Government Shutdown

Medicaid

by Kristin Rowan | Oct 9, 2025 | Medicaid, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Government Shutdown Threatens Care at Home

Lawmakers on opposite sides of the aisle failed to come to a budget agreement by the deadline. This causes an immediate cease to all non-essential government functions and many government employees aren’t being paid.

UPDATE: Shutdown, Day 16

–As of October 16, 2025–

What it Means for Care at Home

After 10 attempts, the government is no closer to an agreement than they were on September 30th. The Senate is expected to break at the end of the day, leaving the next opportunity to negotiate until at least Monday.

Telehealth

The biggest impact on care at home during the government shut down is the ability to complete required face-to-face visits using telehealth appointments. Both home health and hospice have employed telehealth for face-to-face encounters since the COVID-era waiver, which has now been extended several times. The most recent extension, which we anticipated Congress to extend in this budget, expired on September 30th.

All face-to-face encounters occurring after October 1, 2025 must be in person.

According to home health expert Melinda A. Gaboury of Healthcare Provider Solutions says it is unlikely an extension would be retroactive even if Congress includes an extension in the finalized budget.

Payments

Conflicting information on Medicare payments leave us unsure of the actual impact. Some reports say there will be no delay while others mention 10-day holds. It is unclear whether this is in addition to the standard 14-day hold. Either way, we are anticipating (and hoping for) minimal payment disruptions.

Surveys

Initial Medicare certification for home health and hospice as well as recertifications will be delayed. If ACHA, CHAP, or another accrediting body is conducting your survey, however, there should be no delay. These accrediting bodies are continuing without interruption. State agency surbveys will be delayed until after the budget is finalized and the shutdown ends.

Look for continued updates from The Rowan Report as the shutdown and negotiations continue.

–As of October 9, 2025–

The Disagreement

Reporters and spokespoeople from both sides of the debate have suggested various reasons for the shutdown. Equally, both sides claim they are not the holdouts. What we do know for sure is that one of the primary points of contention is the continuation of subsidies for Affordable Care Act Marketplace Insurance plans. One group wants an extension written into the current budget while the other says it’s not necessary since the subsidies currently run through the end of the calendar year.

Push to Extend

The lawmakers who are pushing to get the subsidy issue resolved believe that marketplace users are not going to sign up for insurance in November and do it again in January when the subsidies are fixed. Instead, insurance commissioners warn that without the subsidies, many people will opt not to have insurance at all and others will select substandard plans based on affordability. They will be priced out of the plans they want without the subsidies in place.

Priced Out

In 2025, even with the subsidies, the average family was paying $800 per month on health insurance through the marketplace. When the subsidies expire, those same families will see their existing plan rates jump to $3,000 per month. KFF, the nonpartisan health research organization, estimates that most users will have a 114% rate increase.

Photo Credit – The New York Times

Counter

According to ND insurance commissioner Jon Godfread, lawmakers who oppose the subsidies are actually opposing the cost of health care and insurance across the board. They insist the subsidies aren’t necessary if healthcare and insurance costs drop instead. Proponents of the subsidies agree, but say that is a longer discussion that will take a lot of time to resolve and the subsidies provide an immediate solution to a bigger problem. They are urging the holdouts to include the subsidies in the budget and tackle the rising cost of healthcare later.

Open Enrollment

The clock is ticking. Open enrollment for 2026 begins November first in every state except Idaho, where open enrollment starts next week. Insurers have already locked in their 2026 premium rates, which will likely cause sticker shock for most marketplace users. Most insurers have prepared subsidy and non-subsidy rates, but without the extension, we will only see the much higher non-subsidy rates. These rates are unlikely to change before enrollment starts and the only hope for marketplace buyers is for Congress to extend the subsidies.

Care at Home Impact

There are several ways in which the shutdown and the loss of the subsidy may impact care at home.

Payment delays are the most pressing risk. Government officials have promised no delay for some essential services like SNAP and WIC. It is likely Medicare and Medicaid payments will be delayed. While those payments will come through eventually, care at home agencies have to operate without payment or hope the

payers will process payments locally while waiting on the government to reopen. The longer the shutdown lasts, the more likely it is that payments will be delayed. The 6th Senate budget vote failed today, sending the shutdown to day 8.

The longer term impact for care at home will come if the subsidies are not renewed. If insurance rates increase by more than 100% on November 1, users will opt for lower priced coverage, which may no longer include care at home benefits. Fewer patients seeking care at home means less money for agencies. Long-term, it also means higher hospital and ER usage and costs, which increases government spending and usually leads to additional care at home cuts to offset the costs.

National Alliance for Care at Home has identifed current and potential implications of the shutdown. Read their analysis here.

This is an ongoing story and we will continue to provide additional information as it happens.

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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

MACPAC Rate Setting

CMS

by Rowan Report | Sep 25, 2025 | CMS, Medicaid, Medicare, Medicare Advantage, Partner News

FOR IMMEDIATE RELEASE

Contact: Elyssa Katz
571-281-0220
communications@allianceforcareathome.org

MACPAC Rate Setting

The Alliance Expresses Concerns Regarding MACPAC Approach to HCBS Rate Setting

Alexandria, VA, and Washington, DC, September 18, 2025. The National Alliance for Care at Home (the Alliance) released the following statement in response to the Medicaid and CHIP Payment and Access Commission’s (MACPAC) discussion regarding home- and community-based services (HCBS) rate-setting held during today’s September MACPAC meeting.

The Alliance appreciates MACPAC’s interest in addressing issues related to worker pay in HCBS. These workers should receive higher wages and benefits as they are the backbone of the long-term care system in our country. They are dedicated professionals who provide essential services that promote the community integration, independence, and positive health and social outcomes of older adults and people with disabilities.

Unfortunately, we are concerned about the draft recommendation MACPAC discussed during today’s meeting. Rather than seeking to address the root-cause of low worker wages, MACPAC’s recommendation instead focuses on collecting

additional information that would further describe the issue. This approach increases administrative burden on states and providers without actually proposing solutions to this problem.

MACPAC Rate Setting Report

MACPAC’s report acknowledges that rate studies and wage data are insufficient to address chronically underfunded Medicaid HCBS programs. To create meaningful change, state administrations and state legislators must be held accountable to fund services at levels that enable improved wages for workers. Sixty years of Medicaid program history have demonstrated that such wholesale changes to state actions are only achieved through new and strengthened Federal requirements. We urge MACPAC and its Commissioners to be bold and recommend structural changes to Federal Medicaid law and regulations that mandate payment policies ensuring access to HCBS through livable wages for direct care workers. The Centers for Medicare & Medicaid Services (CMS) should be given the authority to require states to:

Perform comprehensive rate studies no less frequently than every five years that:
- Use generally accepted accounting practices to develop a payment methodology that assures continued adequacy of each component of the rate model; and
- Establish a rate model that includes individualized components for core provider cost drivers as well as a livable wage for workers.
Submit a copy of the rate review report and recommendations with any waiver renewal or state plan amendment and make the report publicly available on their website; and
Require states to justify any variance between the report recommendations and the actual established payment rates.

Further, CMS should be given the authority to disapprove rate methodologies that do not clearly account for all statutory and regulatory requirements of delivering services as well as demonstrating that the rates are sufficient to support a livable wage for workers.

Our members are committed to improving the lives and livelihoods of direct care workers because beneficiaries depend on them. We call on MACPAC to ensure that states and the federal government are equal partners in this critical endeavor.

# # #

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.

© 2025. This press release originally appeared on the National Alliance for Care at Home website and is reprinted here with permission. For more information or to request permissions, please see the contact information above.

Bill Dombi Presents

Advocacy

by Kristin Rowan | Sep 18, 2025 | Advocacy, Home Health, Hospice, Medicaid, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Bill Dombi Presents...

It has become almost customary for the President/CEO of The Alliance, and previously NAHC, to give the keynote address at state association and software user group meetings. The 2025 Kantime event, Passport to Success, was no exception. Dr. Steve Landers was scheduled to speak first thing Tuesday morning. But, Dr. Landers is in D.C. speaking to members of Congress and CMS for Advocacy Week, trying to convince anyone who will listen of the needed changes in Care at Home.

When Kantime asked Bill Dombi, former President of NAHC, to take Landers’s place, they asked him not to give his customary “vanilla” talk about the state of the industry. According to Dombi, Kantime gave him a bit of a license to step outside the traditional industry address. He took that license and ran with it, regaling the audience with stories of his school days, being educated (and tortured) by KCatholic nuns in full habits, his road to both the law and care at home, and his thoughts on the future of the industry.

“I shouldn’t be here. I’m retired! I should have no shoes in, wearing shorts, or maybe still sleeping, waking up just in time to catch Let’s Make a Deal or the Price is Right, have lunch, take a nap, and then watch a movie or mow my lawn. I had retirement dreams of lounging on a two-person hammock by the beach. My hammock is in the basement. And the guitar I bought myself as a retirelment present, with dreams of coming back here with my band, remains unopened in my living room. It has never been out of its case.”

Bill Dombi

President Emeritus, National Alliance for Care at Home

“But, one of my jobs is to make my successor a success. So, here I am.”

This led Bill to his first topic, Passion: Powering Health Care at Home. He invited the audience to think not of his story, but of their own what lead to their passion for care at home. If you’ve ever heard Bill Dombi speak about care at home and his wish to in his lifetime see the industry become what he has advocated for and imagined for more than 50 years, then you know how spirited and passionate he is. He has fought against injustice since the 6th grade and fought for radical improvement in care at home since college.

Bill spoke openly about the fraud, waste, and abuse that has plagued home health and hospice since before most of us knew what home care was. He lamented the continued need for advocacy at both state and federal levels with each new administration, bill, and MedPAC recommendation since before the Reagan era. He recalled the advent of Medicare and Medicaid when care at home was limited and underused. And he warned of the disasterous idea of rolling Hospice care into Medicare Advantage. In true “Bill Dombi style,” he managed to do all of this in a way that left an air of hope in the room rather than doom.

What's in Store for Care at Home?

Bill talked about the progress his successor has made, including his current work on The Hill for Advocacy week. According to Bill, the advocacy focus for the National Alliance for Care at Home is:

PDGM
Hospice Carve-in
HCBS OBBA Risks
HCBS 80/20 rule
Medicare Advantage
Workforce Improvement

Final Thoughts - Dombi's Care at Home Forecast

The scope of Health care at home will continue to expand. There will continue to be technology and artificial intelligence advances in care at home. The provide design and delivery of care model will evolve. Consolidation and competition are definitely in play. And the workforce is a common denominator for success.

# # #

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

Advocacy Week

Advocacy

by Rowan Report | Sep 18, 2025 | Advocacy, Home Health, Hospice, Medicaid, Medicare, Medicare Advantage, Regulatory

Advocacy Week

FOR IMMEDIATE RELEASE

Contact: Elyssa Katz
communications@allianceforcareathome.org
571-281-0220

Over 240 Advocates Rally in DC for the Future of Care at Home

National Alliance for Care at Home Hosts Inaugural Advocacy Week on Capitol Hill

Alexandria, VA and Washington, D.C., September 12, 2025.

More than 240 care at home care advocates from across the country met with over 275 congressional offices this week to discuss key legislative and regulatory priorities for expanding access to home-based care services. The meetings were part of the 2025 National Alliance for Care at Home’s inaugural Advocacy Week.

Alliance Advocacy Week brings together leaders, advocates, and supporters to unite as one voice for care at home, driving positive legislative change and shaping the future of care to ensure broader access to the life-changing home care services for all Americans.

Advocates focused on four key issues during their congressional meetings:

Protecting home health care by preventing dangerous payment cuts
Safeguarding the Medicare Hospice Benefit by ensuring hospice remains a separate holistic managed care model outside of Medicare Advantage
Expanding telehealth access across many care at home services
Supporting robust Medicaid HCBS funding to strengthen community-based care

Advocacy Week National Alliance for Care at Home

In addition to Wednesday’s congressional meetings, Alliance Advocacy Week featured strategy sessions, beginner advocate training featuring a panel discussion with Congressional staffers, and in-depth policy briefings. On Thursday, the Alliance’s Assembly of State Associations – a network of leaders of state home care and hospice organizations – came together for a robust conversation.

The Alliance celebrates the achievements of this inaugural Advocacy Week on behalf of home-based care providers nationwide and will continue engaging in critical policy dialogue to support and expand access to essential care at home services.

# # #

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.

©2025. This press release originally appeared on the National Alliance for Care at Home website and is reprinted here with permission. For questions or to request permission to use, please see press contact information above.

Medicare Advantage Excess Payments

CMS

by Kristin Rowan | Sep 4, 2025 | CMS, Hospice, Medicaid, Medicare Advantage

by Kristin Rowan, Editor

Medicare Advantage Excess Payments

Investigational Study

Researchers from the Department of Health Services, Policy and Practice at Brown Universchool of Public Health and the Department of Geriatrics and Palliative Medicine at Icahn School of Medicine published an original investigative study on spending versus payments in Medicare Advantage under the hospice carve-out model.

Carve-out to VBID to Carve-out

In 2021, CMS started a Value-Based Insurance Design (VBID) to test the impact of adding hospice services to Medicare Advantage benefits. By December of 2024, CMS ended the program due to widespread upset. CMS returned to the hospice carve-out model. Under this model, when an MA beneficiary chooses hospice, any health care expenses related to the terminal illness is paid on a fee-for-service (FFS) basis. MA no longer receives inpatient and outpatient payments, but continues to receive premiu, and rebate payments.

Carve-out Hospice Benefit

Once an MA enrollee enrolls in hospice, MA is no longer responsible for payments. Under the carve-out model, hospice services are paid by Medicare. MA plans are still responsible for paying for services that are not related to hospice care. These services can include inpatient, outpatient, physician, skilled nursing facility, home health care, and prescription drug expenses.

Medicare Advantage Spending and Payments

The study spanned 12 months and looked at 314,087 MA beneficiaries. In that period, 80.5% of enrollees had no spneding unrelated to their terminal illness. MA was not responsible for any healthcare related payments, but continued to receive $120 per enrollee per month. Estimated spending from MA on hospice enrollees was $57-70 per month.

In the 12 months following an enrollee electing hospice, MA plans netted $50-60 per month per enrollee. If half of the rebate payments received pay for supplemental benefits, MA receives excess payments to the tune of $68,808,924 over three years. If no rebate payments go toward supplemental benefits, MA receives $174,185,112 in excess payments over three years. The care a hospice enrollee receives uses the fee-for-service model. Medicare Advantage providers are seemingly paid on a fee-for-no-service model.

Medicare Advantage plans do not currently report the actual amount of rebate payments used to pay supplemental benefits.

Study Conclusion

The researchers conclude that MA receives excess payments under the hospice carve-0ut model. They also note that there is no accountability for spending after hospice election from MA plans to CMS. The researchers suggest that CMS could require MA plans to report actual spending on supplemental services after hospice election and pay premiums and rebates only to cover the amount spent.

I have a different recommendation….MA plans should not receive any additional premium payments or rebates following hospice election. MA plans should be required to report total payments and spending from enrollment date to election date. The balance, less the same 8% average margin of home and health and hospice agencies, should be used to pay for hospice services from election to passing. Any remaining balance after the patient’s passing should be returned to the beneficiary’s family.

# # #

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

DOJ Settles with UnitedHealth and Amedisys

Legal

by Kristin Rowan | Aug 21, 2025 | Legal, M&A, Medicare, Medicare Advantage

by Kristin Rowan, Editor

DOJ Settles with UnitedHealth and Amedisys

Judge to Weigh In

DOJ settles with UnitedHealth and Amedisys after almost nine months of negotiations. The Department of Justice (DOJ) initially blocked the proposed merger between UnitedHealth and Amedisys, citing concerns over eliminating competition in home health and hospice services in some areas of the U.S. After the most recent settlement hearing, the merger seems to be back on track.

Public Comment Period and Judicial Review

Now that the DOJ hurdle has been passed, there is a public comment period. Following the public comment period, the U.S. District Court for the District of Maryland will enter final judgement. From the Justice Department website:

As required by the Tunney Act, the proposed settlement, along with a competitive impact statement, will be published in the Federal Register. Any interested person should submit written comments concerning the proposed settlement within 60 days following the publication to Jill Maguire, Acting Chief, Healthcare and Consumer Products Section, Antitrust Division, U.S. Department of Justice, 450 Fifth Street NW, Suite 4100, Washington, DC 20530.

Antitrust Division Statement

“In no sector of our economy is competition more important to Americans’ well-being than healthcare. This settlement protects quality and price competition for hundreds of thousands of vulnerable patients and wage competition for thousands of nurses. I commend the Antitrust Division’s Staff for doggedly investigating and prosecuting this case on behalf of seniors, hospice patients, nurses, and their families.”

Abigail Slater

Assistant Attorney General, Justice Department Antitrust Division

Divestiture Agreement

According to the new agreement, UnitedHealth will sell 164 home health and hospice locations across 19 states. In addition to the sale, the agreement provides the buyers of these locations with assets, personnel, and relationships to help them compete with remaining UnitedHealth locations. Also included are protections to deter UnitedHealth from interfering with the new owners’ ability to compete.

BrightSpring Health Services and Pennant Group will acquire the 164 locations. Slater said the settlement, which includes the largest ever divestiture of outpatient healthcare, protects quality and price competition patients as well as wage competition for nurses. However, antitrust specialist Robin Crauthers, a partner with McCarter & English, says it doesn’t go far enough. According to Crauthers, the settlement agreement does not address all of the markets that would have less competition and that the DOJ accepted less than they wanted in the agreement.

Additionally, critics argue the divestiture moves 164 home health and hospice agencies from one large player to two other large players in the space. Arguably, rather than preserve competition, this divestiture agreement will only serve to strengthen the largest players in the market, giving them a substantial advantage over smaller agencies in these areas.

UnitedHealth Amedisys divestiture locations

Not the Only Concern

Vertical Integration

Joe Widmar, Director of M&A at West Monroe consulting firm, says that the number of home health and hospice agencies is not the tipping factor in competition. Rather, it is UnitedHealth’s vertical integration. A health insurance company that also owns nearly 2,700 subsidiaries, including pharmacies, home health and hospice, behavioral health, consulting for healthcare organizations, surgery centers, hospitals, mental health, managed care for Medicaid and Medicare, and specialty care. Virtually any referral from a PCP to any other health professional puts more money into the health care giant’s pockets. The lack of competition is across all forms of healthcare, leaving patients no choice buy to support UnitedHealth Group in areas where all local healthcare providers are subsidiaries. I 2024, UnitedHealth insurance paid $150.9 million to its subsidiaries for care. These provider companies are not counted in the profit caps placed on insurance companies.

Upcoding

In addition to side-stepping profit caps, vertical integration aids in upcoding. Upcoding is the practice of digging into a patient’s life to find (or create) additional patient needs. Insurers add as many codes as possible for the greatest reimbursement rates. According to a recent study, UnitedHealthcare overbilled Medicare Advantage by $14 billion through upcoding.

In-home health risk assessments and patient reviews, often offered to beneficiaries as a free service, result in an average risk score 7% higher than in patients seen in medical practices and hospitals. UnitedHealth generates more income from patient review diagnoses than any other MA insurer. The Department of Justice is currently investigating UnitedHealth’s Medicare billing practices.

Final Thoughts

If you own a home health, hospice, or palliative care agency in any of the states shown in the graphic above, write to Jill Maguire with comments and concerns. Our primary objective is providing quality care to patients in their homes. We know that home care is less expensive for the patient and government-funded insurance. But not when all the home care agencies in an area are owned by only a few of the largest home health agencies in the country. And not when the insurer is adding diagnostic codes to pad their bill.

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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

Alliance Responds to Hospice Final Rule

Advocacy

by Kristin Rowan | Aug 7, 2025 | Advocacy, CMS, Hospice, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

The Alliance Responds to CMS Hospice Final Rule

CMS Issues FY 2026 Hospice Final Rule

On August 1, 2026, CMS issues the FY 2026 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Programs Requirements Final Rule. Here are the high-level changes in this year’s final rule:

Rate Setting Changes
- A 3.3% inpatient hospital market basket percentage increase
- A 0.7% productivity adjustment (read decrease)
- Statutory cap increases from $34,465.34 to $35,361.44
Hospice Care Admission
- The physician member of the interdisciplinary group (IDG) may recommend admission to hospice care
Face-to-Face Attestation
- Signature and date requirements restored
- Eliminated requirement for attestation to be a separate and distinct document
- Attestation requirement can be a section or addendum to recert form, or part of a signed and dated clinical note
Hospice Quality Reporting Program

The HOPE tool will replace the HIS tool on October 1, 2025, despite comments to delay implementation
CMS published a HOPE Technical Information webpage ,an HQRP training library, and a Requirements and Best Practices webpage
CMS recognized the error in their HOPE burden calculations. The burden is 21.1% higher than initially reported. The difference will be “taken into consideration” in the next PRA package submission.
The separate reporting tool (QIES) and reports tool (CASPER) will sunset and iQIES will replace both tools.

FY 2026 Hospice Quality Reporting Program

National Alliance for Care at Home Statement

After CMS issued the final rule, the Alliance responds with a statement addressing the wage adjustment, HOPE tool implementation, and sttestation changes. Read the full press release here.

Wage Adjustment

The Alliance recognizes that the 2.6% wage update is higher than the proposed 2.4% adjustment issued earlier this year. However, The Alliance maintains its position that the update does not go far enough to offset the very high and very real operational costs that hospices across the country face.

Regulatory Relief

Both the physician member of the IDG recommending hospice admission and the inclusion of a clinical note to serve as attestation of a face-to-face were welcome changes to hospice regulations. The Alliance thanked CMS for these changes.

HOPE Tool Implementation

The Alliance was among the many commenters to CMS about the October 1, 2025 implementation date for the HOPE tool. Alliance CEO Dr. Steve Landers had this to say:

Despite responsiveness in other areas, the Alliance is deeply disappointed that CMS did not heed recommendations and delay the October 1, 2025 implementation of the Hospice Outcomes and Patient Evaluation (HOPE) tool nor waive the timeliness completion requirement for HOPE record submission. We expect providers to face a burdensome transition and urge CMS to remain responsive to real-world challenges, offering flexibility as providers navigate the change.

Dr. Steve Landers

CEO, National Alliance for Care at Home

The Alliance is committed to working with CMS to reduce spending and strengthen the Medicare hospice benefit. They also continue to support the CMS initiative to reduce fraud, waste, and abuse.

Final Thoughts

The Hospice Final Rule is not what we hoped for. The wage update was increase, but not by enough to make a real impact on the operational burden hospices face. CMS has provided technical training and education for the HOPE tool, but severely underestimated the financial burden connected to the transition. CMS continues to use outdated, incorrect, or faulty information in its calculations of wage rate updates and ignores the repeated comments from advocacy groups and hospice providers.

# # #

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

Fraud, Waste, and Abuse

Clinical

by Kristin Rowan | Jul 10, 2025 | Clinical, CMS, Home Health, Legal, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Fraud, Waste, and Abuse

DOJ, HHS False Claims Act

Fraud, Waste, and Abuse has become something of a mantra within the Department of Health and Human Services (HHS). Secretary Kennedy has committed to combatting fraud, waste, and abuse within the federal healthcare system. The Department of Justice (DOJ) and HHS have a long history of working together to combat healthcare frauding under the False Claims Act (FCA).

Working Group

In furtherance of their goal to combat healthcare fraud, HHS and DOJ have formed the DOJ-HHS False Claims Act Working Group. The Working Group will include leadership from the HHS Office of General Counsel, CMS Center for Program Integrity, the Office of Counsel for the OIG, and the DOJ Civil Division.

Working Group Priorities to Combat Fraud, Waste, and Abuse

1. HHS will refer potential False Claims Act violations to the DOJ that are in line with the Working Group priority enforcement areas:

Medicare Advantage
Drug, device, or biologics pricing
- arrangements for discounts, rebates, service fees, and formulary placement and pricing reporting
Barriers to patient access to care
- violations of network adequacy requirements
Kickbacks related to drugs, medical decives, DME, and other products paid for by federal healthcare programs
Materially defective medical devices that impact patient safety
Manipulation of Electronic Health Records systems to drive inappropriate utilization of Medicare covered products and services

2. The Working Group will maximize collaboration to expedite investigations and identify new leads. They will leverage HHS resources using data mining and assessment of findings.

3. The Working Group will discuss implementing payment suspension according to the CMS Medicare Program Code of Federal Regulations¹

4. The Working Group will discuss whether DOJ will dismiss a whistleblower case under the U.S. Code for Civil actions for False Claims, pursuant to the DOJ Manual for Civil Fraud Litigation²

Report Fraud, Waste, and Abuse

The Working Group encourages whistleblowers to report violations of the False Claims Act within the priority areas. Tips and complaints from all sources about potential fraud, waste, abuse, and mismanagement can be reported to HHS at 800-HHS-TIPS (800-447-8477). Similarly, the Working Group encourages healthcare companies to identify and report such violations.

²DOJ Dismissal of a Civil Qui Tam Action. When evaluating a recommendation to decline intervention in a qui tam action, attorneys should also consider whether the government’s interests are served, in addition, by seeking dismissal pursuant to 31 U.S.C. § 3730(c)(2)(A).

¹Suspension of payment. The withholding of payment by a Medicare contractor from a provider or supplier of an approved Medicare payment amount before a determination of the amount of the overpayment exists, or until the resolution of an investigation of a credible allegation of fraud.

# # #

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

UnitedHealth Bribes Nurses

Medicaid

by Kristin Rowan | Jun 13, 2025 | Medicaid, Medicare, Medicare Advantage, Other Sites, Regulatory

United Health Bribery Update

In the weeks since the below article revealed allegations against UnitedHealth, members of Congress are calling for action. At least one US Senator and two Representatives are engaged in the allegations. Senator Wyden (D-OR) announced that his office is launching its own investigation. Senator Hawley (R-MO), who is on the investigations subcommittee said it was “alarming to hear these serious allegations. I look forward to securing justice for patients, policyholders, and whistleblowers alike who’ve been harmed by insurance companies.” Other Senators expressed similar sentiments.

“If these allegations are true, UnitedHealth must be held responsible for their gross abuse of patients. Patients should always come before profits.”

Buddy Carter

Chair of the House subcommittee on health, U.S. Representative, (R-GA)

Three U.S. Representatives, coming from both sides of the aisle, are calling on the DoJ to investigate. A letter to the DoJ reads:

“The Guardian’s findings reveal the need for a wide-ranging investigation by the Department of Justice into years, if not decades, of potential waste, fraud, and abuse at UnitedHealth.”

Here is another take on the breaking news story, published by whistlebloweraid.org

The Guardian has uncovered some truly disturbing information about UnitedHealth Group. As the investigation and reporting belongs to them, I have reprinted the first part of the article here. Read the full article here.

by George Joseph, The Guardian
Wed May 21, 2025

Revealed: UnitedHealth secretly paid nursing homes to reduce hospital transfers

A Guardian investigation finds insurer quietly paid facilities that helped it gain Medicare enrollees and reduce hospitalizations. Whistleblowers allege harm to residents

UnitedHealth Group, the nation’s largest healthcare conglomerate, has secretly paid nursing homes thousands in bonuses to help slash hospital transfers for ailing residents – part of a series of cost-cutting tactics that has saved the company millions, but at times risked residents’ health, a Guardian investigation has found.

Those secret bonuses have been paid out as part of a UnitedHealth program that stations the company’s own medical teams in nursing homes and pushes them to cut care expenses for residents covered by the insurance giant.

In several cases identified by the Guardian, nursing home residents who needed immediate hospital care under the program failed to receive it, after interventions from UnitedHealth staffers. At least one lived with permanent brain damage following his delayed transfer, according to a confidential nursing home incident log, recordings and photo evidence.

“No one is truly investigating when a patient suffers harm. Absolutely no one,” said one current UnitedHealth nurse practitioner who recently filed a congressional complaint about the nursing home program. “These incidents are hidden, downplayed and minimized. The sense is: ‘Well, they’re medically frail, and no one lives for ever.’”

Confidential Investigation

The Guardian’s investigation is based on thousands of confidential corporate and patient records obtained through sources, public records requests and court files, interviews with more than 20 current and former UnitedHealth and nursing home employees, and two whistleblower declarations submitted to Congress this month through the non-profit legal group Whistleblower Aid.

The documents and sources provide a never-before-seen window into the company’s successful effort to insert itself into the day-to-day operations of nearly 2,000 nursing homes in small towns and urban commercial strips across the nation – an approach which has helped UnitedHealth secure a vast stream of federal dollars from Medicare Advantage plans that cover more than 55,000 long-term nursing home residents.

UnitedHealth Responds

UnitedHealth said the suggestion that its employees have prevented hospital transfers “is verifiably false”. It said its bonus payments to nursing homes help prevent unnecessary hospitalizations that are costly and dangerous to patients and that its partnerships with nursing homes improve health outcomes.

Long-Term Profit

Under Medicare Advantage, insurers collect lump sums from the federal government to cover seniors’ care. But the less insurers spend on care, the more they have for potential profit – an opportunity that UnitedHealth higher-ups have systematically sought to exploit when it comes to long-term nursing home residents.

To reduce residents’ hospital visits, UnitedHealth has offered nursing homes an array of financial sweeteners that sounded more like they came from stockbrokers than medical professionals.

Seven Years of Bribery and Threats

Over the past seven years, the company has shelled out “Premium Dividend” and “Shared Savings” payments that boosted nursing homes’ bottom lines. Through its “Quality and Shared Risk” program, UnitedHealth offered an even bigger cut to nursing homes that drove down medical spending, but threatened to claw back money from those that didn’t, according to former employees and internal corporate documents.

“You gain profitability by denying care, and when profitability suffers for the shareholders, that’s when people get crazy and do things that are not appropriate.”

Anonymous

Former National Executive, United Health

# # #

Fraudsters Arrested, Oz Issues Warning

CMS

by Kristin Rowan | Jun 6, 2025 | CMS, Hospice, Medicaid, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Fraudsters Arrested, Oz Issues Warning

Fraud in California

Fraudsters arrested in West Covina, CA this week were allegedly running a Medicare scheme. Authorities arrested hospice owner-operator Normita Sierra. They charged her with nine counts of health care fraud, one count of conspiracy, and four counts illegal remuneration (kick-backs) for health care referrals. The U.S. Attorney’s Office named co-conspirator Rowena Elegado. They also arrested her and charged her with one count of conspiracy and four counts of illegal remuneration for health care referrals.

Kickbacks

Sierra and Elegado worked together to pay marketers to recruit patients who did not have a hospice referral from their PCP and who were not terminally ill. Some of the kickbacks paid to marketers were as high as $1,300 per patient per month. After six months, the patients were referred out to Sierra’s home health company.

Medicare Claims

According to the U.S. Attorney’s Office, from 2018 to 2022, Sierra’s hospice agences submitted $4.8 million in fraudulent claims. Of those claims, Medicare paid approximately $3.8 million.

Dr. Oz Issues Warning

In a video statement, Dr. Oz explained how Medicare recipients are falling victim to scams. Sales people call, email, and even knock on your door, offering advice, free samples, and referrals. These marketers have one goal: get you sign a piece of paper. That paper signs you up for hospice care and agrees to allow a specific hospice agency to provide that care. The hospice agency then bills Medicare for services they never provide. Watch the video statement here.

HHS OIG Issues Consumer Alert

In a similar statement, HHS issued a consumer alert regarding DME companies. The alert warns that some DME companies are contacting Medicare beneficiaries. They claim to work for or on behalf of Medicare. Once they receive the patient’s Medicare number, they bill Medicare for unnecessary medical items. These items include urinary catheters, knee and back braces, orthotic braces, and prescription drugs, which may or may not ever be sent to the patient. HHS urges enrollees not to give their Medicare number to anyone. Further, they suggest regulary reviewing items charged to insurance, and refusing delivery of any medical supply not ordered by a physician.

Combating Waste, Fraud, and Abuse

Dr. Oz and CMS have spoken numerous times about combatting the waste, fraud, and abuse withing the Medicare and Medicaid systems. Originally a strong proponent for Medicare Advantage, Oz has promised to audit MA after discovering the government pays more for MA than traditional Medicare. Oz also promised to reduce the amount of prior authorization requests needed before a patient gets services. Oz responded to the Republican-backed House bill requiring more oversight on Medicaid eligibility. Oz indicated that some Medicaid patients are enrolled in more than one state and that Medicaid is paying for able-bodied patients. The waste, fraud and abuse across Medicare and Medicaid is costing the government between $1 and $10 billion and Dr. Oz plans to find it and make significant changes to the management of the system.

A Cautionary Tale for Hospice Providers

You may be thinking, “What does this have to do with me?” Unfortunately, even the most scrupulous hospice agencies can fall prey to marketers running schemes. There are legitimate referral resources in the market who can help your agency get more referrals and more clients. There are also underhanded marketers who know how the system works. These predators will promise new referrals (for a fee) and then enroll uneligible patients without your knowledge. If you are working with or looking for a referral partner for your hospice agency, use one that is referred by someone you trust, and/or do a lot of research on the company history before working with anyone. Be especially wary of the ones who promise much more than what most referral companies offer.

# # #

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

CMS

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.

# # #

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

Trouble in MA Paradise?

Advocacy

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.

# # #

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

Vision for CMS

CMS

by Kristin Rowan | Apr 24, 2025 | CMS, Medicaid, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Vision for CMS from Dr. Oz

Last week, Dr. Mehmet Oz issued a statement on his vision for the future of CMS. Dr. Mehmet Oz is a cardiothoracic surgeon and former host of his own TV show. Under the Department of Health and Human Services, CMS has a $1.7 trillion budget and oversees the health outcomes of more than 160 million people.

“I want to thank President Trump and Secretary Kennedy for their confidence in my ability to lead CMS in achieving their vision to Make America Healthy Again. Great societies protect their most vulnerable. As stewards of the health of so many Americans – especially disadvantaged youth, those with disabilities, and our seniors, the CMS team is dedicated to delivering superior health outcomes across each program we administer. America is too great for small dreams, and I’m ready to get work on the President’s agenda.”

Dr. Mehmet Oz

Administrator of CMS, Department of Health and Human Services

Make America Healthy Again

With HHS Secretary Kennedy, Oz is throwing his support behind Make America Healthy Again, under direction from President Trump. Senator Kennedy says that, under the leadership of Dr. Oz, CMS will work to modernize Medicare, the Marketplaces, and Medicaid. The goal is to get Americans the care they want, need, and deserve. The agenda includes:

Empowering the American People with personalized solutions with which they can better manage their health and navigate the complex health care system. As a first step, CMS will implement the President’s Executive Order on Transparency to give Americans the information they need about costs.
Equipping health care providers with better information about the patients they serve and holding them accountable for health outcomes, rather than unnecessary paperwork that distracts them from their mission. For example, CMS will work to streamline access to life-saving treatments.
Identifying and eliminating fraud, waste, and abuse to stop unscrupulous people who are stealing from vulnerable patients and taxpayers.
Shifting the paradigm for health care from a system that focuses on sick care to one that fosters prevention, wellness, and chronic disease management. For example, CMS operates many programs that can be used to focus on improving holistic health outcomes.

Letter to Medicaid

Following the vision statement, Dr. Oz released a letter to state Medicaid Agencies outlining the use of Medicaid dollars during his tenure as Administrator. The two-page letter, citing recent studies on gender dysphoria, directed Medicaid agencies to eliminate gender reassignment surgery from covered procedures, opting instead for psychotherapy. Hormonal interventions will be reserved for exceptional cases.

“My top priority is protecting children and upholding the law. Medicaid dollars are not to be used for gender reassignment surgeries or hormone treatments in minors – procedures that can cause permanent, irreversible harm, including sterilization. We have a duty to ensure medical care is lawful, necessary, and truly in the best interest of patients. CMS will not support services that violate this standard or place vulnerable children at risk.”

Read the full letter here.

Final Thoughts

We believe this will be the first of many changes made to Medicare and Medicaid rules under Dr. Oz. We will continue to share updates from the CMS newsdesk.

# # #

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

Industry Update

Admin

by Kristin Rowan | Apr 24, 2025 | Admin, Advocacy, Medicaid, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Industry Update with Dr. Steve Landers

At last week’s New England Home Care & Hospice Conference, Dr. Steve Landers, President of The National Alliance for Care at Home (The Alliance) gave the keynote address and offered some industry insights and updates.

A Heartfelt Introduction

Ken Albert, Chairman of the Board at The Alliance introduced Dr. Landers before his address. After reading Dr. Landers’s official biography, Albert offered his own thoughts on the first few months of Landers’ tenure.

Last year, five colleagues from organizations across the country sat in D.C. interviewing candidates. While interviewing Landers, I was remarkably engaged by someone who is deeply passionate about care at home. Steve describes hospice care as a national treasure, and I don’t disagree. More than just his passion for care at home, Dr. Landers is savvy in navigating the political paradigms driving policy. He artfully combines data and stories to navigate relationships with policy makers. What I see every day is someone who roles up his sleeves for the patients we take care of with tremendous respect for the caregivers who are in the patients’ homes.

Ken Albert

Chairman of the Board, The National Alliance for Care at Home

Industry Changes, Advancements, and Ongoing Advocacy Efforts

Dr. Landers attributes much of the positive changes in D.C. to the efforts of volunteer leaders looking to move the industry forward. Care at home needs to become more streamlined, more efficient, and with a better voice.

His vision for the care at home industry is an America where everyone can access high-quality care wherever they call home.

Strong Admonition for CMS

Dr. Landers noted positive movement in some areas. However, he became passionately adamant that a payment update is not an increase if it doesn’t keep up with inflation or pay increases. “The Alliance represents providers delivering high-quality, person-centered care to million of individuals in the home, and they deserve to be recognized and compensated for the work they do,” he said.

Our Aging Nation

It should come as no surprise that older adults have a strong preference for aging at home. They prioritize living where they feel in control and connected. They want to be in familiar surroundings and to maintain their routines.

The U.S. population over the age of 85 is expected to triple from 2020-2060 to more than 19 million people. Despite medical advances, only 1/3 of those over the age of 85 say they are free of disability or free of difficulty with daily living.

With the rising number of older individuals, caregiver to patient ratios are falling nearly everywhere across the country. Dr. Landers and The Alliance urge policymakers to make promoting the dignity and independence of our aging population one of their highest health policy priorities. The Alliance will continue to tell anyone and everyone who will listen that care at home offers the win-win solution that policymakers are looking for.

Changes at the Top

We’ve already seen numerous and sometimes drastic changes at the federal level. Dr. Landers points out that eight years ago the “Trump 1.0 Administration” developed the PDGM framework and signed hospice reform legislation. On the campaign trail, President Trump stated he would not be making cuts to Medicare. The “Trump 2.0” care at home priorities are not yet clear, but The Alliance will continue to emphasize cost savings and the preference to age in place.

Secretary Kennedy, head of HHS, placed his emphasis on the chronic disease epidemic, launching Making America Healthy Again. He has stated a preference for community-based solutions and patient-centered care.

New CMS Administrator Dr. Oz seems to be supportive of Medicare Advantage, but did have some critique of the program during senate hearings. Dr. Oz has a stated focus of finding and eliminating fraud, waste, and abuse.

Changes Near the Top

At the congressional level, The Alliance lost a few key supporters with the last election, but many care at home advocates remained. Of the returning members of the Senate and House, care at home advocates include:

Senators Collins (R-ME), Hassan (D-NH), Tillis (R-NC), Barrasso (R-WY), Blackburn (R-TN), CortezMasto (D-NV), and Rosen (D-NV)
Representatives: Adrian Smith (R-NE), Sewell (D-AL) Van Duyne (R-TX), Panetta (D-CA), Guthrie (RKY), and Carter (R-GA)

The support in Congress leaves us hopeful. Large Reconciliation Packages dominate the current conversation. Many questions remain as to what is at risk for care at home and what Medicaid’s future might hold.

Later this year, The Alliance sees opportunities for care at home outside of reconciliation. These include Home Health PDGM reform, hospice reform, the telehealth extension, revocation of the Medicaid HCBS 80/20 rule, tax credits, and long term care insurance.

Public Policy Priorities

As The Alliance moves forward, several key issues will remain priorities:

Access to Care at Home

PDGM Implementation
Telehealth Extension
Medicare Advantage Dynamics
Care for High Needs Beneficiaries

Quality Care at Home

Special Focus Program Implementation
DEA Telehealth Provisions
HOPE tool implementation?

Eliminating Fraud and Abuse in Care at Home

Hospice Concurrent Care
Hospice and Medicare Advantage
Medicaid 80/20 Rule
Caregiver Tax Credits / LTCI

Growing the Care at Home Workforce

Supply is simply not meeting demand
Strengthened rates, incentives, and educational opportunities will attract and retain a qualified workforce

Follow Up

I spoke with Dr. Landers after the keynote address to ask him why lone worker safety was not among the top priorities of The Alliance. He assured me that there is a position within The Alliance who, among other tasks, is focusing on lone worker safety. I urged him to make it a higher priority and will follow up to get the contact information for the position he mentioned.

# # #

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

That’s a No-No

Admin

by Elizabeth E. Hogue, Esq. | Apr 24, 2025 | Admin, Hospice, Medicaid, Medicare, Medicare Advantage, Regulatory

by Elizabeth E. Hogue, Esq.

No-no # 1

“No-No” may seem like something you would say to a toddler, but there is a list of things agency owners do that they should not do. Many of these are things providers may not often consider. This article focuses on the use of private duty services by hospice and home health patients, and what hospices and home health agencies cannot do with regard to aide services.

Aide Services

Both home health and hospice services are usually intermittent and provided in patients’ homes. Patients and their families may elect to utilize the services of private duty/home care companies for additional assistance. At the same time, hospice and home health patients may receive aide services from hospices and home health agencies.

Conditions of Participation

According to Medicare Conditions of Participation (CoPs), hospice and home health aides can only provide personal care services, including bathing. Aides provided by private duty/home care companies may also provide personal care. Unlike aides provided by hospices and home health agencies, however, they can provide additional services; such as laundry, food preparation, light housekeeping, shopping, and running errands.

Private Duty Services

When patients use private duty services, they are often paying for these services out of their own pockets. Even if they have long-term care insurance, patients still bear the financial burden of paying for private duty services. Longterm care insurance often costs thousands of dollars that patients probably paid for themselves. Patients usually pay by the hour for these services.

That's a No-No

Patients may, of course, utilize private duty/home care services to perform any of the services described above. It seems, however, that hospices routinely tell patients who have private duty/home care that they will not provide aide services because private duty/home care aides are able to provide personal care for patients.

Breaking it Down

Here is an example: A hospice admitted a bedridden patient with urinary and fecal incontinence. The patient and caregiver requested aide services from the hospice five days a week to bathe him. He paid for a few hours of private duty/home care services each day. The hospice refused to provide aide services five days a week to bathe him because he had private duty/home care services. No-no!

Compelled to Provide Care

ospices must provide aide services consistent with patients’ needs related to their terminal illnesses. In the example above, the patient clearly had a need for aide services five days a week. If patients and their caregivers state that they prefer to use private caregivers for personal care, then hospices must document the refusal of hospice aide services offered, consistent with applicable standards of care. Then hospices are not required to provide aide services.

Profiteering

When hospices deny aide services that are consistent with applicable standards of care and require patients and caregivers to use private duty/home care services, hospices are shifting the cost of aide services onto patients and their families. Patients and their families may have to pay for additional private duty/home care services to meet patients’ needs. The result for hospices is that they do not incur the costs of aide services, thereby increasing their profits at the expense of patients and their families.

If hospice staff members who refuse to provide aide services to patients and require patients and their families to use private duty/home care services instead are compensated in any way based on the financial performance or profitability of the hospices, let’s hope they look good in orange jumpsuits!

Intent to Defraud

If the private duty/home care services are being paid for by any federal or state health care program; such as Medicaid, Medicaid waiver, VA, or TriCare; then both home health agencies and hospices have engaged in fraudulent conduct by shifting costs that they should have incurred onto other federal government programs.

God forbid that the hospice also owns the company from which patients receive private duty/home care services! Then hospices are limiting their costs while profiting from patients and their families.

Dig Deep and Find Your No-No's

Now is the time for all home health agencies and hospices especially to audit patients’ records to make certain that all patients have been offered services that they are required to provide. If patients and their families choose to use private duty/home care aides instead, documentation must show that they were offered the services but chose to use private duty/home care aides.

No-No's Final Thoughts

The bottom line is that hospices and home health agencies must always provide services needed by patients. Patients may choose to pay for services that are paid for by the Medicare hospice or home health benefits. Patients cannot be required to pay for services privately that hospices and home health agencies must provide. Unacceptable!

This article is the first in a series of “No-no” items for agency owners.

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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.

No portion of this material may be reproduced in any form without the advance written permission of the author.

©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