Advantage Audits on Providers

If CMS is able to audit as many plans and records as they are anticipating, Medicare Advantage payers could be looking at significant overpayments. CMS will aggressively seek repayment. When MA payers lose money, they tend to pass that loss on to providers and patients. We could see MA plans cutting benefits, denying procedures, and other cost-saving measures.

Providers who are aware of the unsupported diagnoses or who profited from them may be on the hook for overpayments. Law firm Ropes and Gray suggests that “[MA] plans should…minimize historical risk by correcting or deleting unsupported diagnoses for any time periods for which they are still able to do so.”

I suggest not using this particular law firm. I also suggest checking your payer contracts for clawback and indemnification clauses. When applicable, negotiate new and renewal contracts very carefully.

Medicare Advantage payers will push back on these audits, file lawsuits, and challenge how CMS is conducting audits. MA payers have historically denied treatments and medications that would be covered under traditional Medicare plans. They go to great lengths to avoid paying for services patients did receive. I’m certain they won’t be happy paying back money for services they never received.

CMS indicates it will start the new audit plan immediately. We will continue watching for updates through the end of the year to see if CMS reaches their goal. Of course, we will continue to report on changes at CMS and with Medicare Advantage payers as they happen.

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BREAKING NEWS: House Passes Bill

by Kristin Rowan | May 23, 2025 | Breaking News, Medicaid, Regulatory

by Kristin Rowan, Editor

House Passes Bill

House passes bill in early-morning vote. The House of Representatives, predictably split along party lines, passed the “Big, Beautiful Bill” in a 215-214 narrow win. All but three Republican representatives cheered at its passing. Republicans who previously stated they would not vote for a higher deficit caved and voted along party lines. The House expects an uphill battling getting the bill passed through the Senate.

House Objections

All House Democrats and two House Republicans voted against the bill. One Republican voted “present.” Democrats were vocal in their opposition.

“Children will get hurt. Women will get hurt. Older Americans who rely on Medicaid for nursing home care and for home care will get hurt. People with disabilities who rely on Medicaid to survive will get hurt. Hospitals in your districts will close. Nursing homes will shut down. And people will die. That’s not hype. That’s not hyperbole. That’s not a hypothetical.”

Hakeem Jeffries

Representative, D-NY

Medicaid Changes

Work Requirement

One controversial change in Medicaid is the community engagement requirement for eligibility. Eligibility is at least one of the following:

Working at least 80 hours in a month
Completing at least 80 hours of community service
Participating in a work program for at least 80 hours
Enrolling at least part-time in an educational program
Any combination of the above totaling at least 80 hours
Having a monthly income greater than minimum wage for 80 hours per month

Exceptions

This rule applies to all eligible individuals at least 19 years old and is under 65 years old, is not pregnant, does not have children under age 7, and is not enrolled in or eligible for Social Security benefits. Mandatory exceptions to the community engagement requirement are:

Indian, Urban Indian, California Indian, or eligible as an Indian for the Indian Health Service
The parent, guardian, or caretaker of a disabled individual or dependent child
A veteran with a total disability rate
Medically frail or has special medical needs including those who:
- are blind or disabled
- have a substance use disorder
- have a disabling mental disorder
- live with a physical, intellectual, or developmental disorder that impairs 1 or more activities of daily living
- live with a serious and complex medical condition
- have any other medical condition approved, but not listed here
In compliance with requirements imposed by the State
The member of a household receiving SNAP benefits
Participating in a drug or alcohol rehabilitation program
An inmate of a public institution
Meet other criteria deemed appropriate

Senate Poised for a Fight

After the vote, the Senate made it clear that it will not send the bill to the President without “major changes.” The problem, however, is that different members of the Senate are calling for different changes. Some want even more spending reductions, others want to keep more of Biden’s green-energy incentives, and still others want to soften the Medicaid cuts. Here is some of the feedback from Senators:

Ron Johnson, Senator (R-Wis.) wants to take the bill “line by line” to find $6.5 trillion in cuts over 10 years.

Rand Paul, Senator (R-Ky.) supports the tax agenda, but not the debt ceiling hike.

Lisa Murkowski, Senator (R-Alaska) is expecting significant changes and wants to address the Medicaid cuts, call them “challenging.”

Patty Murray, Senator (D-WA) called the bill a “scam” and urged Republican senators to vote against it.

“House Republicans don’t want you to know they just passed a bill that makes health care MORE expensive and kicks MILLIONS off Medicaid, all to pass tax cuts for billionaires & giant corporations. We need to make sure America knows. And we need to kill this bill in the Senate.”

Patty Murray

Senator, D-WA

House Passes Bill to Senate

Because of the way the House presented the bill, designed to prevent a filibuster, there are constraints on what can be included.

First, everything included in the bill has to be about the budget. Challenges to parts of the bill and whether they are directly related to the budget go to the Senate parlimentarian. A non-partisan advisor, the parlimentarian advises the Senate if a provision is challenged. Elizabeth MacDonough is the current Senate parlimentarian and has served under Senate Majority Leaders from both parties.

Second, the Senate gets to make its own changes to the bill. If the House does not accept those changes, the debt ceiling will not go up. An impasse means the government defaults on its debt. Congress has to raise the debt ceiling by the summer to avoid default. This could put pressure on the House to accept whatever changes the Senate makes.

More to Come

This is an ongoing story and The Rowan Report will continue to provide updates as they become available. Read our accompanying article this week on organizations and courts attempting to stop Trump’s sweeping changes.

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Pushback on Trump Initiatives

by Kristin Rowan | May 23, 2025 | Regulatory

by Kristin Rowan, Editor

Pushback on Trump Initiatives From All Sides

Pushback on Trump initiatives, including the steep cuts to Medicare, Medicaid, Social Security, and VA benefits erupted this week. Coalitions, associations, and members of Congress seek to stop the cuts before the new bill is passed. The Republican-backed bill, under direction from President Trump, called the “Big, Beautiful Bill” would cut federal spending by billions of dollars over ten years. Pushback on Trump’s executive orders is also making headway, with temporary and preliminary injunctions.

Protect Our Healthcare Coalition

Protect Our Healthcare Coalition is a group of consumer and non-profit organizations in Rhode Island. This week, they joined with Medicaid members and Senators Reed and Whitehouse to speak out against the Medicaid cuts in the bill. The coalition also released a report on the impact of Medicaid services in the state.

“Republicans…want to whack Medicaid so fewer people have coverage and costs go up. These cuts will do real harm, pushing seniors out of nursing homes, increasing hospital closures, and denying families access to preventative care. If you think the emergency room is crowded now, just wait until Trump’s Medicaid cuts happen.”

Jack Reed

Senator, (D) Rhode Island

Protecting Retirement and Health Benefits

Congresswoman Mikie Sherrill (NJ-11) introduced the Protecting Retirement and Health Benefits for Working Families Act. The bill is in response to the recent federal program and job cuts. The legislation requires that before any cuts are made to jobs or programs that the administration can prove those cuts won’t harm to benefits and those who rely on them. It also requires a study within one year of any mass layoffs or closures to ensure no harm was done.

Federal Judge Blocks...

DoE Layoffs

More than 1,300 employees of the Department of Education received notice of termination in March from then-Secretary of Education Linda McMahon. The layoffs reduced the staff by nearly half. McMahon initially said they were part of the plan to reorganize and streamline the department for efficiency and accountability. Trump later revealed the layoffs to be the first step in dismantling the Department of Education altogether. District Judge Myong Joun, a Biden appointee, said, “The record abundantly reveals that defendants’ true intention is to effectively dismantle the department without an authorizing statute.” Judge Joun issued an injunction blocking the mass layoff.

Sweeping Agency Changes

In February, the Trump administration issued an executive order, followed by a number of memos, instructing multiple federal agencies to cut staff. The executive order called for the immediate dismissal of temporary and reemployed annuitant staff members. Specifically, it called out those performing functions not mandated by statute or other law, not designated as essential, or is not suited to federal service due to failure to comply with federal employment requirements. The order also reduced hiring ratios to 1:4, permitting agencies not under a hiring freeze to hire one person for every four that leave.

U.S. District Judge Susan Illston, in San Francisco, as part of a lawsuit filed by labor unions, nonprofits, and local governments, issued a temporary block on the overhaul. The lawsuit alleges that Trump needs authorization from Congress to restructure the federal government. Judge Illston says the office of the president can seek changes to agencies, but only through Congress. Illston also issued a temporary restraining order barring agencies from any further implementation of the executive order. This includes the final dismissal of employees who have received layoff notices that have not yet been executed. The temporary restraining order expires May 23, 2025. Additionally, Illston ordered the administration to submit restructuring plans to the court.

Revoking Student Status

The administration attempted end the legal status of international students. This would effectively nullify their right to stay in the United States. Some individual students challenged the action successfully. On May 22, 2025, a federal judge in California blocked the action. He prohibited the administration from arresting or detaining foreign-born students on the basis of their immigration status. The administration insists the immigration status was only revoked for students who had criminal charges.

Pushback on Trump Initiatives is Ongoing

Along with the passing of the “Big, Beautiful Bill,” these issues are ongoing and The Rowan Report will provide updates as they become available.

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DOJ Rejects Plan

by Kristin Rowan | May 16, 2025 | M&A, Regulatory

by Kristin Rowan, Editor

DOJ Rejects Plan to Divest Assets

DOJ rejects plans to divest assets from UnitedHealth and Amedisys to BrightSpring Health Services and the Pennant Group. Last week, we reported that Amedisys and UnitedHealth had entered an agreement to divest certain home health and hospice agencies to satisfy anti-trust concerns. The plan is contingent on the finalization of the merger between UnitedHealth and Amedisys.

Divesting Assets

The merger between UnitedHealth and Amedisys has been ongoing since last summer. Shortly after the announcement, the Department of Justice sued under anti-trust allegations to stop the merger. According to the DOJ, even if the companies offload the 120 planned locations, it would not safeguard competition in home health and hospice markets. The DOJ cited overlap in certain markets where UnitedHealth and Amedisys both currently have agencies.

This could spell T-R-O-U-B-L-E

Following the lawsuit, Amedisys and UnitedHealth started talks with VitalCaring to divest properties. That deal fell through after VitalCaring lost its own lawsuit last year. This latest blow could stall the merger altogether. The DOJ reportedly rejected the divestiture stating that it wasn’t enough. Unless Amedisys and UnitedHealth divest more properties in certain markets, the DOJ is unlikely to approve the merger.

Mediation

The parties are scheduled to enter mediation on August 18th. The judge has now scheduled a follow-up mediation appointment on August 25th, anticipating that one day of mediation will not resolve the lawsuit. Amedisys and UnitedHealth have 90 days to secure additional divestiture that will satisfy the DOJ before mediation begins.

This is an ongoing story and The Rowan Report will continue to bring you the latest news on the merger. Please see our accompanying articles this week on the new UnitedHealth CEO and the new DOJ investigation on UnitedHealth Group.

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BREAKING NEWS: UnitedHealth CEO Steps Down

by Kristin Rowan | May 16, 2025 | Breaking News

by Kristin Rowan, Editor

Breaking News: UnitedHealth Group CEO Andrew Witty Steps Down

Citing “personal reasons” with no elaboration, UnitedHealth Group CEO Andrew Witty steps down from his position, effective immediately. Witty joined UnitedHealth Group in 2018 and became the company’s CEO in 2021. Despite overwhelming growth during Witty’s tenure, the company continues to face numerous setbacks.

UnitedHealth Group Struggles Since January

The shooting death of Brian Thompson, UnitedHealthcare CEO, in December seems to have set off an onslaught of setbacks for the insurance giant.

Share prices have dropped 38% since December, from $503 down to $308
The company recently cut its annual forecast, after first adjusting it down, causing the final 18% stock drop
For the first time since 2008, UHG missed its forecasted earnings
Statements from the company look to 2026 before growth resumes

New (Old) CEO

Stephen Hemsley is the new CEO of UnitedHealth Group, effective immediately. Hemsley, who currently serves as the director of the board, was the company’s CEO from 2006 to 2017. Hemsley will stay on as chairman of the board and company CEO. Witty will serve as senior adviser to Hemsley.

Contradictions and Conflicts

In an official statement regarding the leadership change, Hemsley said, “We are grateful for Andrew’s stewardship of UnitedHealth Group…. The Board and I have greatly valued his leadership and compassion as chief executive….”

On a call with investors, Hemsley said, “Many of the issues standing in the way of achieving our goals as well as our opportunities are largely within our control.”

During that same call, Hemsley said, “I’m deeply disappointed in and apologize for the performance setbacks we have encountered from both external and internal challenges.”

In addition to the conflicting statements, Hemsley will serve as CEO and Chairman of the Board, creating conflict and reducing oversight. The chairman of the board plays a key role in oversight, governance, and communication with the CEO. They also evaluate the CEO’s performance. Holding both roles, especially in light of the shareholder request for reports, may we be in the best interest of UnitedHealth Group, but probably not in the best interest of anyone else.

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A New Path for Hospice Care

by Kristin Rowan | May 9, 2025 | Partner News

FOR IMMEDIATE RELEASE

Contact: press@empathhealth.org
EmpathHealth.org

Empath Health Introduces One Hospice Model, Bringing Together Florida's Established Not-for-Profit Hospices Under One Mission

CLearwater, FL, May 5, 2025. Empath Health, one of the nation’s largest 501(c)(3) integrated care networks, today unveiled its One Hospice Model—a first-of-its-kind framework that preserves community-based hospice while adding the scale, innovation and accountability of a statewide system. “Families deserve hospice that puts mission before margin,” said Jonathan D. Fleece, President & CEO of Empath Health. “By uniting Florida’s most trusted not-for-profit hospices under one model, we keep local relationships intact and ensure every person facing serious illness receives Full Life Care—supported by the strength and expertise of an entire network.”

The model integrates seven locally known hospice brands—Empath Hospice, Hospice of Marion County, Suncoast Hospice, Suncoast Hospice of Hillsborough, Tidewell Hospice and Trustbridge (Hospice by the Sea and Hospice of Palm Beach County)—which collectively care for one in five hospice patients statewide. Five of these affiliates have served their communities for more than 40 years, delivering generations of compassionate, not-for-profit care.

Regional hubs in Tampa Bay, Sarasota, Palm Beach and Ocala keep decision-making local while enterprise teams provide centralized quality, technology and research support. Regional presidents Travis Fogle (Tampa Bay), Brad Perkins (Sarasota) and Tony Maxwell, PA (Ocala/Palm Beach) oversee clinical operations and community partnerships.

“By uniting Florida’s most trusted not-for-profit hospices under one model, we keep local relationships intact and ensure every person facing serious illness receives Full Life Care – supported by the strength and expertise of an entire network.”

While all Empath Health services are available through direct community access, families who begin care with an Empath-affiliated hospice gain direct referral into the wider Empath network of services—available regionally, when needed. This integrated approach allows patients to easily access Empath Home Health for skilled nursing at home; Empath Palliative Care for earlier symptom relief; Empath LIFE / PACE for comprehensive elder day-center support; Empath GUIDE for dementia education and caregiver coaching; EPIC HIV/AIDS Services for prevention, case management and housing; and Empath Grief Care, including Empath Blue Butterfly programs for children. The result is a coordinated Full Life Care journey—from the first serious illness conversations through loss and healing—thoughtfully adapted to each community’s resources and needs.

As policymakers and the public scrutinize hospice ownership, Empath offers a scalable not-for-profit alternative. The organization reinvests much of its revenue into care, workforce development and community programs, and publicly reports quality metrics that exceed national benchmarks. By pairing local leadership with statewide strength, the One Hospice Model offers a blueprint for mission-driven innovation at scale.

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About Empath Health

Empath Health is a pioneering not-for-profit health network redefining healthcare through Full Life Care—supporting chronic, post-acute, end-of-life, and grief care needs across Florida. Its full spectrum of services includes home health, palliative care, all-inclusive elder care (PACE), HIV/STI prevention, grief support, and compassionate hospice care through seven programs: Empath Hospice, Hospice of Marion County, Suncoast Hospice, Suncoast Hospice of Hillsborough, Tidewell Hospice and Trustbridge (Hospice by the Sea and Hospice of Palm Beach County). With decades of trusted service and deep community roots, Empath Health reaches more than 81,000 people each year and serves one in five hospice patients statewide.

New Deal to Sell HH & Hospice Agencies

by Kristin Rowan | May 9, 2025 | M&A

by Kristin Rowan, Editor

UnitedHealth, Amedisys to Divest Home Health & Hospice...Again

History

UnitedHealth, Amedisys to divest home health and hospice properties to satisfy DOJ. Almost two years ago, the health services division of UnitedHealth Group, Optum, announced plans to by Amedisys. The purchase announcement came after Optum outbid Option Care Health with an unsolicited offer. The Department of Justice launched an anti-trust probe shortly after the announcement. To satisfy the DOJ, UnitedHealth and Amedisys plan to divest some of its businesses as part of the acquisition agreement.

Anti Anti-Trust

We previously reported that Amedisys entered into an agreement with VitalCaring to divest some of its home health and hospice locations. This agreement was meant to satisfy the DOJ concerns raised in its anti-trust lawsuit against Amedisys and UnitedHealth.

In January of 2025, VitalCaring lost a lawsuit filed by Encompass Health and Enhabit and were ordered to pay 43% of all future profits to the two companies. In the wake of that court decision, VitalCaring pulled the agreement and signed a mutual release with UnitedHealth, with all parties walking away from the deal.

BrightSpring

BrightSpring Health Services is an $11.5B company with locations across the United States and employing more than 37,000 people. In January of this year, BrightSpring sold is Community Living Business to Sevita. BrightSprings intends to acquire additional properties, focusing on its home- and community-based businesses. According to the BrightSpring President and CEO Jon Rousseau, BrightSpring is “focused on getting to 3x leverage within the next two years.”

Amedisys operates in 38 states with more than 500 locations. The document Amedisys submitted to the SEC does not indicate how many of its properties and those of UnitedHealth will be divested. A UnitedHealth statement said the company plans to divest at least 128 home health and hospice facilities.

One has to wonder whether we are trading one monopoly for another.

New Deal

As the DOJ lawsuit enters mediation this August, UnitedHealth and Amedisys search for another way to divest its properties. Enter the New Deal. BrightSpring Health Services, parent company to Adoration Home Health Acquisition LLC, Adoration Hospice Care Acquisitions LLC and Senescence LLC, DBA All Saints Hospice will purchase some of the properties from both Amedisys and UnitedHealth. The Pennant Group, parent company to Cornerstone Healthcare, Inc. and Tensaw River Healthcare, LLC, will purchase additional properties from bother companies.

According to documents submitted to the Securities and Exchange Commission (SEC), both agreements have mulitple contingencies, including the finalization of the UnitedHealth/Amedisys merger. Financial information on the two deals was not included in the Amedisys SEC filing. In a separate filing, Pennant valued their part of the agreement at nearly $102.5 million.

No Deal Yet

The sale of properties to BrightSpring and Pennant Group relies on the finalization of the merger between Amedisys and UnitedHealth. A magistrate will oversee mediation between the two companies and the DOJ beginning this August.

The SEC and the DOJ have not yet responded to the intent to divest to BrightSpring and Pennant Group.

Final Thoughts

The proposed merger between UnitedHealth and Amedisys has been ongoing for two years. The two companies, who previously stated their competition helped keep them honest and keep costs low, now state that the merger will lower costs even more. The DOJ disagrees. To alleviate concerns, the merger includes the release of properties anywhere the merger would create an unfair advantage. Mediation in August will reveal more on the position of the DOJ, the response from UnitedHealth and Amedisys, and the specifics of the divestment of home health and hospice agencies. The merger proposal expires December 31, 2025. We will continue to follow the story as the parties enter mediation.

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Update is Not an Increase

by Kristin Rowan | May 1, 2025 | Hospice, Regulatory

by Kristin Rowan, Editor

Updates to Hospice Rule

On April 11, 2025, the Centers for Medicare and Medicaid Services (CMS) issued their proposed rule for hospice rates, Conditions of Participation (CoPs) and face-t0-face encounter requirements for FY 2026. The proposed rule also includes a change in regulatory text for the Hospice Quality Reporting Program.

Following Executive Order 14192, an attempt to reduce the expense attached to following Federal regulations, CMS is seeking feedback on streamlining regulations and reducing expenses. The RFI to submit responses can be found here.

Payment Updates

The proposed update to the hospice payment rate yields a net increase of 2.4 percent. This change includes a 3.2 percent market basket increase based on the estimate cost increase for inpatient hospitalization. The 0.8 percent productivity adjustment offsets the market basket increase. The quality data penalty of 4 percent remains in place.

Market Basket Objections

Not for the first time, commentors on CMS proposed rules objected to the use of the hospital wage index in determining hospice pay rates. According to a report from the Federal Register, a few commenters on the FY 2025 payment update opposed using the IPPS wage index to determine the hospice wage index. According to the commenters, the hospital wage index uses cost report wage data that excludes hospice wage costs. The exclusion of hospice costs skews the accuracy of wage adjustments for hospice providers.

In response to the same proposed rule, MedPAC recommended that wage index policies be repealed and replaced by new Medicare wage index systems that use all-employer, occupation-level wage data; account for wage differences across geographical areas, and match wages in adjacent local areas.

CMS Ignores Objections

Despite years of comments, objections, and suggestions to update the hospice wage index calculations using more accurate data, CMS continues to insist that using the pre-floor and pre-reclassified hospital wage index is the more appropriate for determining hospice payment rates. CMS states that this position is “longstanding and consistent with other Medicare payment systems.”

Productivity Adjustment

The productivity adjustment started with the Affordable Care Act. It’s stated purpose is to “reduce Medicare spending by recognizing that hospitals can improve their efficiency and productivity.” Average efficiency and productivity gains in all private non-farming businesses form the productivity adjustment.

The most recent document from CMS about the productivity adjustment comes from 2022, using data from 2019. The report shows that hospital growth falls far below the average growth of private non-farming businesses. Using two different methods of calculations, hospital growth falls between 0.2 and 0.3 percent. Non-farming business growth is 0.8 percent.

Labor Productivity

CMS uses labor productivity as its measure for the productivity adjustment for Medicare hospitals and hospices. The estimate for labor productivity across all private non-farming businesses is 2.0 percent. The calculation for hospital labor productivity is 0.8 percent. This is the number used in this year’s productivity adjustment. Actual labor productivity growth in hospitals from 1993 to 2018 was 0.4 percent.

Quality Reporting Reduction

Hospices that do not submit the required quality data incur a payment reduction of 4 percent. This yields a 1.6 percent decrease over last year’s rates after factoring in the 2.4 percent increase. Quality data reporting includes the HIS tool, administrative data, and CAHPS hospice survey. The threshold to avoid the 4 percent reduction includes submitting at least 90 percent of HIS records within 30 days of an event date and ongoing monthly participation in CAHPS surveys. The HOPE reporting tool replaces the HIS system beginning October 1, 2025. These requirements are not changing with the FY 2026 proposed rule, with the exception of the change from the HIS tool to the HOPE tool.

Comment from The Alliance

In last week’s newsletter, we summarized Dr. Steven Landers’s keynote address from the New England Home Care & Hospice Conference and Expo. Always passionate about care at home, and particularly about hospice, which he describes as “a national treasure,” Dr. Landers strongly stated that an “update is not an increase” when it doesn’t keep up with inflation and pay increases.

Final Thoughts

Every year, CMS, MedPAC, and HHS make changes to hospice and home health payment rates based on faulty information that doesn’t account for the nature of the work or the person-centered requirements of the industry. Non-farming industries can increase efficiency and productivity in myriad ways that cut staff. We see it in grocery stores with the increasing number of self-checkout lines. We see it in restaurants with QR code menus, ordering kiosks, and payment kiosks. There is no substitute for one-on-one contact in a home setting for care at home, particularly in hospice. Nurses can’t take on enough more patients in a day to make a meaningful impact on efficiency and productivity without sacrificing quality of care.

AI for Efficiency and Productivity

I’ve been speaking for some time now on the advantages of using augmented and generative intelligence in care at home. As long as CMS continues to lower reimbursement rates using the collective productivity rates of impertinent industries, care at home has to embrace the technology that increases productivity and efficiency in the office and in the field. Talk to text, documentation, scheduling, onboarding, and data analytics are readily available through AI platforms and drastically reduce costs across departments.

You can read about some of the AI tools here. For more information or to engage our consulting services for AI adoption, contact me directly.

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Trouble in MA Paradise?

by Kristin Rowan | May 1, 2025 | Advocacy, CMS, Editorial, Medicaid, Medicare, Medicare Advantage

by Kristin Rowan, Editor

Medicare Advantage

It’s no secret within the care at home community that Medicare Advantage is not without its problems. Coverage and care are good when the beneficiary is relatively healthy. When it’s really needed, MA plans deny coverage. Multiple insurance companies have upcoded patient care for higher reimbursements. And predatory marketing tactics target our most vulnerable.

Predatory Marketing

Medicare Advantage payers use unethical marketing to target seniors, sometimes going as far as to call unwitting customers and strong-arm them into changing from their traditional Medicare plans to MA. Anecdotally, a family friend was convinced to switch to Medicare Advantage three times. Each time, his family caregiver reversed that change before any real damage was done. Similarly, our own Editor Emeritus, Tim Rowan, fielded calls aimed at his disabled, grieving brother, urging him to change to a MA plan. Luckily, those calls were deflected by someone who knew better. Not everyone is as lucky.

UHC Projects Lower Earnings

Despite a 9.8 billion dollar year-over-year increase in revenue in the first quarter of 2025, UnitedHealth Group last week submitted a lower earnings outlook for 2025. UHG attributed the revision to “increased care activity” in its Medicare Advantage business.

UHG has strong growth in providing benefits and services to more members. In Massachusetts, for example, the company reported 100% growth in care activity. Simultaneously, Optum Health, the arm responsible for home health, took on more clients with lower reimbursement rates, impacting overall revenue. Optum cites changes to the CMS risk adjustment model particularly for complex patients as a contributor to the problem.

Breaking it Down

UHG initially projected strong growth through 2025. The projection was partly based on the expection of a gradual increase in care activity. More members should increase revenue. What UHG did not account for was rapid growth of high-risk members in a risk-adjustment model that had not yet been thoroughly tested. Medicare Advantage is a money losing model that is propped up by Traditional Medicare. UHG is finally feeling that impact and it will only get worse as HHS cracks down on waste, fraud, and abuse in MA.

Elevance Pulls Plug on MA Marketing

One week after UHG revised its earnings projections for 2025, Elevance announced plans to cut is Medicare Advantage marketing. EVP of payer solutions at ATI Advisory, a consulting firm in the healthcare space, says cutting spending on MA marketing happens for different reasons.

“It’s often a temporary decision to give an MAO a year to ‘catch up’ or right-size impacts from the prior year. For example, it might be in response to larger-than-expected enrollment during the prior year, higher-than-expected utilization the plan is trying to get under control, or a change in federal policy.”

Breaking it Down

Elevance reported better earnings in Q1 2025 than were expected. The company listed home health as one of its key revenue drivers. The operating revenue increase came from higher premiums and growth in MA membership. The announcement to cut marketing spend came less than a week later.

In other words, the company had a surge of MA sign-ups at the beginning of the year when plan coverage started after open-enrollment. Now that the company is seeing how many of those members actually need care and how much they will have to spend to provide that care, they no longer want to enroll additional MA members.

Opposition

The National Association of Benefits and Insurance Professionals expressed “deep concern” over Elevance’s announcement. NABIP represents licensed health insurance agents and brokers with a stated goal of promoting access to affordable health insurance coverage.

“This decision directly harms Medicare beneficiaries by limiting their access to essential healthcare options and support during Medicare’s enrollment period,” NABIP CEO Jessica Brooks-Woods said.

NABIP asked CMS, Congress, and health plans to mitigate the effects of this announcement. They urged CMS to “freeze any carrier-initiated changes after October 1 that would limit agent access.

Breaking it Down

NABIP represents agents and brokers who sell insurance plans to eligible members. They are membership based and rely on member fees as a main revenue stream along with fees collected for education, advertising, and sponsorships. Their PAC raises money from members to support political candidates.

Agents and brokers make money from commissions on sales of healthcare plans. The commission on Medicare Part D is around $109 per member per year. The commission on Medicare Advantage plans varies by state and carrier, but is as high as $780 per member per year. Commissions for Medicare Supplement plans are a percentage of premiums. The average commission for supplement plans is $322.

But, of Course...

It is not surprising, then, that the member-based advocacy group on behalf of sales people who earn nearly 7 times the commission on MA plans wouldn’t want companies like Elevance to stop marketing them.

Final Thoughts

I don’t believe Medicare Advantage is going anywhere anytime soon. I also don’t believe any government agency can monitor itself for fraud, waste, and abuse. Further, I don’t believe an association that makes its living on commissions has the best interest of its customers as its first priority.

Perhaps fewer beneficiaries will be subjected to the predatory marketing and sales calls pushing them into Medicare Advantage plans. Perhaps knowledgeable, well-intentioned individuals and associations can shed light on the real advantages of Traditional Medicare. Perhaps CMS, under the direction of HHS, will turn the “waste, fraud, and abuse” mirror in the direction it belongs.

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