NGS Shutters Valid Hospice

Breaking News

by Tim Rowan | Jul 17, 2026 | Breaking News, CMS, Hospice, Medicare

Will a Typo Shut Down Your Agency?

by Tim Rowan, Editor Emeritus

This is the first of a multi-part, investigative report about fraud, waste, and abuse by federal contractors. A Medicare consultant’s in-depth research found that some MACs may be guilty of worse fraud than the providers Dr. Oz talks about.

July 24 Update

The story below is evolving almost on a daily basis. On Monday, the hospice described in last week’s story will submit a formal complaint against NGS to the Office of the Inspector General in the Department of Health and Human Services. This move is in response to the apparent choice by CMS not to pursue accusations of impropriety by the victim hospice. We will publish the full details as soon as the OIG receives the complaint. In the meantime, we are gathering similar stories from other providers who may have experienced the same abuse by their MAC. Our contact information is at the end of this story.

It Was Supposed to be Routine

Every year, hospices submit revalidation paperwork to keep their Medicare enrollment current. For one unlucky Hospice in Phoenix, however, a paperwork glitch during that process triggered something far more sinister: classification as a “new provider” under the Provisional Period of Enhanced Oversight (PPEO) rules.

No ownership change

There was just one problem. Ownership had not changed since June 2019, as the PECOS enrollment record proved. On November 24 and 25, 2025, the hospice’s authorized officials sent NGS (their Medicare Administrative Contractor) clearly stated emails with an organizational chart attached. It showed that, as of July 13, 2026, official ownership records established in 2019 remained unchanged.

Even more telling: A CMS representative personally instructed the agency to write “Not a new agency” with its established date on the cover sheets of every Additional Documentation Request (ADR) form returned to NGS. NGS’s own auditors received forms bearing that exact, handwritten notation.

NGS received the message…and ignored it.

What is PPEO Fraud Prevention?

The consultant working with the Arizona hospice explained, “PPEO exists for one narrow purpose: enhanced prepayment review of claims from genuinely new providers, or those with qualifying ownership changes. It is not a post-payment cudgel to be applied retroactively to an established hospice’s existing charts to manufacture a “pattern or practice of abusive billing” under 42 C.F.R. § 424.535(a)(8).”

Yet that is exactly what happened, he told us.

NGS abandoned what the record suggests was a far more robust 54-chart review and instead conducted a lightning-fast, 10-chart PPEO “snapshot” over a mere 30-day period. Next, they denied eight claims, on a Post-payment rather than the PPEO standard Pre-payment review, looking back four months to November 2025. The denied claims totaled $54,568.42.

Grounds for denial bordered on the frivolous:

“missing” addendum forms, which are not required
hyper-technical formatting nitpicks
outright misrepresentations of the hospice’s medical record.

The consultant did not fail to notice NGS’s deceptions. Still falsely claiming there was a change of ownership, the MAC selected claims from a previous month before the non-existent ownership change.

The Clinical Reality NGS Ignored

Each of the eight patients had valid election statements. Addenda were either timely furnished via DocuSign (with irrefutable certificates of completion) or expressly declined by the beneficiary on the election form itself. Physician Certifications of Terminal Illness contained detailed narratives tying primary diagnoses — end-stage heart failure (NYHA Class IV), sarcopenia, senile degeneration of brain, end-stage MDS, advanced COPD — to synergistic comorbidities.

Objective prognostic indicators far exceeded LCD L33393 thresholds: PPS scores of 40–50%, 5/6 to 6/6 ADL dependence, MUAC measurements of 22–27 cm confirming severe malnutrition, serial weight loss, FAST progression to stage 6e–7A, incontinence, recurrent infections, oxygen or transfusion dependence (hemoglobin as low as 5).

Deadly consequences

In at least two cases, the beneficiary died within days or weeks of the service period — one during the benefit period itself, another just 37 days later. This is not “abusive billing.” This is hospice care for patients whose prognoses were tragically accurate.

Yet NGS’s initial denials were bare codes (commonly 55H1L or similar) with zero explanation — violating the regulatory requirement that determinations be written so a beneficiary can understand the reasons. At redetermination, new and contradictory theories emerged: one claim denied after NGS invented a “151-pound weight loss” when the chart showed a radically different number of pounds; another claimed “good appetite” while records documented clear decline.

These shifting rationales, and the refusal to engage the provider’s detailed page-by-page roadmaps mapping every regulatory element to the actual medical record pages, directly violate MLN Matters SE1521 and 42 C.F.R. §§ 405.921, 405.956, and 405.976.

Widely Known, Ongoing Issue

This case is not unique but is representative of the dilemma Medicare providers have faced since the early years of this century. The OIG has already issued reports documenting NGS’s systemic failures. Inspectors reopen cost reports after finding “obvious errors” by NGS, They have uncovered hundreds of thousands in net overpayment accusations, as well as 100% error rates in some desk-reviewed cost reports.

It does not speak well of the entire Medicare program that a contractor this error-prone in its accounting work was somehow trusted to make life-or-death clinical judgments and ownership determinations. Worse, the Milwaukee-based insurance company with the MAC contract rarely admits errors but instead doubles down, aggressively pursuing termination when caught in the act.

When the consultant fighting for the hospice could not shake loose satisfactory responses from NGS, he escalated. He managed to arrange a video conference with member of Dr. Oz’s staff. The conversation centered around hundreds of pages of documented contractor misconduct, including the “Not a new agency” notations NGS itself had accepted. Their response?

“We called the MAC and they said they didn’t do that.”

The case has now moved beyond Maximus QIC reconsideration. A master supplemental submission was filed this week (July 13–14, 2026) demanding reversal of all eight denials and a declaration that the PPEO was unlawful from day one. Protective ALJ hearings have been filed. A DAB appeal on the related enrollment revocation is pending. Federal court is the next stop if necessary.

This entire 2025-26 incident does not signal new behavior, but has been going on nearly 20 years. It is the exact pattern the Medicare Appeals Council condemned in Quality Home Health Services, Inc. v. Trust Solutions, LLC (DAB, Sept. 14, 2009) — a case in which NGS itself was the intermediary whose “very brief and conclusory,” “stock phrase,” non-individualized denials were rejected wholesale.

Sound Familiar?

As this is written, the Arizona hospice’s saga progresses toward a federal trial or a pre-trial settlement. We will stay on top of developments for future reports.

Administrator Oz, and the HHS OIG, may respond to NGS behavior by initiating measures to curb contractor fraud, or he may continue to stand before TV cameras to keep his focus on bad actors on the provider side. Neither consultants nor the press hold the power to influence CMS one way or the other.

United front

That will be up to the provider community. It will be up to you, dear reader. If anything like the Arizona experience happened to your agency at the hands of your MAC, please tell us. We will share your stories, anonymously if requested. The more stories we can deliver about insurance companies with CMS contracts that engage in lawbreaking, the more difficult it will be for top officials to ignore it. The most powerful evidence is first-person stories about improper MAC determinations that result in harm to a patient. Send your stories to editor@therowanreport.com.

More to Come

We are still receiving additional information on this breaking news story. We are communicating with the consultant involved and will have more information next week. Some of what we have learned game changing. Stay tuned.

# # #

Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He is also the creator of the new “Home Care Technology Buyer’s Guide,” which will be released in the 4th quarter this year. More information: RowanResources.com
Tim@RowanResources.com

©2026 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

Justice Department’s Next Target

Medicaid

by Kristin Rowan | Jun 19, 2026 | Medicaid, Waste Fraud and Abuse

By Kristin Rowan, Editor

Justice Department's Next Target

New York Sued for Fraud

The past several months, Vice President JD Vance, Dr. Oz, and the anti-fraud task force have investigated home health and hospice agencies suspected of fraud. Much of the focus has been in Minnesota, Georgia, and California. Now, New York joins the list of targeted states, as the Justice Department suis the New York State Department of Health, the state’s Medicaid director, Public Partnerhsips, LLC (PPL), the company operating the $10 billion Consumer Directed Personal Assistance Program (CDPAP) for the state.

CDPAP Management

Prior to the fall of 2024, CDPAP was managed by hundreds of individual agencies. The state opted to consolidate management into one firm and selected PPL. At the time, CDPAP was one of the largest public health benefits programs in the state with more than 250,000 patients.

Justice Department Allegations

Skimming

In the lawsuit, the Justice Department alleges unauthorized profits going to PPL. These profits allegedly come from PPL skimming a percentage of each hour of care billed to Medicaid. The skimmed percentage, according to the suit, amounts to millions of dollars.

Favored Vendor

The Justice Department further alleges PPL was untruthful in its bid regarding its staffing plan, its financial readiness to handle the contract, and the quality of its software, among other aspects of the plan.

The Department of Justice is blaming New York Governor Kathy Hochul and her administration for allowing the fraud. The DOJ alleges PPL was “preselected” as the winner of the contract in a fixed bid process.

Misrepresentation

The lawsuit further alleges that PPL won the contract after a “sham bid” process. The Justice Department claims PPL intended to stray from the representations made in their bid, that the New York Department of Health learned of the deceit, and failed to hold PPL accountable.

JD Vance Speaks

At a recent campaign event, Vice President JD Vance spoke about the lawsuit.

“You do not want your government facilitating fraud; you want your government fighting against fraud. You know what these fraudsters are doing? They’re taking advantage of American generosity to enrich themselves.”

JD Vance

Vice President of the United States

Response

New York State Department of Health spokesperson Cadence Acquaviva called the lawsuit a “baseless complaint” and an attempt by Republicans to “score political points at the expense of vulnerable New Yorkers.” Acquaviva called the lawsuit “inexcusable and completely lacking in merit.”

The Rowan Report reached out to PPL for comment, but did not hear back as of the publication of this article. We will provide updated information as it becomes available.

# # #

Kristin also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. She works with care at home software providers to create dynamic content that increases conversions for direct e-mail, social media, and websites. Connect with Kristin directly at kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

Response to HHS Reports

Advocacy

by Rowan Report | Jun 19, 2026 | Advocacy, Medicare Advantage

FOR IMMEDIATE RELEASE

Contact: Colleen Knudsen
cknudsen@leadingage.org
202-508-1215

Post-Acute Care Medicare Advantage Coalition Statement on OIG Reports Confirming Barriers to Post-Acute Care in Medicare Advantage

Washington, D.C, June 16, 2026. The Post-Acute Care Medicare Advantage (PAC MA) Coalition issued the following statement in response to the U.S. Department of Health and Human Services (HHS) Office of Inspector General’s (OIG) two new reports, The Three Largest Medicare Advantage Organizations Denied Requests for Long-Term Acute Care and Inpatient Rehabilitation at Some of the Highest Rates and Medicare Advantage Organizations Overturned Nearly All Appealed Prior Authorization Denials for Skilled Nursing Facility Admission, Raising Concerns About Initial Denials:

Coalition Statement

The PAC MA Coalition has long championed critical yet commonsense and necessary reforms to ensure Medicare beneficiaries’ access to medically necessary care across all post-acute settings. These June 2026 OIG reports provide important, independent confirmation of what providers and Medicare beneficiaries have experienced for years: Medicare Advantage (MA) plans are using prior authorization (PA) and similar tactics to restrict beneficiaries from receiving the services that Medicare Advantage Organizations (MAO) are legally required to provide.

Across the post-acute care (PAC) continuum, OIG found concerning denial patterns, wide variation of the rate of denials among MA organizations, and high rates of successful appeals. Even when a denial is later overturned, the patient may still have faced unnecessary care delays, a prolonged hospital stay, an interruption in recovery, or placement in a less appropriate care setting. Given each PAC setting’s distinct role and value in the rehabilitation continuum, these outcomes can cause significant disruptions in patients’ recovery trajectory and place patients at higher risk for complications and readmissions – all of which produce poorer outcomes and increase costs for the Medicare program.

For Medicare beneficiaries recovering from serious illness, injury, surgery, stroke, or other complex medical events, timely access to the right post-acute care setting is essential. These decisions are not simply administrative; care in the appropriate setting can affect whether a patient regains function, avoids complications, returns home safely, or receives the services needed to recover altogether.

The Coalition is also concerned by OIG’s findings regarding third-party contractors and vendors involved in PA decisions. MAOs remain responsible for ensuring that their contractors, which may deploy algorithmic or artificial intelligence-supported tools in PA decision-making, comply with Medicare coverage rules. High denial overturn rates should prompt closer CMS oversight of whether these entities are applying Medicare standards accurately and enforcement with meaningful penalties when there are patterns of non-compliance.

The OIG reports underscore the need for better data, transparency, and stronger accountability. The Coalition urges the Centers for Medicare and Medicaid Services (CMS) to implement OIG’s recommendations to collect detailed, request-level PA data–including standardized service type, contractor involvement, denial rationales, decision timelines, appeal outcomes, and information on continued-stay requests. CMS should make these data publicly available and also examine why denial and overturn rates vary so widely across plans and contractors and take corrective action, where appropriate.

The Coalition further urges OIG and CMS to conduct a similar review of MA practices affecting home health services. Home health providers report that even when care is approved, MA plans frequently authorize fewer visits than clinically appropriate and reimburse at rates significantly below traditional fee-for-service (FFS) Medicare. As a result, patients may be left without the full scope of services they need to recover safely at home.

MA plans are required to provide access to Medicare Part A and Part B services in a manner comparable to traditional FFS Medicare. The OIG reports make clear that stronger oversight, greater transparency, and more consistent enforcement are needed to ensure MA beneficiaries receive the post-acute care they are entitled to under Medicare, in the most clinically appropriate setting. Our groups collectively applaud the OIG’s observation that, “as enrollment in Medicare Advantage continues to grow, so does the urgency and importance of ensuring that MAOs are delivering on the value that the Federal Government pays them to provide.”

The PAC MA Coalition therefore stands ready to work with CMS, Congress, OIG, MA organizations, and other stakeholders to address PA, reduce unnecessary administrative burden to providers, ensure adequate payment, and protect timely access to medically necessary post-acute care.

The PAC MA Coalition renews its request for CMS to standardize post-acute care prior authorization procedures across MA plans. Greater consistency, compliance, and accountability are needed to ensure decisions reflect traditional Medicare FFS standards. Expedited PA is essential so beneficiaries receive timely, medically necessary services and avoid unnecessary delays in recovery.”

# # #

About the PAC MA Coalition

Post-Acute Care (PAC) is made up of approximately 15,000 skilled nursing facilities (SNFs), 11,500 home health agencies (HHAs), 1,200 inpatient rehabilitation facilities (IRFs), and 370 long-term acute care hospitals (LTCHs), among other provider types.

The Post Acute Care Medicare Advantage (PAC MA) Coalition is comprised of LeadingAge, the American Health Care Association and National Center for Assisted Living (AHCA/NCAL), the American Medical Rehabilitation Providers Association (AMRPA), the National Alliance for Care at Home (the Alliance), the National Association of Long Term Hospitals (NALTH), and the Center for Medicare Advocacy. Together, the Coalition represents the interests of PAC providers and the Medicare beneficiaries who require their services.

The Coalition’s objective is to ensure Medicare beneficiaries enrolled in MA and Special Needs Plans (SNPs) receive comparable and timely access to Medicare Part A and B services as their Traditional Medicare counterparts, while also ensuring the financial viability of providers who participate in MA networks through adequate payment and reduced administrative burden.

Alliance Responds to CMS

Advocacy

by Rowan Report | May 14, 2026 | Advocacy, CMS, Medicare, Regulatory, Waste Fraud and Abuse

FOR IMMEDIATE RELEASE

Contact: Hannah Kristan
communications@allianceforcareathome.org
202-355-1647

The Alliance Responds to CMS’s Announcement of Nationwide Enrollment Moratoria on Hospice and Home Health Providers

Washington, D.C, May 13, 2026. On May 13, the Centers for Medicare & Medicaid Services (CMS) announced a six-month national moratorium on hospice and home health enrollment in response to program integrity concerns within the Medicare programs. While the National Alliance for Care at Home (the Alliance) strongly supports efforts to root out bad actors who exploit these essential programs, undermine confidence in care at home, and threaten the patients and families who depend on it, the Alliance has long advocated for targeted strategies that distinguish between high-fraud markets and communities where fraud is not an identified problem and patients already face shortages of providers.

Concerns

The Alliance welcomes the Administration’s focus on combatting fraud, waste, and abuse and appreciates that CMS has indicated providers will still be able to conduct face-to-face recertification visits via telehealth during the enrollment moratorium, which will help avoid unnecessary care disruptions for patients and families. However, an enrollment moratorium does not distinguish between bad actors and compliant providers and will ultimately reduce competition and slow innovation. More importantly, an enrollment moratorium raises serious access-to-care concerns in areas where patient demand is growing or existing capacity is already strained, leading to longer wait times, reduced service availability, and fewer choices for patients – particularly in rural or underserved communities.

Less Severe Recommendations

Public reports show that fraud is concentrated in specific geographies and among specific actors, signaling that targeted reforms and oversight strategies are needed to identify and remove fraudulent entities from the Medicare program. The Alliance and other national organizations have repeatedly provided CMS with recommendations that focus on preventing bad actors from entering the Medicare and Medicaid programs and better leveraging existing tools to fight fraud without creating unnecessary burden for good-faith providers who are already meeting program requirements.

From the Alliance CEO

“The majority of home health and hospice providers deliver compliant, patient-centered, and clinically appropriate care to individuals with complex needs, often in their most vulnerable moments. CMS must use data-driven, risk-based program integrity measures and focus resources on boots-on-the-ground surveys and enforcement of existing oversight mechanisms that root out the blatantly bad actors without potentially limiting patient access to care or punishing high quality providers operating in good faith.”

Jennifer Sheets

CEO, National Alliance for Care at Home

Final Thoughts

This moratorium, effective May 13, applies only to new providers and certain changes of ownership, and may be extended if CMS deems it necessary.

The Alliance has been and will remain a proactive, constructive partner to Congress and federal regulators on program integrity efforts. The Alliance will continue to engage with the Administration on a path forward that holds bad actors accountable while protecting patient access to the safe, high-quality care at home they need and deserve.

# # #

About the National Alliance for Care at Home

The National Alliance for Care at Home (the Alliance) is the leading authority in transforming care in the home. As an inclusive thought leader, advocate, educator, and convener, we serve as the unifying voice for providers and recipients of home care, home health, hospice, palliative care, and Medicaid home and community-based services throughout all stages of life. Learn more at www.AllianceForCareAtHome.org. 

Medicare Moratoria

Breaking News

by Kristin Rowan | May 14, 2026 | Breaking News, Medicare, Regulatory, Waste Fraud and Abuse

by Kristin Rowan, Editor

Medicare Moratoria

CMS Halts All New Home Health & Hospice Agencies

As part of it’s ongoing efforts to curb Medicare waste, fraud, and abuse, the Centers for Medicare and Medicaid Services (CMS) is taking a bold step. On Wednesday, May 13, 2026, CMS announced a 6-month moratoria on home health and hospice agency enrollment. Aimed at protecting Medicare beneficiaries and taxpayer dollars, the moratoria will temporarily stop new enrollment of providers in home health and hospice, which CMS calls “high-risk” categories and key sources of fraudulent activity. CMS states this effort builds on additional fraud prevention initiatives, including enhanced screening, site visits, and expanded oversight activities across the hospice and home health sectors

More Investigations

Together with Vice President JD Vance’s Anti-Fraud Task Force, CMS will increase its targeted investigations of hospice and home health agencies that are suspected of fraud. CMS promises to use advanced data analytics and to accelerate the removal of fraudulent hospice and home health agencies.

Skirting Authority

CMS investigations revealed that some agencies intent on committing fraud are closing their businesses and reopening under different names in different states to perpetrate additional fraud. The moratoria will prevent these agencies from skirting authority in this manner. Additionally, the moratoria applies to some changes in ownership, which is a common technique used to hide these “bad actors.”

What it Means for You

The moratoria do not apply to existing providers with current enrollments. You can continue to deliver services to Medicare beneficiaries as long as your enrollment is current and in good standing.

Statement from CMS

“We’ve seen systemic and deeply troubling fraud in the hospice and home health space, with bad actors exploiting some of our most vulnerable Medicare patients and stealing money from the American taxpayer. Today we’re shutting the door on fraud—preventing new bad actors from entering Medicare while we aggressively identify, investigate, and remove those already exploiting them. This is about protecting patients, restoring integrity, and safeguarding taxpayer dollars.”

Dr. Mehmet Oz

Administrator, Centers for Medicare and Medicaid Services

More Information

The administration’s anti- fraud, waste, and abuse efforts are ongoing.

Read the CMS Press Release

Full text of the Home Health Moratorium

Full text of the Hospice Moratorium

# # #

Private Payors Against Fraud

Admin

by Elizabeth E. Hogue, Esq. | Apr 17, 2026 | Admin, CMS, Home Health, Hospice, Medicaid, Medicare, Regulatory, Waste Fraud and Abuse

by Elizabeth E. Hogue, Esq.

Private Payors Against Fraud

Join Enforcement Efforts

There seems to be a persistent myth among providers of private duty/homecare services that the federal anti-kickback statute applies to Medicare-certified providers only. On the contrary, the anti-kickback statute applies to providers who receive funds from any state or federal healthcare program; including the Medicaid Program, VA, TRICARE, etc. Private duty providers: This means many of you! Lately it has become clear that private payors have joined fraud enforcement efforts.

Guilty

In a recent case, a provider in Detroit pled guilty to conspiring to commit health care fraud. The conspiracy resulted in losses totaling $1.9 million to Medicare, Medicaid, and Blue Cross Blue Shield of Michigan. The investigation was conducted by the FBI and the Office of Inspector General of the U.S. Department of Health and Human Services, the primary enforcer of fraud and abuse prohibitions.

Ghost Services

At the plea hearing, the provider admitted to creating and operating a scheme to submit false and fraudulent claims that were medically unnecessary or not actually provided. In some instances, services billed were not ordered by physicians. The scheme continued for over five years. The provider used the proceeds of fraud for his personal use and to benefit others.

Consequences

After a presentence report is prepared, the provider faces a possible maximum sentence of ten years in prison, a fine of up to $250,000 and up to three years of supervised release following any term of imprisonment.

Federal and Private Prosecution

It is important to note that the provider was criminally prosecuted not only for fraud with regard to claims submitted to Medicare and Medicaid Programs, but also fraud committed against a private payor, Blue Cross Blue Shield.

Your Payor Could Report You

It now appears that providers who receive payments from third party payors must be concerned about fraud enforcement. Consequently, providers of private duty/home care services must develop, implement, and update Compliance Programs.

Compliance Programs

Compliance Programs are specific types of documents that routinely address issues that providers do not usually cover in internal policies and procedures. In addition, providers may not gain benefits related to fraud enforcement if there is no formal document called a Compliance Program.

More than Accreditation

Some providers think that accreditation means they are in compliance. On the contrary, providers may be accredited but fail to meet applicable compliance standards for fraud and abuse. Compliance Programs appropriately address potential fraud and abuse issues. They also include mechanisms for helping to ensure compliance, such as processes for identification and correction of potential problems that are not addressed during the certification process.

It Could Save You

Providers also need to know that developing, implementing, and updating Compliance Programs may make a considerable difference during fraud enforcement actions. If providers have Compliance Programs in place that are current and fully implemented, enforcers may be less aggressive in pursuing potential violations.

Corporate Integrity Agreement

When enforcers discover problems with fraud and abuse in organizations, providers are usually asked to develop and implement a Corporate Integrity Agreement (CIA). This type of agreement is likely to include processes for stringent monitoring on a continuous basis. These monitoring activities can be extremely burdensome to providers in terms of both time and money. Providers with valid Compliance Programs are not necessarily asked to develop and implement CIA’s.

Final Thoughts

Now is the time for all providers, including private duty/home care companies, to recognize and act upon the need to establish and maintain Compliance Programs. “Working on it” is no longer good enough.

# # #

Elizabeth E. Hogue, Esq The Rowan Report

Elizabeth Hogue is an attorney in private practice with extensive experience in health care. She represents clients across the U.S., including professional associations, managed care providers, hospitals, long-term care facilities, home health agencies, durable medical equipment companies, and hospices.

©2026 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.

Medicaid Reform

Home Health

by Kristin Rowan | Apr 17, 2026 | Home Health, Medicaid, Regulatory, Waste Fraud and Abuse

by Kristin Rowan, Editor

Medicaid Reform

New Efforts to Stop Fraud Before it Happens

As auditors continue to investigate fraudulent activity, new initiatives through Medicare reform aim to stop fraud before it happens. The new initiative, the Combating Deceptive Practices in Assistance Programs Act adds oversight to the Medicaid program.

Preserve Medicaid through Reform

Chairman of the Joint Economic Committee and Chairman of the House Ways and Means Oversight Subcommittee, Rep. David Schweikert, announced the legislation that would tighten eligibility requirements for home health services through Medicaid. The bill requires Medicaid recipients to prove they are unable to perform three or more ADL’s without assistance.

If we seriously want to preserve Medicaid, and provide for the people most in need, we must crack down on fraud. Reaching people that need these services the most should be the top priority of these programs, not growing one of the largest jobs corps in the state. With the U.S. adding almost $87,000 per second to our national debt, making commonsense reforms can save tens of billions of dollars while protecting the truly vulnerable.”

Rep. David Schweikert

Chairman, Joint Economic Committee and House Ways and Means Oversight Subcommittee

Medicaid Waiver Programs

According to the statement from the Joint Economic Committee, the federal waiver programs that allow states to provide at home care for Medicaid beneficiaries are lacking guardrails and oversight. The state policies are “egregious” and lead to waste, fraud, and abuse.

For example, the New York State Medicaid program includes the Consumer Directed Personal Assistance Program (CDPAP) which allows beneficiaries to choose their caregiver. This broad eligibility program allows enrollees to choose friends or family members with no caregiving experience. New York’s Medicaid spending jumped from $2.5 billion in 2019 to more than $9 billion in 2023 with estimates of $12 billion in 2025.

More Information

Read H. R. 7713

Read the accompanying brief from the Joint Economic Committee: From Care to Cash: Correting Misaligned Incentives in Home Health

# # #

Idaho Approves $22M Cut

Advocacy

by Kristin Rowan | Apr 17, 2026 | Advocacy, Medicaid, Partner News

by Kristin Rowan, Editor

Idaho Approves $22M Cut

Provider Reimbursement Rates Slashed

Idaho Governor Brad Little approved House Bill 863 in late March after the bill passed the House and Senate. Little directed the state to balance the budget and sent a recommended list of cuts. Among the recommendations was provider reimbursement rates for residential habilitation services, where lawmakers chose to cut nearly $22 million.

Cut Reverses Raises

The State approved pay raises for providers in 2022. This bill reduces those raises for next fiscal year. Combined with previous Medicaid rate cuts, this amounts to a 10% rate reduction for habilitation providers. Lawmakers say this rate is still 33% higher than four years ago.

An Impossible Decision

Lawmakers say balancing the budget required impossible decisions. For Medicaid, the decision was between cutting the Medicaid expansion, and cutting services for people with disabilities. As evidence of the difficulty of the decision, the proposal was delayed twice and was replaced once with a proposal to repeal Medicaid expansion.

Tighten Your Belt

Co-sponsor of the bill, Senator Julie VanOrden, said to follow the money. “The money [goes] from the state to the provider to the caregiver. Somewhere along there, maybe somebody needs to tighten the belt somewhere…. That might mean, as a provider, I don’t take as much money, but I still pay the people that are doing the work the amount that they need.”

HHAeXchange Responds

The Rowan Report reached out to HHAeXchange president Stephen Vaccaro for a comment.

“Idaho’s recent Medicaid disability-services cuts and Colorado’s proposed reductions point to a broader pattern. When states look for Medicaid savings, home and community-based services (HCBS) are often among the first areas affected. But for people who rely on care at home, these supports are essential. They make it possible for individuals to remain safely in the community, rather than shifting into disruptive, higher-acuity settings.

While cutting HCBS may lower spending in one line item, states can end up shifting costs to more intensive settings, like emergency departments and long-term care facilities. To build a more sustainable Medicaid program, states must look beyond immediate savings and consider the longer-term impact of weakening access to services that help prevent more costly outcomes.

States must continue to address fraud, waste, and abuse to protect the long-term health of Medicaid. However, jeopardizing the critical services that people rely on is not the answer. Oversight and accountability should go hand in hand with preserving access to care at home.”

Stephen Vaccaro

President, HHAeXchange

# # #

California Hospice Fraud

CMS

by Kristin Rowan | Apr 10, 2026 | CMS, Home Health, Hospice, Waste Fraud and Abuse

by Kristin Rowan, Editor

California Hospice Fraud

Update 04-16-2026

Reports continue of additional arrests and revoked licenses in the California Hospice Fraud investigations. The anti-fraud task force suspensions rose to 447 hospices and 23 home health agencies this week. The total estimated fraud is more than $600 million. A White House official said, “[the task force] is reviewing and pursuing every possible lead. These suspension numbers, and the dollar values saved, are only going to increase.” Dr. Oz has promised to investigate “every single hospice in California.”

Multiple Arrests and Charges

Hospice fraud has been under investigation with much scrutiny by CMS. National efforts against waste, fraud, and abuse have focused on states with high probability of defrauding the Medicare Trust Fund. On April 9, 2026, California Attorney General Rob Bonta announced charges filed against 21 suspects accused of defrauding the government of $267 million. Five people were arrested and two handguns and more than $750,000 in cash were seized.

Intent to Defraud

After a credible report of fraud, an investigation ensued. The investigation uncovered this scheme. Individuals bought personal identifying information (PII) from people not living in California. They bought the PII through the dark web. They then enrolled these “people” in Medi-Cal, the California Medicaid program. Straw owners purchased 14 hospice companies and started billing Medi-Cal for hospice services for the stolen identities without providing those services.

Location Search

As part of a separate hospice fraud investigation, agencies conducted compliance reviews at a single location in Van Nuys. The address is home to more than 125 individual businesses. Of those, only 19 are licensed by the state and eligible to bill Medi-Cal. 60 percent of the remaining 109 businesses applied for hospice licenses and were denied by the state based on the moratorium on new hospices in place in California since 2021.

The 71 Million Dollar Doctor

Dr. Rajiv Bhuva has connections to Medicare claims from 126 different hospices in California, 115 of which are in LA County. The claims are for almost 2,800 patients. The average doctor cares for 140 patients annually. Dr. Oz confirmed that CMS has revoked Dr. Bhuva’s ability to bill Medicare. Dr. Bhuva has not yet been charged with a crime. A similar case in 2024 resulted in the conviction of Dr. Domingo Barrientos on the charge of conspiracy to commit healthcare fraud. Dr. Barrientos is in federal prison.

Task Force Suspends Providers

A federal anti-fraud task force working in California is investigating both hospice and home health providers. The focus is currently on Los Angeles and LA County, where high numbers of new agencies raised suspicion. As efforts have ramped up, the task force reported suspending 70 providers last week and a staggering 221 total providers suspended so far. The task force anticipates dramatically higher numbers before they’re done. The operation has identified multiple defendants and hundreds of millions in fraudulent claims.

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Accountability and Sustainability in Medicare Advantage

CMS

by Kristin Rowan | Apr 10, 2026 | CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Accountability and Sustainability

CMS Finalizes 2027 Medicare Advantage and Part D Changes

As part of its ongoing efforts to reduce unneccessary payments, CMS issued the 2027 Medicare Advantage (MA) and Part D announcement to “improve payment accuracy” in both programs. The changes aim to make MA sustainable, allow beneficiaries to choose the best health coverage for their needs with maximum value, and make Medicare coverage more affordable.

“CMS’ vision for Medicare Advantage and Part D is clear: a great choice for seniors and a smart deal for taxpayers. The Rate Announcement improves payment accuracy and strengthens competition based on quality—not on coding practices—helping put the program on a more sustainable path for the long term.”

Chris Klomp

Director of Medicare and Chief Counselor, U.S. Department of Health and Human Services

Rate Changes for MA Risk Adjustment Model

The Rate Announcement policy changes address coding differences between MA and traditional Medicare. MA is moving toward a risk adjustment system guided by:

Reducing administrative burdens for plans and providers
Equalizing competition for all MA plans regardless of size or resources
Achieving payments that accurately reflect health risk
Facilitating the efficient use of healthcare resources, enhanced program integrity, and greater accountability

CMS will continue using the 2024 risk adjustment model in pursuit of these changes. However, CMS will exclude diagnosis information from unlinked chart review records from risk score calculation. There is an exception from the exclusion for beneficiaries who switch MA providers. The exclusion does not apply to PACE organizations, which will continue to use a blend of the 2017 and 2024 risk adjustment models. CMS expects this change to lower payments to MA plans by more than $7 billion in 2027.

Part D Risk Adjustment Model

Deductible

Part D beneficiaries cover 100% of the costs of their prescriptions, except insulin and recommended vaccines, until the deductible is met. The 2027 deductible will increase from $615 to $700.

Out-of-pocket maximum

After sunsetting the coverage gap phase in 2025, beneficiaries no long have an initial coverage limit. The initial coverage phase lasts until the annual out-of-pocket (OOP) maximum is reached. CMS is also using the API indexing method to establish the annual OOP threshold. The annual OOP will increase from $2,100 to $2,400 in 2027.

Calculation method

CMS can use one of two methods to update the annual deductible amount. The annual percentage increase (API) measures the average plan expenses per beneficiary. The Consumer Price Index (CPI) measures the annual percentage increase of all items across the U.S.

The 2026 API is 9.37%. The 2026 CPI is 2.31% CMS chose to use the API indexing method to set the 2027 deductible.

Accountability and Sustainability API and CPI 2027 Medicare Advantage Part D

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WISeR Model Not so Wise

Artificial Intelligence

by Kristin Rowan | Apr 3, 2026 | Artificial Intelligence, CMS, Medicare, Medicare Advantage

by Kristin Rowan, Editor

WISeR Model

Dangerous and Troubling

WISeR model is not as wise as CMS had hoped. For many months, we have been reporting on the waste, fraud, and abuse initiatives from HHS and CMS. From stricter oversight to fewer new agencies to broad investigations, the crackdown on wasteful spending of the Medicare Trust Fund has increased steadily. One initiative, the Wasteful and Inappropriate Service Reduction (WISeR) model, launched in Arizona, Ohio, Oklahome, Texas, New Jersey, and Washington. As the name implies, the model aimed at reducing unnecessary services by using an AI powered prior authorization algorith.

Sounds like Medicare Advantage

The WISeR model includes a limited number of procedures that require prior authorization. Even before the model launched, some were concerned that the preauthorization requirement would delay or deny necessary care, much like the prior authorization requirements in Medicare Advantage plans. The Center for Medicare Advocacy testified in opposition to the WISeR model. The spokesperson for CMA, David Lipschutz, supported three bills discussed during that hearing, including one that would stop the WISeR model altogether and prohibit using or testing any payment models for prior authorization in traditional Medicare.

Foresight was 20/20

Three months before the WISeR model launched, CMS founder Judy Stein said the program would create barriers between physician orders and approved procedures. She cautioned:

“Adding prior authorization requirements to traditional Medicare will create costly problems and barriers to necessary care. Instead, to truly address waste and abuse in Medicare, CMS should look to the dramatic overpayments and unreasonable denials in Medicare Advantage.”

Judy Stein

Founder & Senior Advisor, Center for Medicare Advocacy

Early Reports

Physician struggles

Just three months into the WISeR model demonstration, early reports from providers and patients are discouraging. The Washington Post analysis of the model didn’t include a lot of positive feedback. Physicians report challenges with the approval process. Patients wait in pain until needed care is approved. Issues with the technology include problems with online portals as well as struggles with coordination and communication with tech firms and claims processors. Physicians also report denials for care that is within coverages guidelines and decisions that take longer than federal guidelines allow.

Unintended consequences

Part of the model intended to reduce unnecessary spending is a built-in incentive program for cost savings. The tech companies handling the AI algorithms are paid partly on the savings realized after denying medical services. This creates an inherent goal of adjusting the algorithm to deny more services, even if those services are necessary. The model supposedly balances this with pay adjustments for quality measures that include accuracy in decision-making. These tech companies are not staffed by medical professionals and it is unclear what they use as the basis for their decision-making algorithm.

Exemptions

Officials from Medicare say they intend to offer exemptions to physicians with a high authorization rate. These physicians would no longer be subject to the AI prior authorization if, over time, most of their submitted services are authorized. Taking this to its logical conclusion:

Physicians may dial back on recommended procedures until they get the exemption
Once exempt, physicians can circle back and get the procedures for their patients without prior approval
Tech companies may increase denials to ensure continued work
AI oversight of federal health spending could increase if the pilot program saves money, regardless of patient outcomes

Writing was on the Wall

Long before the WISeR model existed, AI algorithms for care authorizations had denied needed care. Insurance companies started using AI to process prior authorizations in 2020. Both UnitedHealth Group and Humana used nH Predict AI for care authorizations for Medicare Advantage. The family of an elderly couple sued UnitedHealth after their care was denied and the couple died. A class action suit against Humana claimed nH Predict AI Model predictions are highly inaccurate and are not based on patients’ medical needs. In February of 2024, CMS clarified the use of AI cautioning that “compliance is required with all of the rules at § 422.101(c) for making a determination of medical necessity, including that the MA organization base the decision on the individual patient’s circumstances.”

Unclear Future

After only a few months, officials have not indicated whether the WISeR model could expand into additional states or to cover additional procedures in the future. Beneficiaries say they stayed with the traditional Medicare plans specifically to avoid the prior authorization hurdles inherent in Medicare Advantage plans. CMS may have additional information by July, when the program has more data.

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Hospice CARE Act

Hospice

by Kristin Rowan | Apr 3, 2026 | Hospice, Medicare, Regulatory

by Kristin Rowan, Editor

Hospice CARE Act

Congress breathes new life into hospice protection

In 2024, Representative Blumenauer (D-OR) introduced the Hospice Care Accountability, Reform, and Enforcement Act. The Bill, H.R. 9803, aimed “to amend title XVIII of the Social Security Act to ensure the integrity of hospice care furnished under the Medicare program.” The House referred the act to the Committee on Ways and Means and the Committee on Energy and Commerce for consideration. The Committee on Ways and Means later referred the act to the Subcommittee on Health, where it apparently remains under consideration.

On March 18, 2026, Congresswoman Sanchez (D-CA) and Senator Warner (D-VA) introduced, or re-introduced, the Hospice Care Accountability, Reform, and Enforcement (Hospice Care) Act. According to the joint press release from its sponsors, the act will “modernize the Medicare hospice benefit, protect patients and taxpayers from fraud, and expand access to essential services and caregiver support.”

Program Integrity and Payment Reform

The two primary foci of the act are program integrity provisions and payment reforms. The hospice benefit remains largely unchanged since it began in 1982 despite significant changes in both the providers delivering and patients receiving end-of-life care. The rise in reports of fraud and abuse puts into question whether the current system can ensure both meeting the needs of patients and families and safeguard the Medicare Trust Fund.

“Hospice should provide comfort and dignity at the end of life, yet the benefit has not evolved to meet families where there is need. This bill strengthens and enhances Medicare’s hospice benefit so it provides the critical care patients and their families need – like respite care for caregivers and coverage of palliative treatments like dialysis and radiation – all while protecting the program from those trying to exploit it.”

Linda T. Sanchez

Congresswoman, D-CA

Program Integrity

According to the sponsors, the bill “creates additional safeguards to precent fraudulent providers from enrolling in Medicare and increases oversight of hospices, especially new hospices.”

Specifically, the bill:

Temporarily prevents new hospices from enrolling in Medicare, while allowing exceptions for instances where additional access to care is needed.
Requires increased transparency of hospice ownership and managing control information, ensuring CMS’s enrollment records are up to date.
Increases survey frequency for new hospices to ensure they meet hospice health and safety standards and prohibits payments to hospices that do not submit required quality data to the Secretary, with appropriate exceptions.
Reduces the potential for inappropriate financial conflicts of interest when certifying individuals’ eligibility for hospice care, while allowing nurse practitioners and physician assistants to also certify eligibility.
Requires CMS to conduct additional oversight activities to ensure hospices are providing holistic and comprehensive care.
Provides patients with an explanation of benefits within 15 days of an individual’s hospice election to increase beneficiary awareness of hospice enrollment and prevent extended periods of fraudulent billing.

Payment Reform

The bill “ensures that providers are incentivized to deliver high-quality care to individuals and their families.”

Specifically, it:

Revises the payment structure for routine home care to reward hospices for providing in-person care.
Increases payments to hospices for furnishing palliative radiation, chemotherapy, blood transfusions, and dialysis to address access barriers for individuals that require these costly treatments under a hospice election. Additionally, it creates an outlier payment policy to provide a backstop for providers delivering care to high-cost patients.
Adds home respite care to the Medicare hospice benefit, allowing individuals to receive respite care at home rather than in a facility, which is a key benefit for families and caregivers that are taking care of loved ones at the end-of-life.
Creates a new transitional inpatient respite benefit to support patients and families through their transition from a hospital into hospice care in the setting of their choice, allowing patients to move from hospital to general inpatient care to transitional respite, when appropriate. This new transitional payment seeks to eliminate the current pattern of care whereby terminally ill individuals are discharged from the hospital and inappropriately admitted to a skilled nursing facility in lieu of electing hospice care.

“Making decisions about hospice and end-of-life care is one of the most difficult moments that families can endure, yet Medicare’s hospice benefit is out-of-touch with the needs of patients and providers. I’m proud to introduce this legislation that will prioritize patient comfort at home as well as in a health care facility, and protect patients and taxpayers from bad actors attempting to steal essential resources.”

Mark Warner

Senator, D-VA

Industry Support

The Hospice CARE Act received wide-spread industry support after its introduction to Congress.

American Academy of Hospice and Palliative Medicine

“Patients and families in need of the care, comfort and quality of life that hospice care provides need to trust that they are receiving the best possible services. We look forward to working with Representative Sánchez and Senator Warner on these important issues and to ensure that all patients have access to this vital care.”

– Kristina Newport, CMO for AAHPM

Center for Medicare Advocacy

“In addition to significant payment reforms and program integrity measures, this bill takes important steps towards improving access to care for individuals on hospice.”

-David Lipschutz, Co-Director for the Center for Medicare Advocacy

National Alliance for Care at Home

“Hospice care is one of the most profound services our healthcare system offers, providing patients and families with compassionate, dignified care during life’s most difficult moments. As the number of Americans turning to hospice continues to grow, it is critical that the benefit keeps pace with how care is delivered today and what patients, families, and providers actually need. The Alliance looks forward to working with Representative Sánchez and Senator Warner and their congressional colleagues on this legislation. We are committed to being a constructive partner in any effort to protect what’s working, address what isn’t, and modernize the Medicare hospice benefit in ways that serve patients, families, and the future of care in our country.”

-Jennifer Sheets, CEO for The Alliance

LeadingAge

“At its best, compassionate, high-quality, person-centered care is delivered to beneficiaries and families by ethical, forward-thinking, competent providers, in keeping with the sector’s nonprofit origins, which established a standard of quality care. Currently, however, hospice is at an inflection point. Increased scrutiny – an appropriate response to fraudulent behavior of a limited group of bad actors – highlights the need for modernization.

-Katie Smith Sloan, President and CEO for LeadingAge

National Partnership for Healthcare and Hospice Innovation

“This legislation provides an important opportunity to pursue thoughtful reforms to the Medicare hospice benefit that both preserve patient access and address ongoing concerns related to program integrity. While the bill represents meaningful progress toward modernizing the benefit and reducing incentives for fraud, waste, and abuse, NPHI believes certain provisions – particularly those related to payment reform – present opportunities for further discussion and refinement.”

– Tom Koutsoumpas, Founder and CEO of NPHI

More Information

A section-by-section analysis of the bill is available HERE
A one-pager of the bill is available HERE

Congress is on recess until the middle of April. The last few months will dictate the priorities when the next session starts, which will likely be focused on finalizing the budget and fully reopening the government. Whether the Hospice CARE Act will progress past its 2024 version is unclear. The Rowan Report will continue to monitor its progress.

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Kristin Rowan is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news. She is also a sought-after speaker on Artificial Intelligence, Technology Adoption and Lone Worker Safety. She is available to speak at state and national conferences as well as software user-group meetings.

Kristin also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. She works with care at home software providers to create dynamic content that increases conversions for direct e-mail, social media, and websites. Connect with Kristin directly at kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2026 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

MedPAC Finalizes Recommendation to CMS

Advocacy
by Kristin Rowan | Jan 30, 2026 | Advocacy, CMS, Home Health, Hospice, Medicare, Regulatory

by Kristin Rowan, Editor

MedPAC Recommends 7% Cut

Vote Finalized

In December, MedPAC published a proposed recommendation for calendar year 2027 that included a 7% cut to home health reimbursement rates and no increase for hospice. Last week, MedPAC voted to finalize that recommendation and send it to CMS.

Industry Objection

Both the proposal and final recommendation met with strong industry backlash.

“MedPAC’s dangerous and misguided recommendations to reduce the Medicare home health base payment rate by 7% for CY 2027 and eliminate the update to the 2026 Medicare base payment rate for hospice do not reflect both home health and hospice agencies’ operating realities as well as the cumulative impact of recent policy changes. For home health agencies, any cut – let alone one of such great magnitude – will threaten the ability to meet individuals’ healthcare needs. Yet again, the Commission is failing to understand the operating reality providers face and the potential patient harm that any further payment cuts pose.”
Dr. Steve Landers
CEO, National Alliance for Care at Home

Consistently Wrong

The MedPAC recommendation may not be built on solid data, use accurate calculations, consider Medicare Advantage and Medicaid rates along with Traditional Medicare FFS, consider the number of agencies that will go out of business, have any recommendations for maintaining nurse and caregiver hourly rates, or fairly distribute Medicare funds across disciplines, but, wait…where was I going with this? Oh, right! At least they’re consistent. MedPAC recommended a 7% decrease in Medicare payments for 2027, 2026, 2025, 2024, and 2023. They may be completely wrong, but they are dedicated to maintaining their wrongness.

Final Thoughts

Despite the years of 7% cut recommendations from MedPAC, the final numbers from CMS are rarely in line with those recommendations. We will, of course, know more when CMS publishes their proposal later this year. LeadingAge, National Association for Care at Home, individual and corporate HHAs and Hospices, and anyone else with a stake in the care at home industry, should contact their congressional representatives and CMS directly to voice concerns over these cuts.

# # #

Kristin Rowan is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news. She is also a sought-after speaker on Artificial Intelligence, Technology Adoption and Lone Worker Safety. She is available to speak at state and national conferences as well as software user-group meetings.

Kristin also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. She works with care at home software providers to create dynamic content that increases conversions for direct e-mail, social media, and websites. Connect with Kristin directly at kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2026 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

UnitedHealth Group Publicity Stunt

CMS
by Kristin Rowan | Jan 30, 2026 | CMS, Editorial, Medicaid, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

UnitedHealth Group Publicity Stunt

How to Distract the Public: 101

When customers and regulatory bodies start to complain about company practices, reputation management usually gets involved. An internal or external public relations, crisis communication, and/or reputation management specialist advises the company on how to overcome negative press.

Transparency & Action

When Dominos Pizza employees recorded a disturbing “hoax” video, the CEO went to the same medium (YouTube) to address the video, apologize, and reassure customers. This issue was handled so well that it is used as a teaching tool in PR classes.

In 1982, when a couple tampered with bottles of Tylenol in Chicago and seven people died, parent company Johnson & Johnson stopped advertising, recalled 31 million bottles across the country, switched to tamper-proof packaging, and personally communicated with 450,000 retailers.

Subterfuge, Smoke & Mirrors

Last week, when UnitedHealth Group, already under investigation for bribing nurses, wrongful death, and Medicare Advantage billing fraud, was called to testify before House committees about their record-high premiums, rising claims denials, and unneccessary waiting over prior approvals, UHG CEO prepared a written statement to read to the Energy & Commmerce Committee that included blaming hospital costs, pricing differences, frequency of testing, drug prices, and pharmaceutical advertising for higher premium rates; extolling the virtues of Medicare Advantage over Traditional Medicare, using incorrect and misleading information; and casually mentioning that they will “voluntarily eliminate and rebate our profits” for their ACA customers.

Gesture too Small to be Meaningful

The months long Congressional stand-off on healthcare premium subsidies continues. Affordable Care Act participants saw healthcare premiums jump over night when the subsidies expired. (Mine went up 400%).

In 2025, UnitedHealth recorded $12.1 billion in profit. But, that profit is spread out over nearly 3,000 wholly owned subsidiaries who take almost 30% of what UHG pays out in care costs. The company has increased its Medical Loss Ratio to 87% by hiring their own subsidiaries to engage in “quality improvement,” virtually eliminating ACA profit.

Of its 50 million subscribers, only about 1 million are ACA customers. Even if the company returns the ACA profits, it will return 1/50th of its profits and keep the rest. In their third quarter earnings call, UHG said it expected 2026 enrollment to be 1/3 of that in 2025. The 2026 outlook estimates an overall increase in profit to more than $14 billion, most of which will never find its way back to ACA participants.

The Truth Behind the Curtain

On January 27, 2026, just one week after the profit-sharing announcement, UnitedHealth Goup addressed shareholders in its Q4 and 2025 Earnings Call. During that call, newly appointed UnitedHealthcare CEO Tim Noel said:

“Nearly all of our employer Group and fully insured pricing align with continued increases in care activity for 2026. In the Individual ACA market, we repriced nearly all states in response to higher medical trends and the elevated needs of ACA beneficiaries in 2025…. These actions should expand operating earnings margins for UnitedHealthcare by 40 basis points, and are expected to result in membership contraction of 2.3 to 2.8 million.”
Tim Noel
CEO, UnitedHealthcare

Other statements during the call reinforced the company’s drive toward profit.

They are focusing attention in markets where they have “complimentary wrap-around services” already in place. Which means they have owned subsidiaries to shift money to instead of lowering premium rates. Additionally, they have “narrowed [their] affiliated network…with the goal of having a more optimal alignment of physicians….”

New Speak

Throughout the earnings call, company spokespeople used terms like repositioned, streamlined, aligned, membership contraction, and repriced. They carefully avoided saying that they dropped physician services outside those they owned, removed plans that paid out too much, consolidated businesses to increase profits, lost millions of members due to price increases and other plan problems, and raised prices across the board, even on plans that were already profitable.

Final Thoughts

UHG CEO Hemsley made a few statements to Congress I agree with. Drug prices are too high. Hospital and Ambulance prices are too high. Pharmaceutical companies advertise too much and use the cost to offset tax liability.

There were also some statements Hemsley almost got right.

He said small businesses should be allowed to join AHPs with fewer restrictions. There should be no restrictions on industry or geography.

He said HSA thresholds should be lowered for HDHPs. HSAs should be available to everyone, regardless of plan, deductible, payer, or whether they are on a group, individual, or ACA plan.

Hemsley thinks broker compensation should be standardized in the ACA market. If payers want broker compensation, standardized or not, ACA or Medicare Advantage, the compensation should come from the payer and not be included in premiums.

He wants consumers to have expanded access to catastrophic plans and to allow the use of premium tax credits. All plans and payers should be available to everyone, everywhere. Increasing competition in plans and players will drive down costs.

I applaud Congress for bringing the large payers in to discuss exhorbitant premium rates, but I’m still waiting on them to take action based on the information they received.

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Kristin Rowan is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news. She is also a sought-after speaker on Artificial Intelligence, Technology Adoption and Lone Worker Safety. She is available to speak at state and national conferences as well as software user-group meetings.

Kristin also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. She works with care at home software providers to create dynamic content that increases conversions for direct e-mail, social media, and websites. Connect with Kristin directly at kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2026 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

VA Updates Community Cares Contracts

Admin
by Kristin Rowan | Jan 23, 2026 | Admin, CMS, Regulatory

by Kristin Rowan, Editor

VA Issues RFP

Updates to Community Care Contracts

Some Veterans receive care from VA providers. Non-VA providers can still provide care for Veterans through a Community Care contract with the U.S. Department of Veterans Affairs (VA). In late 2025, the VA released a Request for Proposal (RFP) for new CC contracts. The new contracts are designed to substantively change non-VA provider care to Veterans.

According to the VA, the new contracts are intended to:

Increase choice through an IDIQ model that allows multiple health plans to compete to serve Veterans

Raise quality of care by requiring plans to follow broad standards of care adopted by major health systems

Improve oversight and quality of care using better data, technology, and real-time management

Add flexibility so the VA can issue competitive task orders and remove underperforming contractors

How Does This Impact Care at Home?

The primary contractor, and therefore the ones responsible for bidding and ensuring quality of care are the health plans. So, how does this change impact home care and home health providers? Here’s how:

Fast changes in network participation along with sudden shifts will inevitably come as a result of plans competing and task orders changing

Plans will need to align with VA targets, so expect waves of onboarding, recurring pushes for credentialing, and increased local networking

Because the plans will be held to quality standards, you can expect that those standards will flow through provider documentation, timeliness, claims accuracy, and EVV and FWA compliance

IDIQ is specifically designed to allow changes in the middle of care, which means the VA and health plans can add or change rules or portal, and make revisions to edit sets during the contract

Get Ahead of the Changes

Plan to make some changes before these new Community Care contracts come to your local health plans. In order to comply with the contract requirements, your credentialing packets need to be updated to include up-to-date CAQH, insurance, licenses, and compliance. This will help minimize the lag-time before getting paid.

Anticipate Expectations

The health plans will be competing for contracts, so they will expect you to compete as well. Awarded contracts will likely be fulfilled by agencies who have a high clean claim rate and quick response to edits and denials. Whatever you are using for coding, documentation, and rules need to be validated before the new care contracts start. Complete documentation will comply with the VAs focus on better data and real-time management. Make sure your team is executing precise reports; centralize your records, documentation, and audits to prove performance records and decrease issue resolution time.

Final Thoughts

Non-VA providers who want to be considered to provide care to Veterans need to show alignment with the VA’s goals to expand choice, raise quality, and increase oversight. Planning ahead by meeting those standards early will make the transition process smoother one the new contracts roll out. We will continue to provide resources and information on these Community Care contracts as they are available.

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Kristin Rowan is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news. She is also a sought-after speaker on Artificial Intelligence, Technology Adoption and Lone Worker Safety. She is available to speak at state and national conferences as well as software user-group meetings.

Kristin also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. She works with care at home software providers to create dynamic content that increases conversions for direct e-mail, social media, and websites. Connect with Kristin directly at kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2026 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

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