Special Focus Program Ends

Advocacy

by Kristin Rowan | Feb 20, 2025 | Advocacy, CMS, Hospice, Regulatory

by Kristin Rowan, Editor

Special Focus Program Not Well Received

When the Hospice Special Focus Program (SFP) first appeared, the industry was told the program would help CMS identify and improve the performance of hospice providers that were struggling to meet quality standards. CMS developed the program to strenthen oversight, promote quality improvements, and ensure compliance for underperforming hospice agencies.

Soon after its inception and implementation in 2022, numerous concerns emerged. The National Alliance for Care at Home (then NAHC and NHPCO) voiced concerns over the program’s reliance on incomplete data as well as the potential for the program to unfairly targed providers in underserved communities.

Between February 2020 and January 2025, numerous state and national organizations have introduced Hospice Acts to Congress, given feedback to CMS on improvements to SFP, and filed lawsuits against the CMS.

Ramping Up the Opposition

In mid-2024, following the Council of States meeting, monthly opposition to the SFP became standard:

The McDermott Report highlighted significant flaws in the algorithm used for the program. Again, there was an objection over the use of incomplete and inconsistent data.
Bi-partisan Congress members sent a letter to CMS requesting revisions to SFP, criticizing outdated survey data and suggested that the quality metrics were inappropriately weighted.
Alliance CEO Steve Landers publicly criticized the implementation of SFP in his op-ed.
Representatives introduced Bill H.R. 10097 to delay SFP implementation, stating it would give CMS time to address the problems with the program and ensure fair application of standards for low-performing hospices without impacting quality programs.
The Texas Association for Home Care & Hospice; Indiana Association for Home & Hospice Care; Association for Home & Hospice Care of North Carolina; South Carolina Home Care & Hospice Association; and Houston Hospice filed a lawsuit challenging the SFP as unlawful and arbitrary.

CMS Backs Down

This week, CMS announced that it has paused the implementation of SFP for the calendar year 2025. The CMS statement say the pause will allow CMS to “further evaluate the program.” There is no mention of the opposition or the ongoing lawsuits.

The hospice special focus program page on the CMS website reads:

Effective February 14, 2025, implementation of the Hospice Special Focus Program for CY 2025 has ceased so that CMS may further evaluate the program. Please contact QSOG_Hospice@cms.hhs.gov for policy questions.

All additional information about the program has been removed from the website page.

Special Focus Program gets First Positive Feedback

For the first time since 2020, industry leaders are applauding a CMS move regarding SFP. The move is halting the program altogether, but at least its positive feedback.

“This decision is a positive move acknowledging that the current approach is not working as intended. The hospice community has long advocated for strong oversight and patient protections, but the SFP, as implemented, was deeply flawed, unlawful, and harmful to the very patients it was meant to protect.”

National Alliance for Care at Home

You can read the full statement from The Alliance in their press release.

Final Thoughts

It seems it is not often that CMS hears what the industry tells them. Reimbursement rates continue to drop, documentation is increasingly complex, and the industry has suffered from their misconceptions about what we need. This time, at least, there was enough pressure and advocacy from Congress and from you, the people who are impacted daily by their decisions, to cause them to rethink this program. Keep up the good work and continue to advocate for yourself and for care at home. Perhaps this is not the last time CMS will listen.

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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 .She also has a master’s degree in business administration and marketing and 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

Perfect Storm

Admin

by Rowan Report | Feb 20, 2025 | Admin, Clinical, CMS, Regulatory

by Hannah Vale, CMO HealthRev Partners

Care at Home Industry Faces Perfect Storm

Industry Challenges in 2025

The care at home industry is grappling with an unprecedented crisis as staffing shortages, technological hurdles, and complex reimbursement models converge to create significant operational challenges. Industry experts warn that without immediate intervention, patient care could be severely impacted.

Staffing Crisis Reaches Critical Levels

The staffing shortage in home health care has intensified dramatically since the COVID-19 pandemic. Carole Carlson, Registered Nurse (RN), Administrator at Avant Home Care, is a veteran with 36 years of experience in the field. She reports unprecedented difficulty in recruiting registered nurses.

“We’re seeing a mass exodus of healthcare workers who have found remote work alternatives. This exodus has also led to a significant caregiver shortage, causing a decline in non-skilled care services.”

Carole Carlson

Administrator, Avant Home Care

RN Shortage

“The other issue is the RN shortage. This is our first time ever experiencing an RN shortage. We are not even getting applicants, whereas in the past we have always had nurses apply and were able to hire within a relatively short period of time,” Carlson added.

Michael Greenlee, Founder and CEO of HealthRev Partners, notes that the shortage is systemic, with insufficient new workers entering the field to meet growing demand. The situation is particularly dire in rural areas, where agencies face additional challenges in attracting and retaining staff.

Connectivity Issues on Top of Documentation Burden

The documentation requirements for home health care are proving to be a major source of burnout among nurses. Pointedly, in rural areas, the problem is exacerbated by poor connectivity:

Many patients still rely solely on landlines
Large areas lack cell coverage
Limited or no WiFi access is common

These issues often force nurses to complete documentation after hours, significantly impacting their work-life balance. Greenlee suggests that emerging satellite connectivity solutions could potentially address these issues in the future.

EMR Limitations

Electronic Medical Record (EMR) systems, while essential, present their own set of challenges. Agencies find that basic systems require multiple costly add-ons for full functionality.

Carlson identifies several gaps in current EMR systems:

Lack of built-in HIPAA-compliant dictation capabilities
Limited care plan template libraries requiring extensive manual input
Need for multiple add-ons to achieve full functionality

These limitations are forcing agencies to invest in additional software solutions, further straining already tight budgets.

Medicare Advantage Complicates Operations

The growing prevalence of Medicare Advantage plans is adding another layer of complexity to home health care operations. In one agency’s case, Medicare Advantage patients now represent 30% of their 160-patient census, equal to traditional Medicare patients. Each Medicare Advantage plan comes with different requirements, creating a significant administrative burden for agencies.

“Keeping up with the varying billing requirements across plans is a constant challenge for our small staff,” Carlson notes. “The need to maintain efficient workflows with clearinghouse and software updates for different payers is putting additional strain on already stretched resources”

Final Thoughts

As the care at home industry navigates these multifaceted challenges, experts stress the urgent need for comprehensive solutions to ensure the continued delivery of quality care to an aging population increasingly preferring to receive treatment at home.

# # #

Hannah Vale, M.Ed. is a dynamic leader bringing a wealth of experience and marketing innovation to her role at HealthRev Partners. Hannah is dedicated to helping post acute agencies streamline processes, optimize reimbursement, and embrace tech-driven solutions. She is recognized as an advocate for empowering agencies with the tools and knowledge they need to drive successful growth. A lifelong learner and former educator turned entrepreneur with a proven track record in launching and scaling businesses, passionate about creating impactful strategies that unite purpose and business. Hannah is also the co-host of the Home Health Revealed podcast, where she discusses industry insights and shares stories from experts in all things pertaining to home health, hospice, and palliative care. Hannah holds a Bachelors Degree in Education from Cleveland State University and a Masters in Educational Leadership from Evangel University.

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Treatment in Place from Emergency Medical Services

Clinical

by Elizabeth E. Hogue, Esq. | Feb 14, 2025 | Clinical, Medicare Advantage, Regulatory

by Elizabeth E. Hogue, Esq.

Treatment in Place

Providers of services to patients in their homes are anecdotally familiar with situations in which patients need help at home, but do not qualify for home health services and have not arranged for or are unable to afford home care/private duty services. These patients need assistance, but do not need transport.

The Problem

The problem for Emergency Medical Services (EMS) is nonpayment for services if patients are not transported for services.

Can EMS Charge Without Transport

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services has weighed in on whether local EMS can meet this need and bill patients’ insurance for treatment in place (TIP) services. The OIG has “blessed” the provision and billing of these services in Advisory Opinion No. 24-09 issued on November 21, 2024.

Treatment in Place Requirements to Bill Insurance

Specifically, the OIG says that EMS may provide services to patients in their homes or TIP services and bill Patients’ insurers if the following requirements are met:

Charges to patients’ insurers would be limited for emergency responses only.
Charges for TIP services must be based on the level of care furnished to patients and cannot exceed amounts currently claimed for payment for the same levels of care furnished in connection with ambulance transports.
Charges are made regardless of whether patients are enrolled in commercial insurance plans or federal health programs.
EMS accepts payment for TIP services from patients’ health insurances as payment in full.
Patients will not be billed for any cost-sharing amounts under patients’ health insurance, including federal health care programs for covered TIP services, regardless of whether they are residents or nonresidents of the county where TIP services are provided.
EMS cannot later claim cost-sharing amounts waived as bed debts for payments under federal health care programs or otherwise shift the burden of cost-sharing waivers onto federal health care programs, other payors, or individuals by, for example, balance billing.

Cost-Sharing

In light of the above, the OIG first acknowledged that the prohibition on waivers of cost-sharing under the federal anti-kickback statute (AKS) is applicable and that the requirements of a safe harbor that addresses waivers of cost-sharing amounts for municipally owned ambulances are not met by the proposed arrangement. The OIG also said that the proposed arrangement would result in remuneration in the form of cost-sharing waivers for TIP services and TIP services provided at no charge to patients. Consequently, remuneration provided implicates both the AKS and the Beneficiary Inducements CMP.

Risk

Nonetheless, the OIG concluded that the arrangement involves a low risk of fraud and abuse. In addition to the above requirements, the OIG concluded that neither Medicare Part B nor the State Medicaid Program currently covers TIP services; only a handful of Medicare Advantage Plans and some Medicaid Programs currently cover TIP services. This means that, in most circumstances, the arrangement will result in no costs to federal health care programs and, in fact, may reduce costs by avoiding ambulance transport or subsequent hospital care. Patients may also receive care more quickly and efficiently, and at more appropriate levels of care when they receive TIP services.

Treatment in Place Cost-sharing Waivers

Finally, according to the OIG, waivers of cost-sharing for TIP services or the provision of free TIP services are unlikely to affect patients’ decisions to use future emergency ambulance services reimbursed by federal health care programs.

Providers are increasingly aware that patients need a variety of services in their homes. The OIG has opened another door!

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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

Medicare Advantage Lowers Home Health Care Use

Hospice

by Kristin Rowan | Feb 6, 2025 | Hospice, Medicare Advantage

by Kristin Rowan, Editor

End-of-Life Care in Medicare Advantage vs Traditional Medicare

Using research from CMS, researchers from Mt. Sinai in New York and Brown University in Rhode Island studied the data of adults aged 66 and older who passed away and had Medicare coverage in their final year of life. Included in the study were people potentially eligible for home health care and not in a nursing facility, hospital, or hospice care setting. Data from close to 1.8 million people was analyzed. The researchers identified whether the participants received home health care and how many days of end-of-life care they received.

Home Health Higher in Traditional Medicare

Of the nearly 1.8 million participants, the average age was 82. 51.5% were female and 36.5% were enrolled in Medicare Advantage. In the final year of life, home health care use was recorded at 37.5% for MA enrollees and 41.7% for traditional Medicare.

When the researchers looked at different demographic groups within the data sets, home health care usage was higher in traditional Medicare in most groups. However, among American Indian and Alaska Native groups, Medicare Advantage had a slightly higher rate of home health use at 37.9% compared with 37.1% in Traditional Medicare.

Conversely, in the Asian or Pacific Islander demographic, home health use rate was 32.6% in MA and 41.8% in TM. Similarly, the rate of use among the Hispanic group was 33% in MA and 44% in TM. Following a similar trend, in the non-Hispanic Black group home health usage in MA was 38.8% compared with 42.9% in TM. Likewise, among the non-Hispanic White group, home health use in MA was 37.9% versus 41.5% for TM. For those of unknown race, usage was 36.1% in MA compared with 40.1% in TM.

Days of Care Lower in Medicare Advantage

Home health users across all racial and ethnic demographic groups enrolled as Medicare Advantage beneficiaries had fewer days of care in home health than those enrolled in Traditional Medicare. The stand-out group in this part of the research was those of Hispanic descent, who averaged 81.9 days in home health care in Medicare Advantage compared with 111.9 days in Traditional Medicare.

Implications

The researchers indicated some limitations in the study, namely that data was pulled from pre-covid patients because of the changes in home health during covid. The study should be repeated with post-covid data. One of the researchers received personal fees while serving as a senior advisor to CMS. Another received personal fees as a section editor for UpToDate. A third researcher reported receiving personal fees from Abt and UpToDate.

Despite these limitations, the implications of the study show that end-of-life care is not the same between Medicare and Medicare Advantage patients. Medicare Advantage is largely operating on a Value-Based Purchasing Model. The fewer services the beneficiary receives, the more money the primary doctor, hospital, and payer keep. It is not surprising, therefore, that MA patients get fewer services for less time. Patients who switch from Traditional Medicare to Medicare Advantage, especially if they are your patients, should be informed that they are still eligible for home health care and hospice care, but they may have to ask for it.

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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 .She also has a master’s degree in business administration and marketing and 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 Increase for Payers, not Providers

Artificial Intelligence

by Kristin Rowan | Jan 23, 2025 | Artificial Intelligence, Breaking News, CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

CMS Announces Medicare Advantage Pay Hike

On January 13, 2025, CMS announced its plans to increase payments to Medicare Advantage plans by 4.33%. Policy changes for Medicare Advantage and Part D include changes in how the agency calculates payments to health plans. A spokesperson from CMS said that the policy change provides access to affordable, high-quality care. The changes, however, don’t increase payments to the people actually providing the care, only to the payers.

Opposition

While major health plans across the U.S. were thrilled with the announcement and saw substantial stock price hikes immediately after, not everyone is on board. The American Medical Association (AMA) outlined how physicians who treat Medicare patients are getting pay cuts from CMS for the fifth year in a row. Meanwhile, HHS OIG released a report finding that MA insurers profited $7.5 billion from risk-adjusted payments in 2023.

“It’s unbelievable they’re giving insurance companies that had record profits an increase while at the same time cutting payment to physician practices that are struggling to survive. This contrast highlights the urgent need for Congress to prioritize linking payment to physician practices to the cost of providing care.”

Bruce Scott, M.D.

President, American Medical Association

Out-of-Pocket Cost Increase

In addition to the higher payments, the advance proposal includes an increase in the Part D deductible from $590 to $615. With this proposal, the out-of-pocket maximum will increase from $2,000 to $2,100 as well. Cost sharing after the deductible is reached but before the out-of-pocket max is reached will also increase. There is no increase for beneficiaries whose income is less than 100% of the Federal Poverty Level.

Coverage Increase

The CMS advance proposal calls for coverage and policy changes. Medicare and Medicaid programs will now cover anti-obesity medications. The plan imposes stricter rules on MA policies to prevent denial of reasonable and necessary services that would be covered under Medicare Part A and B. Finally, imposed guardrails on the use of AI. The guardrails will ensure AI systems are unbiased in patient care decisions. Additionally, the guardrails will ensure they do not perpetuate existing inequity in access to and receipt of medical services. The American Hospital Association appplauded this last change.

“The AHA commends CMS for taking important steps to increase oversight of 2026 Medicare Advantage plans to help ensure enrollees have equal access to medically necessary health care services. The AHA has previously raised concerns about the negative effects of certain Medicare Advantage practices and policies…that are more restrictive than Traditional Medicare and can compromise enrollee access to Medicare-covered services.”

Ashley Thompson

Senior Vice President, American Hospital Association

Changes are not Definite

Even though CMS has announced these changes to start in January, 2026, they are not set in stone. As of January 20, 2025, we are operating under anew administration and the changes under Trump have already started. CMS intends to continue it’s three-year plan to update the MA risk adjustment model and the implementation of the Inflation Reduction Act. However, it seems likely that the Inflation Reduction Act will be replaced with a different plan for inflation.

Jeff Davis, director of health policy at McDermott+ believes it is likely that Trump’s team will throw out the updates to MA and Part D as well as Biden’s proposed staffing mandate for SNFs. In the first 24 hours of his Presidency, Trump revoked both Biden’s “Strengthening Medicaid and the Affordable Care Act” and “Continuing to Strengthen Americans’ Access to Affordable, Quality Health Coverage” executive orders. He also rescinded the Drug Pricing Model executive order that covered obesity drugs, lowered the price of some drugs, and accelerated FDA approval for drugs that address unmet medical needs.

As Yet Unknown

As was to be expected, many of Trump’s initial 78 executive orders are already facing lawsuits from various entities. There are as of yet no definitive answers to changes in Medicare, Medicare Advantage, or other policies that impact healthcare and care at home. The Rowan Report will continue to follow these stories as they unfold.

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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. She also has a master’s degree in business administration and marketing and 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

Whistleblower Case Impedes Lawsuits

CMS

by Kristin Rowan | Jan 16, 2025 | CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Whistleblower Action

A United States District Court in Tampa, Florida ruled against a whistleblower action under the False Claims Act (FCA) against her former employer. In 2019, a family care physician filed a whistleblower, or qui tam, action against her employer for increasing the risk adjustment scores of Medicare Advantage patients in order to receive higher payments.

Whistleblower Protection

When an employee or person with information about a company’s wrongdoing, they can file a lawsuit against that company. Whistleblowers are protected under OSHA, EEOC, and several federal and state regulations against retaliation from their employer. A whistleblower, the person who brings evidence of wrongdoing to the court, is called a “relator.”

Before the Ruling

The False Claims Act is the first and one of the strongest whistleblower laws in the U.S. Under the FCA whistleblower rules, any private citizen can sue any individual, company, or other entity that is defrauding the government and recover damages and penalties on the government’s behalf. Whistleblowers also receive compensation when these suits are settled between 15% and 30% of the total proceeds. As the FCA has expanded since its passing in 1863, the law made it possible for anyone to serve as a whistleblower.

The Ruling

In the case noted above, the court ruled that FCA whistleblowers act as officers of the United States when they sue on behalf of the federal government. The decision reasoned that whistleblowers are appointing themselves as officers of the federal government by bringing these lawsuits.

Article II, Section 2, Clause 2 of the Constitution states that the President can appoint officers and officials to the government and that they require Senate approval for some of these. Cabinet appointments, judicial appointments, and other high ranking positions are often the subject of news stories during Senate hearings to confirm these appointments.

The court ruled that an FCA whistleblower becomes an officer of the federal government through self-appointment, violating the Appointment Clause of the Constitution. The court further ruled that the False Claims Act in itself is a violation of the Constitution, effectively nullifying the FCA, at least in Florida for now.

Widespread Implications

Any company who has lost a False Claims Act suit may now be able to challenge those rulings, using this case as precedent. However, there are some hoops they would need to jump in order to do so, depending on how this case is interpreted. Ironically, this case states that whistleblowers cannot be officers of the government without appointment, but if that’s true, then all False Claims Act decisions become easier to challenge.

If this decision stands and is adopted as precedent across the U.S., it could completely nullify the False Claims Act. It may even be considered for a Supreme Court ruling. In 2023, the U.S. government recouped $2.6 billion from FCA suits, nearly $2.3 billion of which were claims brought by whistleblowers.

Care at Home Implications

Medicare and Medicare Advantage are rife with fraudulent claims, “coding intensity“, upcoding, and predatory marketing. In 2024, CMS announced changes to the risk adjustment model in the Risk Adjustment Validation Final Rule after seeing higher-than-expected risk scores. The changes could help CMS recoup up to $4.7 billion in the next ten years.

MedPAC estimates that Medicare Advantage plans received as much at $88 billion in excess payments in 2024. The lowest share of overpayment reimbursement through the Fraudulent Claims Act would give whistleblowers a combined $13.2 billion. Eliminating the FCA may discourage employees and contractors from reporting fraudulent claims and overbilling through Medicare and Medicare Advantage.

Final Thoughts

A safeguard for people trying to do the right thing, a means to save the federal government billions of dollars that can be spent elsewhere, and ultimately better care for patients are all at risk if the FCA is struck down. A law that has been in place for more than 150 years should carry more weight than the ruling of one district court who applies a new definition to a long-standing term.

Whistleblowers and the federal government have generally been considered co-defendants in these suits. Two parties with separate interests in the same suit, acting independently, not a joint case like a class action suit would be. I anticipate an appeal on this decision and hopefully a panel of judges who better understand the necessity of the False Claims Act and the Whistleblower provisions.

# # #

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 .She also has a master’s degree in business administration and marketing and 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

Congress Allows Medicare Advantage to Deny Coverage

Advocacy

by Kristin Rowan | Jan 9, 2025 | Advocacy, Editorial, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Medicare Advantage Bill Dies in Congress

The 118th United States Congress, ran from January 3, 2023 to January 3, 2025. This Congress’s first law was passed on March 20, 2023, much later than most previous congressional sessions. In its first year, it passed only 34 bills. In the two years of this congressional run, the 118th passed 209 public laws, almost half the average since 1989. Among the many bills that died on the floor before time ran out was the Improving Seniors’ Timely Access to Care Act (H.R. 8702/S. 4532). Senate and House members introduced the bill on June 12, 2024.

Improving Seniors' Timely Access to Care

In June of 2024, senators and representatives introduced bipartisan legislation that would have curbed Medicare Advantage’s ability to deny claims. The bill included language that allowed CMS the authority to establish standard timeframes for electronic prior authorizations requests including expedited requests and real-time decisions for routinely approved services. The bill also included requirements for transparency and reporting, including:

- establishing an electronic prior authorization process
- establishing a process for real-time decisions for routine services
- providing more detailed reports on use of prior authorization including
  - rates of approvals
  - denials
  - average time for approvals
- pressing Medicare Advantage providers to incorporate input from health care providers on their authorization processes and decisions
- adopting prior authorization programs that adhere to evidence-based medical guidelines
- requiring Medicare Advantage providers to report on the percentage of denied claims that were later overturned

Overwhelming Support

At the time this bill was reintroduced to Congress in June, 135 House co-sponsors and 44 Senate co-sponsors signed on. By the end of July, the bill had been read, sent to the House Ways and Means Committee, and passed. Representative Mike Kelly (R-PA) noted that more than 500 organizations had endorsed the act.

Urgent Need for Change

In early 2024, an audit from the Office of the Inspector General (OIG) at the U.S. Department of Health and Human Services (HHS) revealed that Medicare Advantage plans eventually approve 75% of authorization requests for services that were initally denied. More recently, HHS OIG released a report showing that MA plans incorrectly denied services to beneficiaries even though they met the requirements for coverage. Following the report, HHS OIG made the following recommendations to CMS:

- issue new guidance on the use of MAO clinical criteria in medical necessity reviews
- update audit protocols for Medicare Advantage to address the issues of MAO use of clinical critera and examining service types
- direct MAOs to indentify and address the causes for manual review errors and system errors.

CMS agreed with all three recommendations.

Dead in the Field

Despite the bipartisan, bicameral support of this much needed overhaul of Medicare Advantage providers, the bill is currently in pile of unaddressed issues that the 118th Congress just didn’t get to. Despite having it in front of them for five months, and despite passing nearly half the legislation of the 17 most recent congressional sessions, the bill that would keep MA beneficiaries from waiting inordinate amounts of time for routine care will have to wait for the next session to resume. Let’s hope the 119th Congress is more productive.

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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 .She also has a master’s degree in business administration and marketing and 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

Proposal to Update HIPAA Security Rule

CMS

by Rowan Report | Jan 9, 2025 | CMS, Partner News, Regulatory

HHS OCR Proposes Updates to the HIPAA Security Rule to Respond to Emerging Threats

by Paul F. Schmeltzer and John F. Howard, Clark Hill PLC

HHS Proposal

On Dec. 27, the Department of Health and Human Services (HHS) issued proposed updates to the HIPAA Security Rule to address evolving cybersecurity threats in healthcare. Introduced through a Notice of Proposed Rulemaking (NPRM) by the Office for Civil Rights (OCR), the substantial updates aim to enhance the protection of electronic protected health information (ePHI) while aligning the two-decade-old regulations with current technological advancements. These changes are especially crucial in a healthcare environment increasingly reliant on electronic health records (EHRs), online patient portals, telehealth platforms, and interconnected medical devices.

Since its adoption in 2003, the HIPAA Security Rule has served as the foundation for safeguarding ePHI. However, the healthcare landscape has changed dramatically with the rise of cyber threats like ransomware, phishing attacks, and hacking incidents that result in data breaches. OCR’s investigations into HIPAA compliance across the healthcare industry have also revealed significant inconsistencies, underscoring the need for updated regulations that provide clarity and enforceability.

Revisiting “Addressable” vs. “Required” Specifications

Among the most significant aspects of the proposed changes in the NPRM is the reconsideration of the distinction between “required” and “addressable” implementation specifications, a hallmark of the original Security Rule that has often caused confusion. Required specifications must be implemented as outlined, with no exceptions. Addressable specifications, on the other hand, give entities the flexibility to evaluate their feasibility and adopt alternative measures if implementing the original specification is deemed unreasonable or inappropriate. This flexibility has often been relied on by mid and small-sized HIPAA-covered entities in their compliance efforts.

The NPRM proposes eliminating the concept of “addressable” implementation specifications and making all implementation specifications required, with limited exceptions. This includes reclassifying encryption of ePHI at rest and in transit as a required specification, reflecting its essential role in mitigating cyber risks and its widespread availability. Previously, entities could justify not using encryption if they documented their rationale and implemented alternative measures. The proposed change eliminates this flexibility, simplifying compliance expectations and reinforcing encryption as a baseline safeguard for ePHI. This same change would follow for other specifications under the rule, highlighting OCR’s desire to strengthen and simplify the Security Rule.

Strengthened Administrative Safeguards

The NPRM introduces several enhancements to administrative safeguards to address modern security risks. Comprehensive risk analysis remains a cornerstone of HIPAA compliance, but the proposed updates add specificity to these requirements. Entities will be required to maintain a detailed inventory of all technology assets that interact with ePHI and map how ePHI flows within their systems. This mapping ensures visibility into where sensitive data resides and how it is accessed, helping organizations proactively identify and address vulnerabilities. The inventory and map would then be required to be reviewed every 12 months as part of an entity’s risk assessment and risk management processes.

Incident response planning is also emphasized. Entities must develop robust written plans that include protocols for detecting, containing, and recovering from cyberattacks or breaches. These plans should be regularly updated to align with emerging threats and best practices. Workforce training requirements are also expanded under the NPRM, with a focus on providing comprehensive and role-specific education. These programs must address unique vulnerabilities tied to specific job functions and be updated regularly to combat threats like phishing and social engineering.

Strengthened Physical and Technical Safeguards

Physical and technical safeguards also receive significant attention in the NPRM. To secure ePHI, physical access to facilities and devices must be tightly controlled through advanced measures such as biometric authentication, badge systems, and video surveillance. These controls aim to protect ePHI from unauthorized access, theft, or tampering.

The NPRM proposes a definition of the term “multi-factor authentication” (MFA) that entities would be required to apply when implementing the proposed rule’s specific requirements for authenticating users’ identities through verification of at least two of three categories of factors of information about the user, such as passwords combined with biometrics, to secure access to systems containing ePHI. Additionally, the NPRM encourages using advanced threat detection tools like intrusion detection systems, AI-powered anomaly detection, and real-time breach alerts to proactively address security risks.

Addressing Challenges for Small and Rural Providers

HHS recognizes the unique challenges faced by smaller healthcare providers, particularly those in rural and tribal areas, where resources for implementing complex security measures are often limited. The NPRM seeks to provide scalability, allowing entities to implement solutions proportional to their size and complexity. Tailored guidance and tools are expected to support these providers, and regional collaborations are encouraged to pool resources and expertise for improved cybersecurity.

Implications for Stakeholders

For healthcare providers and business associates, the proposed updates necessitate significant investment in technology, training, and compliance infrastructure. Allocating budgets for tools like encryption and MFA, revising and drafting policies and procedures, and updating vendor contracts to ensure alignment with new standards are critical steps. Failure to comply with these updated requirements could lead to stricter enforcement actions and penalties. Fortunately, the proposed changes also remove some of the guesswork needed to comply with the Security Rule. Making areas where investment is needed easier to identify.

Patients stand to benefit significantly from the proposed changes, as stronger protections for sensitive health information can help rebuild trust in healthcare systems. By reducing the frequency and severity of breaches, the NPRM supports greater patient engagement and the adoption of digital health technologies. Regulators, equipped with clearer enforcement guidelines, will be better positioned to ensure compliance and address violations effectively.

Alignment with Broader Cybersecurity Efforts

The proposed updates align with national and international cybersecurity frameworks, including the NIST Cybersecurity Framework and the General Data Protection Regulation (GDPR). These alignments position the U.S. healthcare sector as a global leader in data security while promoting best practices like continuous monitoring, risk management, and strong encryption.

Implementation Timeline and Next Steps

The NPRM is to be published in the Federal Register on Jan. 6, 2025, after which a 60-day public comment period will follow. The final rule will take effect 60 days post-publication. Entities will have 180 days to achieve compliance, with additional time provided to update business associate agreements. The NPRM encourages stakeholders to provide feedback on the practicality and cost-effectiveness of the proposed changes during the comment period.

Conclusion: A Necessary Evolution in Cybersecurity

The proposed updates to the HIPAA Security Rule represent a critical step forward in securing ePHI against today’s sophisticated cyber threats. By reclassifying key specifications, enhancing safeguards, and providing greater clarity for compliance, the NPRM builds a robust framework for protecting both patients and providers. While these changes may pose challenges for some organizations, they are an essential evolution in safeguarding sensitive data in an increasingly digital world. As healthcare continues its digital transformation, these updates underscore the importance of cybersecurity as a cornerstone of quality care and public trust. Investment in a strong cybersecurity posture up front will prove valuable and ultimately save the entire healthcare industry in the long run.

# # #

This publication is intended for general informational purposes only and does not constitute legal advice or a solicitation to provide legal services. The information in this publication is not intended to create, and receipt of it does not constitute, a lawyer-client relationship. Readers should not act upon this information without seeking professional legal counsel. The views and opinions expressed herein represent those of the individual author only and are not necessarily the views of Clark Hill PLC. Although we attempt to ensure that postings on our website are complete, accurate, and up to date, we assume no responsibility for their completeness, accuracy, or timeliness.

Updates on UnitedHealthcare CEO Shooting

Breaking News

by Kristin Rowan | Dec 12, 2024 | Breaking News, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Last Week

As most of the U.S. now knows, last week, UnitedHealthcare CEO Brian Thompson was shot and killed outside a hotel in Manhattan just hours before the UnitedHealth Group Investor Event. The Rowan Report provided the breaking news story with the information available at the time.

Manhunt

According to reports, after the shooting, a man fled the scene on foot and then rode an e-bike toward Central Park. Police were in pursuit based on early descriptions of the shooter and later on video footage of the shooting. The suspect was wearing a hoodie in the images of the shooting. Further investigation found a photo of the suspect in the lobby of a hostel where it is believed he stayed, smiling. Police followed the suspect into Central Park, where it is believed he got into a taxi and left the park.

He was later spotted at a bus station near the George Washington bridge.

Conflicting Images

Images obtained of the suspect taken inside the hotel show a man appearing to be in his 20s, wearing a dark jacket with the hood up and a black face mask resting under his chin. An image of the suspect at a nearby Starbucks puts the suspect in a dark jacket with a black mask covering his mouth. Twenty minutes after the shooting, he is spotted getting into a taxi wearing a black jacket and a white surgical mask covering his mouth and nose. Conspiracy theories about why he would change his mask started circulating quickly.

Ongoing Investigation

A video shows the suspect entering the bus station near the George Washington Bridge. There is no video of him exiting the station. Police believe he got on a bus.

Meanwhile, police found a backpack in Central Park they believe belonged to the suspect. The investigation also discovered a cell phone that may be linked to the shooting. Early on Monday, December 9, police returned to Central Park with dive crews to search for evidence.

Delay, Deny, Defend

Delay Deny Defend by Jay M. Feinman is a book criticizing health insurance companies. The sub-title, “Why Insurance Companies Don’t Pay Claims and What YOu can Do About It,” supports the description of the book indicating that Feinman explains how to be more custios when shopping for policies and what to do when you have a disputed claim. Feinman also includes a play for the legal reforms he feels are needed to end the abuse.

NYPD officers found writing on the three shell casings left at the scene of the shooting. Initially reported as “Deny, Defend, & Depose”, police have now clarified that the permanent marker found on the casings read “Deny, Delay, & Depose.”

Former FBI agent Brad Garrett said he believes the shooter is “trying to send a message.” Police have not commented on what they think the words might mean. Meanwhile, “Deny Defend Depose merchandise appeared overnight, followed quickly by the corrected “Deny Delay Depose.”

Person of Interest

Around the time the dive crews arrived to search for clues in Central Park, a man entered a McDonald’s in Altoona, PA, nearly 280 miles away. An employee recognized him as the man from the photos and alerted local police. The person of interest, now identified as Luigi Nicholas Mangione, had a weapon, a mask, and writings that linked him to the shooting. The writings suggest he has issues with corporate America in general, and named several other people in the document in addition to Brian Thompson. He also had a fake ID that matches the one used to check in to the hostel in New York. Mangione has now been charged with Thompson’s murder.

Mangione was taken into custody by local police. Several members of the NYPD were later seen entering the police station in Altoona. As of Monday afternoon, Mangione was refusing to talk to police and did not have an attorney.

A DNA swab was taken and will be compared with DNA from a Starbucks cup found near the scene. Reports indicate Mangione will be extradited to New York. Mangione was denied bail and will remain in the Pennsylvania prison while he and his attorney fight the extradition to New York.

Additional information about Mangione surfaced on December 11. Mangione’s grandfather founded Lorien Health Services. The company, based in Maryland, operates six ALFs and eight nursing homes. Mangione often volunteered with the company in high school. Additionally, Mangione’s former roommate said in an interview that Mangione recently had surgery that was “heinous” and left him with multiple screws in his body.

Public Outcry

The customary sentiments of comfort, sympathy, and condolences were pointedly absent in the days after Thompson’s death. Instead, stories of denied claims, limitations on access to care, and other frustrations with the industry flooded social media. Of the 60,000 reactions to the UnitedHealth Group post about Thompson’s death, 57,000 were laugh emojis.

Many industry professionals noted that the incident has brought up bigger issues with healthcare insurance in general. The Rowan Report previously wrote about UnitedHealthcare using AI in place of medical professionals to determine medical necessity. This resulted in a much higher than expected denial rate and more than 90% reversal of denials on appeal.

For more information on how healthcare might change after the shooting death of Brian Thompson, please see our complimentary article this week, “Will Thompson’s death change healthcare?”

# # #

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Health Insurance Impact after Thompson’s Death

Advocacy

by Kristin Rowan | Dec 12, 2024 | Advocacy, Editorial, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Will Thompson's death change healthcare?

It's all Relative

On the same day that Brian Thompson died, Blue Cross Blue Shield announced a reversal of an earlier planned policy change. In November, the insurance giant announced it would change its process for anesthesia claims. The change would start in three states and begin on February 1st, 2025. The new process would limit the amount of time the company would cover anesthesia for surgeries and other procedures that called for anesthetization.

The announcements said the company would deny any claim for a surgery or procedure needing anesthesia that goes beyond the time limit they established. Reportedly, the policy would not apply to people under 22 or any maternity related care. A press release from the American Society of Anesthesiologists criticized the policy. It said BCBS “will no longer pay for anesthesia care if the surgery or procedure goes beyond an arbitrary time limit, regardless of how long the procedure takes.”

The new policy was confusing. Some reports indicated there would be a time limit set by the insurer and all claims over that time limit would be denied. Another interpretation said the company would initially approve the claim but would only cover the anesthesia up to a point, leaving the balance to the insured. Yet another report implied BCBS shield would still pay for the surgery, surgeon, and facility, but not for any of the anesthesia.

Reversal of Fortune

Though the initial announcement received backlash from anesthetists, surgeons, insured patients, and Connecticut Senator Chris Murphy, the policy was not widespread news. That is, until the shooting of Brian Thompson shed light on all health insurance company policies. Citing “misinformation” the company announced on Thursday, December 4, that it would not proceed with the policy change.

To be clear, it never was and never will be the policy of Anthem Blue Cross Blue Shield to not pay for medically necessary anesthesia services. The proposed update to the policy was only designed to clarify the appropriateness of anesthesia consistent with well-established clinical guidelines.

Spokesperson

Anthem Blue Cross Blue Shield

Social Media Backlash

The New York Times referred to the reactions to Thompson’s death as “morbid glee.” Comments on social media posts, videos, and news stories include:

“Thoughts and deductibles to the family.”

“Unfortunately my condolences are out-of-network.”

“I pay $1,300 a month for health insurance with an $8,000 deductible. When I finally reached that deductible, they denied my claims. He was making a million dollars a month.”

“Cause of death: Lead poisoning! It’s a pre-meditated condition. Payout denied.”

UnitedHealth Group Responds

UnitedHealth Group CEO Andrew Witty called the media interest in Thompson’s death “aggressive” and “frankly offensive.” In a video to UnitedHealth Group employees, Witty said, “I’m sure everybody has been disturbed by the amount of negative and in many cases citriolic media and commentary…particulary in the social media environment.” Witty noted there were few poeple who had a “bigger positive effect” on the U.S. healthcare system than Thompson.

From Bad to Worse

Witty’s leaked internal video compounded the negativity towards health insurance companies. Witty decryied the media and public vitriol. He then praised Thompson’s impact on healthcare and defended the company policy.

“Our role is a critical role, and we make sure that care is safe, appropriate, and is delivered when people need it,” Witty said, “What we know to be true is the health system needs a company like UnitedHealth Group.” Witty followed his seemingly innocuous statement with, “We guard against the pressures that exist for unsafe care or for unnecessary care to be delivered in a way which makes the whole system too complex and ultimately unsustainable.” Public outcry was amplified after the video was leaked, with insured persons using this as proof that the company’s policy is to deny care.

Experts Weigh In

Ron Culp, a public relations consultant at DePaul University said if the attack is related to health insurance policies it “could cause companies in the sector to make some changes,” noting that, “empathy and potential alternative solutions will play greater roles.”

Fortune predicts that the incident will cause fewer people to aim for the corner office.

While disgruntlement with corporate America is not new, The Wall Street Journal said this incident is “tinged with class rage and anti-corporate venom….[The] current outpouring is on a grander scale….”

Loss of Faith in Insurance Stock

Between close of business on Tuesday, December 3, the day before Thompson’s shooting, and Tuesday, December 10, major insurance stocks have dropped more than 6%. This includes UnitedHealth, CVS Health, and Cigna, three of the largest private health insurers in the country.

Jared Holz, a health-care equity strategist, said the stock performance appears to be in response to the rhetoric condemning health insurance business models that include denied claims in deference to higher profits.

Final Thoughts

After just one week, the public is still uncovering and pronouncing issues with the healthcare insurance industry. The long-term health insurance impact regarding company policies, denial rates, or anything else remains to be seen. The Rowan Report will never condone violence against another person. However, if Thompson’s death brings about changes in the corruption of for-profit insurance companies, we will all be the better for it.

This is an ongoing story. The Rowan Report will continue to provide updates as they become available.

# # #

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Meet the CMS Administrator Nominee

Admin

by Tim Rowan | Dec 6, 2024 | Admin, Advocacy, Breaking News, CMS, Hospice, Medicare Advantage

by Tim Rowan, Editor Emeritus

Mehmet Oz, MD, MBA is the CMS Administrator nominee in the new administration that assumes power on January 20. A popular TV personality and former gubernatorial candidate, the public side of Dr. Oz is well known, but the details of his life and his qualifications to head a $1.16 trillion government program less so. We reached out to the nominee’s PR firm on November 22 to request an interview but have not received a response. We gathered the following background information from his web site and other sources.

Heritage and Education

Mehmet Cengiz Öz was born on June 11, 1960 in Cleveland, Ohio, of Turkish immigrant parents. Raised in Wilmington, Delaware, he holds dual U.S. and Turkish citizenship and comes from healthcare roots. His father, Mustafa Oz, graduated at the top of his class at Cerrahpaşa Medical School in 1950 and moved to the United States to join the general residency program at Case Western Reserve University in Cleveland, where Mehmet was born. His mother, Suna Atabay, was the daughter of an Istanbul pharmacist.

Mehmet graduated with a biology degree from Harvard University in 1982. He earned an MD at the University of Pennsylvania School of Medicine and an MBA from Penn’s Wharton Business School in 1986. He completed his surgical training at NewYork-Presbyterian Hospital and served as a professor of surgery at Columbia University.

Completing his general surgery residency and cardiothoracic fellowship at Columbia-Presbyterian Medical Center in New York City, Oz became an attending surgeon at NewYork-Presbyterian Hospital/Columbia University Medical Center in 1993. He was later appointed professor of surgery at Columbia University in 2001. An advocate for integrating alternative medicine with conventional practices, he co-founded the Cardiac Complementary Care Center in 1995.

During his time at New York-Presbyterian, Oz patented the Mitraclip, a small implantable clip that can be placed using a catheter to repair the heart’s mitral valve. Oz reported earning over $333,000 in royalties from that product in his 2022 disclosures.

Rise to Fame

Oz gained national attention through appearances on “The Oprah Winfrey Show.” Winfrey’s production company, Harpo Productions, and Sony Pictures produced the daytime syndicated program, “The Dr. Oz Show,” which debuted in 2009. It won 10 Emmy Awards during its run.

The program, which focused on health and wellness topics, aired until 2022, when he left it to run for the U.S. Senate in Pennsylvania, winning the Republican nomination and eventually losing to Democrat John Fetterman. Oz is also a prolific author, with eight of his books on the New York Times bestselling list. The Dr. Oz Show gained in popularity during its run but occasionally faced criticism for promoting unproven health products and practices.

Finances

Most of what can be learned about Oz’s personal finances comes from disclosures he made during his Senatorial campaign. He reported a salary of $2 million as host of The Dr. Oz Show and $7 million from his stake in Oz Media. He was also paid $268,000 as a guest host on Jeopardy in 2021. In addition to salaries, Oz and his wife, Lisa, reported investments in big tech, health care, private equity funds, and various real estate holdings.

Oz’s 2022 financial disclosures showed Amazon stock worth up to $25 million; Microsoft, Apple, and Alphabet (Google) stock, each valued up to $5 million, and Nvidia stock valued up to $1 million. He also owned stock in UnitedHealth Group worth up to $500,000, and in CVS Health (Aetna), valued at up to $100,000. They also owned shares in privately owned gas station and convenience store chain Wawa valued between $5 million and $25 million. His 2022 disclosures showed he earned $5 million in dividends from his investment in Wawa.

The Oz’s also reported a real estate portfolio that includes residential and investment properties in New Jersey, New York, Pennsylvania, Florida, Maine, and his parents’ native country, Turkey, each valued from $1 million to $25 million. His 2022 disclosures also showed an investment property in Palm Beach and a cattle farm in Okeechobee, Florida, worth up to $5 million each, and $500,000 worth of cattle.

In addition to these investments, Oz currently runs the non-profit organization HealthCorps, which trains teenagers to share the organization’s curriculum on mental health, physical health, and nutrition. He also serves as Global Advisor and Stakeholder at iHerb, a company that sells supplements, personal care, grocery, and beauty products.

What Kind of CMS Would Oz Create?

What we know of Dr. Oz’s opinions regarding Medicare and Medicaid we learned from his 2022 Pennsylvania campaign message. During that campaign, Oz was a vocal supporter of privatizing Medicare. In 2020, Oz co-wrote an opinion piece in Forbes, suggesting “an affordable 20% payroll tax” to fund a “Medicare Advantage For All” program that could replace private insurance.

His plan, co-authored with Steve Forbes, suggested a 20% payroll tax, half paid by the employer, which the government would use to purchase a Medicare Advantage plan for everyone. The proposal did not explain how this would replace private insurance as MA plans are administered by insurance companies. Of course, this was four years ago, before it was widely known that MA plans pad patient assessments and deny care at a higher rate than straight Medicare does.*

CMS Administrator Nominee Outlook

Uncertainties to keep watch over include the CMS Administrator’s supervision over Medicaid and negotiating Medicare drug prices. If confirmed by the Senate, Oz would have the power to approve states’ requests to change their Medicaid plans, such as adding work requirements for beneficiaries.

He will also oversee drug price negotiations. The Inflation Reduction Act gave CMS the power to negotiate with pharmaceutical marketers to reduce the price of popular medications for people covered by Medicare Part D. The first round of negotiations concluded in August, and the next slate of drugs up for negotiations will be announced in February.

In nominating Dr. Oz, the President-elect said Oz will “help cut waste and fraud.” Whether that goal or seeing to the health of the more than a third of Americans insured through CMS programs becomes Mehmet Oz’s priority should be the first question asked in his Senate confirmation hearings.

Statement from National Alliance for Care at Home

I congratulate Dr. Oz on his nomination for CMA Administrator, I believe it generally is a good thing for patient care when physicians engage in public service and public policy leadership. I am still learning about his priorities and approaches for CMS and am looking forward to speaking with him about the importance of a vibrant and growing care at home sector. Home care and hospice offers CMS the greatest win-win opportunity in American healthcare; people get the independence and dignity they want and deserve while the taxpayers and families save on the costs of unnecessary hospitalization and institutionalization.

Steve Landers, MD, MPH

Chief Executive Officer, National Alliance for Care at Home

* Click to read previous Rowan Report news articles and analyses of Medicare Advantage plans.

# # #

Tim Rowan is a 31-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 also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Survive Medicare Advantage

Admin

by Rowan Report | Nov 15, 2024 | Admin, Clinical, Medicare Advantage

by Alexandria Nelson, Communications Specialist, Axxess

How to Survive Medicare Advantage in Home Health

Navigating the complexities of Medicare Advantage continues to be a sticking point for organizations trying to scale their business. In an education session at the 2024 Axxess Growth, Innovation and Leadership Experience (AGILE), Brent Korte, CEO of Frontpoint Health, and Wendy Conlon, MSPT, Senior Vice President of Client Experience at Axxesss, discussed the ways organization can adapt to the changing reimbursement landscape and ensure their survival.

The Evolution of Care

Conlon and Korte began the session by examining how care is delivered under Medicare Advantage, highlighting the differences in care rates among beneficiaries. They emphasized the importance of organizations being aware of these variations in care.

“I think it’s important that we recognize our role as providers of the target population while also considering the various factors that influence the care we provide,” Conlon said.

Conlon also encouraged organizations to understand the margin of care they provide, highlighting that the care at home industry, and healthcare in general, continues to be an undervalued space.

Korte added that organizations should focus on what Medicare Advantage is looking for in terms of providing care, and set expectations for beneficiaries.

Strategies for Success

Conlon noted that organizations providing care for Medicare Advantage beneficiaries need to have a plan in place to see success in their business.

“It’s about strategy,” Conlon said. “It’s truly about disciplined commitment to excellence when caring for patients and a plan to do so appropriately with appropriate measures in place to get to that success and to watch those margins.”

Operations and Structures

Conlon stressed the importance of organizations finding operational efficiencies and strategizing their approach to patient care. She encouraged them to embrace the financial and administrative aspects of home care, treating it as a business to ensure sustainability and growth.

Conlon and Korte also encouraged organizations to look at their staffing models and clinician structures when strategizing their business.

“Do we have all of our clinicians seeing all of our patients, or have we strategized and almost stratified our clinicians to understand how to see different subsets of patients very specifically and understand those payer models behind them?” Conlon asked.

Korte advised leaders to continue to advocate for an episodic payment model for Medicare Advantage to improve the quality of care patients receive.

“That really, really matters because not only do we get paid more so we can provide better care and get to that 24.9% margin or maybe 14.9% margin, but it doesn’t disrupt our model of episodic care which is very much, ‘give the patient what they need,’” Korte said.

Use Technology to Survive Medicare Advantage

Leaders were also encouraged to use technology to help streamline operations and keep their organizations accountable and their records accurate.

“How nimble is the technology and intuitive for setting up those payers to allow us to make those changes that we need to make when we need to make them, but also to ensure that we’ve got accuracy?” Conlon asked.

The pair concluded the session by emphasizing the importance of not only examining and refining internal organizational processes but also looking outward. They advised leaders to leverage community resources and collaborate with payers.

“Externally, understanding our community and our community resources and then also understanding how we can speak to the payers and negotiate with the payers [is essential],” Conlon said. “We may think, when there’s a group of folks that are advocating for that, that tends to bring about a lot of positive change, but that doesn’t mean that one person [or] one organization cannot be the catalyst for that change to happen.”

# # #

This article orginally appeared on the Axxess blog and is reprinted with permission. For more information or to request print permission, please contact Axxess.

UnitedHealth Group Acquisition of Amedisys Under Fire by DOJ

CMS

by Kristin Rowan | Nov 15, 2024 | CMS, M&A, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Justice Department Sues

In September of 2023, UnitedHealth Group made a bid to purchase Amedysis. That acquisition has been under scrutiny since last year. When the bid was announced, the Department of Justice began an inquiry, asking for additional information. At the time, Amedysis indicated that they anticipated the inquiry.

Now, more than a year later, the Department of Justice, along with the Attorneys General of Maryland, New York, New Jersey, and Illinois, have filed an antitrust lawsuit to block the acquisition. The proposed $3.3 billion acquisition would eliminate competition between the two companies. It would also give too much control to UnitedHealth Group, according to the suit.

Statement from the Department of Justice

The DOJ and the Attorneys General stated that the merger is illegal. The two companies own so much of the market share in the space already that combining the two would mean less choice for patients and fewer employment options for nurses seeking competitive pay and benefits.

UnitedHealth Group already acquired Amedisys’s biggest home health and hospice rival, LHC Group. Since that acquisition, UnitedHealth Group and Amedisys have been two of the largest providers of home health and hospice care in the United States.

American healthcare is unwell. Unless this $3.3 billion transaction is stopped, UnitedHealth Group will further extend its grip to home health and hospice care, threatening seniors, their families and nurses.

Jonathan Kanter

Assistant Attorney General, Justice Department anti-trust division

Surprisingly, the former CEO and current board chairman of Amedisys acknowledged the problems. He said that the competition between the two companies has helped keep them honest. He also said it has driven better quality to the benefit of their respective patients. The former CEO went on to say that the companies also compete for nurses and the merger may threaten the benefits nurses receive. It seems even the heads of the companies involved know this is a bad idea.

UnitedHealth Group's Proposed Solution

In response to the concerns voiced by the DOJ, UnitedHealth proposed to divest some of its facilities to VitalCaring Group. UnitedHealth said this would prevent the monopoly the merger creates. The DOJ responded to that proposal somewhat harshly.

The complaint alleges that the UnitedHealth Group’s market share would be illegal in home health markets in 23 states and the District of Columbia. It would also be illegal in hospice markets in 8 states, and in the nurse labor market in 24 states.

UnitedHealth’s proposed divestiture would only alleviate the monopoly in a few areas. This leaves hundreds of markets across the U.S. in jeopardy. Further, VitalCaring Group has poor quality scores and is facing its own legal judgement of close to half a billion dollars. Allegedly, the current CEO of VitalCaring Group was the CEO of a competitor while running VitalCaring behind the scenes.

Good News for Home Health and Hospice

The complaint describes home health and hospice services as “critically important parts of the American healthcare system….Patients rely on the skill and expertise of home health and hospice nurses, who must effectively treat patients at home.

Millions of patients depend on United and Amedisys to receive home health and hospice care in the comfort of their homes. The Department’s lawsuit demonstrates our commitment to ensuring that consolidation does not threaten quality, affordability, or wages in these vital healthcare markets.

Benjamin C. Mizer

Principal Deputy Associate Attorney General

Attorney General Merrick B. Garland said, “We are challenging this merger because home health and hospice patients and their families experiencing some of the most difficult moments of their lives deserve affordable, high quality care options. The Justice Department will not hesitate to check unlawful consolidation and monopolization in the healthcare market that threatens to harm vulnerable patients, their families, and health care workers.”

Final Thoughts

Mister Attorney General, please turn your attention to CMS and Medicare Advantage, as they continue to threaten the safety and well-being of patients, families, and caregivers with increasingly low reimbursement rates and denials of coverage.

# # #

Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Here We Go Again

Clinical

by Tim Rowan | Nov 8, 2024 | Clinical, CMS, Editorial, Medicare Advantage, Regulatory

by Tim Rowan, Editor Emeritus

OIG Accuses Medicare Advantage Providers of Padding Patient Assessments...Again

“Hello, this is your Medicare Advantage company calling. I am one of their clinicians and it is time for us to update your health assessment. If you will agree to a home visit, we will send you a $50 gift card to CVS.”

This phone call my brother received is typical, increasingly common, and not necessarily on the up-and-up, according to a new report to CMS from the Department of Health and Human Services Office of the Inspector General (OIG). OIG found that these home visits, known in the insurance industry as “Health Risk Assessments,” (HRA) when coupled with HRA-related claims data, increased Medicare Trust Fund payments to MA companies $7.5 billion in 2022 and twice that in 2023. Most of it went to the top 20 companies.

The October 2024 report, “Medicare Advantage: Questionable Use of Health Risk Assessments Continues to Drive Up Payments to Plans by Billions,” accuses the industry as a whole of improperly padding payments by “finding” new health conditions during these HRA’s that may indicate the need for additional care at additional cost to the company. It questions the use of MA plan employees doing these assessments instead of relying on the customer’s primary care physician’s reports.

OIG references CMS’s own report, “Part C Improper Payment Measure (Part C IPM) Fiscal Year 2023 (FY 2023) Payment Error Rate Results,” to determine that gross overpayments to Medicare Part C plans in 2023 amounted to just over six percent of total payments, or $14.6 billion. The net increase to MA plans, after adjusting for underpayments, brought the percentage to 4.62. Total 2023 payments to MA plans came to $275,605,962,817.

The report also points out that identifying additional customer need during an HRA does not necessarily translate into the insurance company paying for additional care.

OIG Recommendations

In addition to implementing prior OIG recommendations, the new report asks CMS to:

- Impose additional restrictions on the use of diagnoses reported only on in-home HRAs or chart reviews that are linked to in-home HRAs for risk-adjusted payments,
- Conduct audits to validate diagnoses reported only on in-home HRAs and HRA-linked chart reviews, and
- Determine whether select health conditions that drove payments from in-home HRAs and HRA-linked chart reviews may be more susceptible to misuse among MA companies.

CMS concurred with OIG’s third recommendation but rejected the other two.

While the entire 38-page report is well-worth reading, OIG has also published a one-page summary.

At this year’s annual conference of The National Alliance for Care at Home, the new merger of NAHC and NHPCO, a number of education sessions were devoted to teaching Home Health agency owners how to negotiate with Medicare Advantage plans in order to minimize losses and better care for patients who chose those plans. Comments included the high rate of care denial, unreasonable prior authorization policies, and slow payments as compared to traditional Medicare. Other healthcare entities have chosen a potentially more effective response: Just Say No.

Hospital systems have had enough

According to a roundup of recent decisions by large and small healthcare systems in Becker’s Hospital CFO Report (10/25/24), no fewer than 30 healthcare providers are severing their relationships with one or more MA plans, with another 60 who told Beckers they are seriously considering the same move.

States Have as Well

A sister publication, Becker’s Payer Issues, reported in its October 23 edition that more and more states are issuing fines against MA plans for violations ranging from excessive denied claims to collection of co-pays when none was required.

How Much Longer?

All of this demands a serious question. How much longer will Home Health continue to tolerate abuse by these giant, for-profit payers now that a different path forward has been paved by hospital systems and state regulatory arms? The loudest voice for Home Health to join the “Just Say No” movement over the last few years has been that of Bruce Greenstein, CTO of LHC Group. Following his company’s acquisition by UnitedHealth’s Medicare Advantage division, Optum, his less loud message is to work with MA plans to teach them what Home Health is and what it can do for them.

Statement from Dr. Landers

In his inaugural address to The Alliance last month, new CEO Dr. Steven Landers called for our entire industry and everyone taking a paycheck from it to join him in advocacy. We fully support that call to action, recognizing that no national association can influence lawmakers and CMS regulators without member support, but he was referring to Medicare rules and payment structures. As we know, that includes less than half of Medicare beneficiaries today. Thanks to deceptive TV ads during open enrollment every year, that number will continue to shrink.

Widespread Advocacy

We need to turn at least part of our advocacy focus to the dominant payers, the MA divisions of insurance companies. Read the Beckers report on the 30 healthcare systems that have torn up their MA contracts. Read the companion report about the epidemic of care denials. Yes, it is a David vs. Goliath story, with even the largest organizations in Home Health dwarfed by the size of the payers. As so many hospital systems have shown, however, it is possible to switch from begging for a few more cents per visit to forcing a plan to beg you to take their patients.

It will only work though if everyone does it. We have already lost LHC Group, and Optum is in the final stages of adding Amedisys to their stable. Out of 11,000 HHAs, there is still a chance we have a united voice loud enough to be heard and taken seriously.

Final Thoughts

One of their improper cost-cutting tactics is routine care denial. For example, the Labor Department alleged that UnitedHealth subsidiary UMR denied all urine drug screen claims from August 2015 to August 2018 without determining whether a claim was medically necessary. In my brother’s case, following his wife’s HRA by her MA company, with no additional care offered, he made the tough choice to put her on in-home hospice care. The assessing nurse immediately detected she had a UTI and ordered the appropriate antibiotics. She responded quickly and may be discharged from hospice soon. Hospice care, of course, is paid by traditional Medicare, not Medicare Advantage.

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 also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com or contact Tim at Tim@RowanResources.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com

2025 Final Rule

Advocacy

by Kristin Rowan | Nov 8, 2024 | Advocacy, CMS, Regulatory

by Kristin Rowan, Editor

CMS Releases Home Health Final Rule 2025

Last week, the Centers for Medicare & Medicaid Services (CMS) released the Calendar Year (CY) 2025 Home Health Prospective Payment System (HH PPS) final rule. Included in the final rule are updates the Medicare payment policies and rates for Home Health Agencies (HHAs), intravenous immune globulin (IVIG) items, and payment rates for Durable Medical Equipment (DME) suppliers. Estimates indicate that CMS payments to HHAs will increase by 0.5% over 2024.

Partnership for Quality Home Healthcare

The Partnership for Quality Home Healthcare issued a press release in response to the final rule.

[We] were again disappointed that the Centers for Medicare & Medicaid Services (CMS) continued its policy of cuts by finalizing a -1.975 percent permanent cut to home health.

The Partnership for Quality Home Healthcare

The Partnership urged Congress to intervene to “fix the broken payment system” that continues making payment rate cuts year after year. The cuts are reducing patient access. According to recent data, patient visits per 30 days are down nearly 20 percent. The partnership notes workforce shortages, capacity limitations, and closures of providers as the primary reasons behind the decline in patient visits.

Legislative Action

As we have reported previously, a number of organizations have worked together to advocate for home health with members of Congress. NAHC and NHPCO (Now The National Alliance for Care at Home), The Partnership for Quality Home Healthcare, and others, have proposed bipartisan legislation, the Preserving Access to Home Health Act (S. 2137/H.R. 5159).

NAHC last year filed a lawsuit claiming that CMS used flawed formulae in their calculations of budget-neutrality. That lawsuit has been paused while NAHC/NHPCO follow administrative processes required by the judge. Once those administrative paths are exhausted, The Alliance will look at next steps to continue their objections to the pay cuts. The overturning of “Chevron Deference” will open new avenues for The Alliance as well.

CMS Facts

CMS published its Final Rule Fact Sheet after the issuance of the final rule for CY 2025. According to the fact sheet, the 2025 rule:

- Finalizes a permanent prospective adjustment of -1.975% (half of the calculated permanent adjustment of -3.95%) to the CY 2025 home health payment rate to account for the impact of implementing the Patient-Driven Groupings Model (PDGM)
- Includes the final CY 2025 home health payment update of 2.7%
- Adds an estimated 1.8% decrease to reflect the permanent behavior adjustment
- Also has an estimated 0.4% decrease that reflects the updated FDL

This yields an aggregated 0.5% increase in payment rates over 2024.

Increase=Decrease

Despite the overall 0.5% increase in payment rates, PQHH, The Alliance, and many other organizations see this as a drastic pay cut. The increase will not account for inflation, higher operating costs, or any other adjustments. These organizations continue to call upon you to contact your Senators and Representatives as well as to support them in their ongoing efforts with the bipartisan bills and the lawsuit.

Ongoing Updates

The information in the 2025 final rule is still being analyzed and is further complicated by the change in leadership at the national and local levels after this week’s election. Please see our Upcoming Events section on the website for several webinars discussing these issues. The Rowan Report will continue to bring additional insights as they become available.

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Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com