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Bi-partisan Congress members sent a letter to CMS requesting revisions to SFP, criticizing outdated survey data and suggested that the quality metrics were inappropriately weighted.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.

# # #

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

Reduce Insurance Claim Denials

Admin

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

by Lynn Labarta, SimiTree

Reduce Insurance Claim Denials

2025 Guide for Home Health and Hospice Agencies

Is your home health or hospice agency struggling with insurance claim denials? You’re in good company. As we move into 2025, claim denials remain the #1 challenge affecting revenue cycles across the industry. But there’s hope – we’ve compiled the latest strategies and insights to help you overcome this persistent challenge.

The Current State of Home Health & Hospice Billing

The healthcare landscape continues to evolve, and with it, so do the complexities of billing and reimbursement. Home health and hospice agencies face unique challenges, from managing PDGM requirements on the home health side to navigating multiple payer systems on the hospice side. Recent data shows that denied claims significantly impact not just revenue but also patient care delivery and operational efficiency.

Understanding Home Health & Hospice-Specific Denial Triggers

Let’s examine the primary causes of claim denials in our sector:

Home Health Eligibility Challenges

Medicare homebound status verification issues
Face-to-face documentation gaps
PDGM period confusion
Medicare Advantage plan authorization complexities

Hospice-Specific Documentation Issues

Terminal illness certification problems
Level of care documentation gaps
Missing physician narratives
Notice of Election timing issues

Strategic Solutions to Reduce Insurance Claim Denials in 2025

Optimize Your Intake Process

Implement robust homebound status verification- Home health
Establish face-to-face documentation protocols
Create PDGM period tracking systems- Home health
Develop payer-specific authorization workflows

Leverage Technology Effectively

Use specialized home health & hospice billing software
Implement automated eligibility verification systems
Set up PDGM period alerts- Home health
Utilize NOE and NOA tracking tools

Build a Specialized Denial Management Approach

Create dedicated teams for Medicare vs. non-Medicare appeals
Develop PDGM-specific denial protocols- Home Health
Establish hospice-specific documentation review processes
Implement specialty-focused staff training programs

Pro Tips for Implementation

Focus on specialty-specific staff training in home health and hospice billing requirements
Create separate workflows for different payer types (Medicare, Medicare Advantage (home health), private insurance)
Implement weekly PDGM period reviews- Home Health
Establish clear communication channels between clinical and billing staff

Looking Ahead in 2025

The home health and hospice landscape continues to evolve, but with proper strategies in place, your agency can thrive. Focus on building robust processes that address the unique challenges of our industry while maintaining compliance and optimization.

Action Steps to Reduce Insurance Claim Denials for Your Agency

Evaluate your current denial rates by payer type
Assess your PDGM period management effectiveness- Home Health
Review your hospice documentation protocols
Implement targeted improvements based on your findings

Remember, reducing claim denials isn’t just about better processes – it’s about ensuring your agency’s financial health so you can continue providing essential care to your community.

# # #

Lynn Labarta reduce insurance claim denials

Lynn Labarta, VP of Post Acute RCM and the founder of Imark Billing (now SimiTree) has a wealth of experience in the healthcare industry. Lynn provides comprehensive billing services for home health and hospice agencies, streamlining their revenue cycle management process while supporting and managing billing challenges and compliance with evolving healthcare regulations and managing billing challenges; essentially acting as a key partner to ensure accurate and timely claim submissions and optimal revenue collection for agencies.

©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

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

Threats to Your Business

Editorial

by Tim Rowan | Feb 14, 2025 | Editorial, Regulatory

by Tim Rowan, Editor Emeritus

Threats to Your Business

Two seemingly unrelated news items jumped out at me that could be threats to your business while I was away tending to funeral preparations for my brother’s wife. Before I analyze those reports, please indulge me as I start with a personal note. I cannot speak highly enough of the end-of-life care my sister-in-law received from the team at Dynamic Hospice of the Los Angeles area, coordinated by longtime friend of The Rowan Report, Michelle Hofhine. They deserve more than this simple public thanks can accomplish.

Health Insurance's Uncertain Future

In a February 7 article for Axios, Caitlin Owens speculates that the Trump administration’s economizing efforts may eventually move to health insurance, particularly the excessive profits from their Medicare Advantage business lines. Explaining why both Moody’s and S&P Global Ratings downgraded their outlook from “stable” to “negative,” Owens cited rising medical costs, the inability to fully offset those costs by hiking premiums, pharmacy benefit manager tightening the screws, and recent strain in operating performance as regulators crack down on insurance abuses in both Medicare Advantage and Medicaid.

Image of letters spelling health and wealth

The author of the piece also mentioned the trend of large providers refusing to renew MA contracts due to underpayment and unjustified care denials. Some employers, she said, are bypassing insurers and contracting directly with providers. The inability to provide service to MA beneficiaries, who make up 50% of the Medicaid patients, could be a threat to your business and the care at home industry.

The downside of this analysis for Home Health and Hospice providers, as well as Medicare Home Care agencies, is that MA and Managed Care may start to shift more costs to their customers to make up their “losses.” The upside is that this is another opportunity for the industry as a whole to renew its advocacy efforts to try again to convince government payers that in-home care saves them more than it costs them.

It is too soon to predict what policy changes HHS Secretary Kennedy and CMS Administrator Oz will enact, but it is safe to assume they will adopt the White House’s goal to slash government spending. During a time when private payers see their margins squeezed and public payers are looking to cut costs, renewing our sector’s decades-long message that we are the quintessential economizing solution may mean that message will finally be heard.

Private Equity Bad for Patients, Senate Finds

The second surprising report came from the U.S. Senate Budget Committee. In a scathing bipartisan report of an in-depth investigation spearheaded by Chuck Grassley (R-Iowa) and Sheldon Whitehouse (D-RI), the committee declared that “private equity investment in health care has negative consequences for patients and providers.”

Titled “Profits Over Patients,” the 162-page report focuses on two of the largest private equity firms that have recently invested in two large hospital systems. We mention it because there has been an atmosphere of celebration in recent years at post-acute care conferences about the renewed interest in Home Health and Home Care among investors.

Here are some of the reasons the Senate recommends caution:

Emphasis on profit over quality of care: “Documents obtained by the Committee detailed how private equity’s ownership of hospitals earned investors millions, while patients suffered and hospitals experienced health and safety violations, understaffing, reduced quality of patient care and closures.”
“Chronic understaffing” leads to much longer wait times for patients
Closures for “economic reasons” force patients to drive long distances for care
Higher frequency of health and safety violations puts patients at risk
Minutes of some board meetings show discussions focus only on profit maximization tactics — cost cutting, increasing patient volume, and managing labor expenses — with little to no discussion of patient outcomes or quality of care at their hospitals
In one extreme case, according to Senator Whitehouse, one firm “paid out $645 million in dividends and preferred stock redemption to its investors and shareholders, while it took out hundreds of millions in loans that it eventually defaulted on.

Senator Whitehouse added in the report, “Private equity investors have pocketed millions while driving hospitals into the ground and then selling them off, leaving towns communities to pick up the pieces.”

Let's Finish With Optimism

Three weeks is not enough time to evaluate the impact of any one four-year term in office. We have clues about the new administration’s approach to healthcare in general and in-home care in particular, but only clues. Perhaps the future is malleable. Perhaps now is the time to turn up the volume. We know patients prefer care in the home. Maybe, with our advocacy, this government will prefer it too.

# # #

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
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

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!

# # #

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

Creditable Coverage for Medicare Part D

Admin

by Kristin Rowan | Feb 14, 2025 | Admin, Regulatory

by Kristin Rowan, Editor

CMS 2026 Updates to Prescription Plan

The Centers for Medicare & Medicaid Services (CMS), as part of the Inflation Reduction Act of 2022 (IRA), released a draft of the calendar year 2026 redesign program instructions. The new provisions for Medicare Part D include:

An annual out-of-pocket maximum of $2,100, up from $2,000 in 2025
A selected drug subsidy program
The requirement that Part D plans offer enrollees the option to spread out their out-of-pocket costs over the year
Maximum charge of $35 for insulin regardless of deductible, co-pay, or out-of-pocket spending reached
No out-of-pocket costs for recommended vaccines
New requirements for Creditable Coverage

Current Creditable Coverage Determination

The current simplified determinations method is as follows:

The plan provides coverage for brand and generic prescriptions;
The plan provides reasonable access to retail providers;
The plan is designed to pay on average at least 60% of participants’ prescription drug expenses; and
The plan satisfies at least one of the following:
- The coverage has no annual benefit maximum or maximum annual benefit payable by the plan of at least $25,000;
- The coverage has an actuarial expectation that the amount payable by the plan will be at least $2,000 annually per Medicare-eligible individual; or
- For employer plan sponsors that have integrated prescription drug and health coverage, the integrated plan has no more than a $250 deductible per year, has no annual benefit maximum or a maximum annual benefit of at least $25,000, and has no less than a $1,000,000 lifetime combined benefit maximum.

Creditable Coverage

Medicare beneficiaries must enroll in Medicare Part D, unless they have other prescription coverage. If a beneficiary goes more than 63 days without prescription coverage, they may incur a late enrollment penalty. Creditable coverage has to have a value equal to or greater than the defined coverage for Part D. This requirement is not new. Group health plans have been calculating creditable coverage since the inception of the Part D program. What is new is that CMS has determined that the simplified method of determining creditable coverage is no longer accurate. The revised method must include all of the following:

Provide reasonable coverage for brand name and generic prescription drugs and biological products
Provide reasonable access to retail pharmacies
Is designed to pay on average at least 72% of participants’ prescription drug expenses

Impact

Persons over the age of 65 who qualify for Medicare, but who are still employed may have an employer sponsored or paid health insurance plan. Many of these plans have combined health and drug coverage. These plans will now have to provide creditable coverage, presumably for all beneficiaries, not just those who are eligible for Medicare.

The coverage has no annual benefit maximum or maximum annual benefit payable by the plan of at least $25,000;
The coverage has an actuarial expectation that the amount payable by the plan will be at least $2,000 annually per Medicare-eligible individual; or
For employer plan sponsors that have integrated prescription drug and health coverage, the integrated plan has no more than a $250 deductible per year, has no annual benefit maximum or a maximum annual benefit of at least $25,000, and has no less than a $1,000,000 lifetime combined benefit maximum.

For Additional Information

If you are currently offering an employee sponsored health plan, or need more information on Part D coverage, refer to the CMS Fact Sheet and the Program Instructions.

# # #

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

Is Medicaid Down for the Count?

Breaking News

by Kristin Rowan | Feb 6, 2025 | Breaking News, Regulatory

by Kristin Rowan, Editor

Medicaid Payment System Goes Dark

On Monday, January 27, President Trump, through the Office of Management and Budget, announced a temporary freeze on federal spending while his newly designated head of the Department of Government Efficiency ensures all spending follows the executive orders the President has signed. The memo was vague and caused widespread confusion across government departments. Almost immediately after the memo was circulated, Medicaid programs could not access the Payment Management Services web portal, the entity responsible for paying Medicaid claims.

The Memo

The language used in the memo on federal spending was broad and overreaching. As such, many federal organizations were unclear as to whether the memo applied to them. The message in the memo was that the administration intended to curb any spending that does not improve the day-to-day lives of the people. Throughout the day Monday, the White House sent clarifications about what programs would not be impacted. Among them were food assistance programs like SNAP, WIC, and Meals on Wheels, and Medicaid. The medicaid payment portal went down, despite this clarification.

Exclusions

Multiple state and federal agencies reached out to the White House for clarification following the release of the memo. Explicitly excluded from the freeze are direct benefit plans like Social Security and Medicare. In addition to the programs named in the memo, clarification on additional programs that would not be impacted included Medicaid. Despite the temporary website outage, claims were still being processed and payments were still being made.

Immediate Lawsuits

Almost simultaneously with the distribution of the memo, several non-profit organizations filed suit against the federal government. They called Trump’s action an “unlawful and unconstitutional” act, even temporarily. The pause on federal spending was set to go into effect at 5 p.m. ET on Tuesday. Minutes before, U.S. District Judge Loren L. AliKhan put a pause on the pause.

Temporary Freeze on the Temporary Freeze

To allow both sides time to construct an argument, the judge stayed the funding freeze until Monday, February 3. That morning, the judge will hear arguments and consider the issue. After the stay, attorneys general from 22 states and D.C. filed their own lawsuit to permanently block the freeze and prevent any future attempts to cut off already approved federal funding.

Then Comes the Thaw

If the judge allows the freeze to move forward, Trump has given every agency until February 10 to account for and explain all spending programs within their departments. Once the accounting has been reviewed, likely the OMB and the Department of Government Efficiency will determine which federal spending programs can resume operation.

There is no indication yet as to whether Trump will extend the February 10 deadline, given the delay in the courts. By the time the judge rules on Monday, however, we hope the White House will have issued additional details and guidance to avoid additional disruption to essential services like Medicare and Medicaid.

Final? Ruling

Early Monday, Judge AliKhan said she was not convinced by the argument that nonprofit groups have no case against the funding freeze since the OMB rescinded the memo. The administration argued that a brief pause on funding to align federal spending is within the law. The administration also suggests that the courts have no standing to block it. AliKhan has indicated that she will likely grant a longer temporary order to stay the funding freeze.

# # #

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

Bill Dombi to Continue the Care at Home Fight in D.C.

Advocacy

by Kristin Rowan | Feb 6, 2025 | Advocacy, Regulatory

by Kristin Rowan, Editor

Bill Dombi Key Supporter of Care at Home

The end of 2024 and the official merger of NAHC and NHPCO also brought to a close the extensive service to the care at home industry by former NAHC President Bill Dombi. Dombi served as vice president for law from 1987 to 2017. He was named interim presidnt in 2017 and president in 2018, where he served until 2024.

Bill has been instrumental in the advancement of care at home policies at the federal level, a champion for advocacy for care at home at local, state, and national conferences and organizations, and spearheaded lawsuits and challenges to CMS rulings for year. His retirement, though well-earned, was a great loss to the industry.

Back in Action

On February 4, 2025, Arnall Golden Gregory law firm, of Atlanta and Washington D.C. an Am Law 200 law firm with a client-service model of “business sensibility” announced the additional of Bill Dombi to the firm as senior counsel. With more than 40 years of experience with litigation and policy in the care at home industry, Bill will continue his fight to advance care at home in D.C.

“It’s not a stretch to say that Bill is the face of the home healthcare space and the standard-bearer for advocating on its behalf, whether in state or federal court or through his deep-rooted experience and relationships within Congress and various federal agencies. In addition to tackling major policy issues, Bill has fiercely defended providers and patients in litigation across the country. His broad perspective and exceptional legal acumen will be invaluable to our already outstanding Healthcare practice, particularly in the areas of home health, hospice, and post-acute and long-term care litigation, benefitting both our teams and the clients we serve.”

Jason E. Bring

Healthcare Litigation co-chair, Arnall Golden Gregory LLP

From AGG

Bill has been actively involved with significant litigation matters affecting home health policy since 1976. Notably, he served as lead counsel in the lawsuit that resulted in the expansion of Medicare home health coverage in 1980, and he was pivotal in the creation of the Medicare hospice benefit in 1983, the institution of the Medicare Prospective Payment System (PPS) for home health in 2000, and national healthcare reform legislation in 2010. In 2017, Bill was selected as NAHC’s president and served through 2024, ultimately concluding his tenure as president emeritus and counsel of the National Alliance for Care at Home, the combined organization of NAHC and the National Hospice and Palliative Care Organization.

“To call Bill a major addition to AGG’s Healthcare practice would be an understatement,” said Sean P. Fogarty, AGG’s managing partner. “Bill has been a pillar in the home health industry for years, and I know I speak on behalf of the entire firm when I say we we’re thrilled to have him join our team.”

Bill is renowned for his commitment to advancing care at home through legal, legislative, and regulatory advocacy. His background spans all key advocacy forums, including Congress, regulatory bodies, and the courts, where he has engineered laws and regulations that directly impact home health and hospice providers. This breadth of experience empowers his private practice to offer clients with a practical framework for compliance standards and operational excellence.

“As I look to the next chapter of my career after almost 40 years at NAHC, it’s exciting to join such an impressive firm and group of professionals with a well-established and supportive culture. AGG is so unique in its earnest focus on collegiality and collaboration, and I look forward to continuing my hard work with my new colleagues on behalf of the dedicated home health providers we serve.”

Bill Dombi

Senior Counsel, AGG

A hall of famer among several home care and hospice organizations, Bill has also served as executive director for the Center of Health Care Law and Home Care and Hospice Financial Managers Association at NAHC. He continues to serve the industry as a member of the board of directors of the Research Institute for Home Care and the Hospice and Home Care Foundation of North Carolina. With Medicaid expenditures now exceeding $130 billion annually and Medicare home health services growing from $300 million to over $25 billion, Bill’s work has seen the evolution of home care from a cottage industry to a cornerstone of long-term care in the U.S.

Bill attended the University of Connecticut, where he earned his law degree, as well as a B.A. in political science.

About Arnall Golden Gregory LLP

Arnall Golden Gregory (AGG) is an Am Law 200 law firm with offices in Atlanta and Washington, D.C. Our client-service model is rooted in taking a “business sensibility” approach of fully understanding how our clients’ legal matters fit into their overall business objectives. Our transaction, litigation, regulatory, and privacy counselors serve clients in healthcare, real estate, retail, technology, fintech/payment systems, global commerce/global mobility, life sciences, logistics and transportation, government investigations, and government contracts. With our rich experience and know-how, we don’t ask “if,” we figure out “how.” Visit us at www.agg.com.

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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

Telemedicine Rules from DEA

Clinical

by Elizabeth E. Hogue, Esq. | Jan 23, 2025 | Clinical, Regulatory, Telehealth

by Elizabeth E. Hogue, Esq.

DEA Issues Three Telemedicine Rules

On January 16, 2025, the United States Drug Enforcement Administration (DEA) announced three new rules to make permanent some temporary flexibilities for telemedicine established during the COVID-19 public health emergency, including new provisions intended to protect patients. The DEA worked with the U.S. Department of Health and Human Services (HHS) to develop the new rules. The DEA made significant revisions to the draft rules proposed on March 1, 2023.

Exemptions

It is important to note that the new rules do not apply to telemedicine visits when patients have already been seen in person by medical providers. After patients have in-person visits with medical providers, any medications may be prescribed through telemedicine indefinitely. Also, if no medications are prescribed during telemedicine visits, the rules about telemedicine do not apply. In other words, patients can always have telemedicine visits with medical practitioners. The rules apply only if patients have never been seen in person by practitioners and controlled medications are prescribed during telemedicine visits.

Rule #1 - Remote Access to Opiod Meds

First, the DEA expanded remote access to buprenorphine, the medication used to treat opioid use disorder, via telemedicine encounters. This change allows patients to receive six-month supplies of buprenorphine through telephone consultations with providers. Additional prescriptions will, however, require an in-person visit to medical practitioners.

Rule #2: Schedule III-V Without In-Person Evaluation

The DEA also issued proposed rules that establish special registrations that allow patients to receive prescribed medications even though they have never had an in-person evaluation from a medical provider. This special registration is available to practitioners who treat patients for whom they will prescribe Schedule III-V controlled substances.

Prescribing Registrations for Schedule II

Advanced Telemedicine Prescribing Registrations are available for Schedule II medications when practitioners are board certified in one of the following specialties:

- Psychiatrists
- Hospice care physicians
- Physicians rendering treatment at long term care facilities
- Pediatricians for the prescribing medications identified as the most addictive and prone to diversion to the illegal drug market
These specialized providers can issue telemedicine prescriptions for Schedule II-V medications.

Call for Public Comment

The DEA seeks public comment on the following issues related to the proposed rules, including whether:

- Additional medical specialists should be authorized to issue Schedule II medications
- Special registrants should be physically located in the same state as patients for whom Schedule II medications are prescribed
- To limit Schedule II medications by telemedicine to practitioners whose practice issues less than 50% of prescriptions by telemedicine.

Online Registration

The DEA will also require online platforms to register with the DEA if they facilitate connections between patients and medical providers that result in prescription of medications. In addition, the DEA will also establish a national prescription drug monitoring program (PDMP) so that pharmacists and medical practitioners can see patients’ prescribed medication histories.

Rule #3: Exemption for Dept of Veterans Affairs

Finally, the DEA will exempt U.S. Department of Veterans Affairs (VA) practitioners from requirements for Special Registrations. After patients receive in-person medical examinations from VA practitioners, the provider-patient relationship is extended to all VA practitioners who engage in telemedicine with the patients.

Final Thoughts

Prescribing controlled substances is essential for some patients, including hospice patients. Practitioners must have the option to prescribe using telehealth.

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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 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

Care at Home Coming to Medicaid?

Advocacy

by Elizabeth E. Hogue, Esq. | Jan 16, 2025 | Advocacy, Regulatory

by Elizabeth E. Hogue, Esq.

Brown v D.C. Decision is Another Boost for Care at Home

In Olmstead v. L.C., the U.S. Supreme Court decided that unjustified segregation of disabled persons constitutes discrimination in violation of Title II of the Americans with Disabilities Act.

The Court said that public entities must provide community-based services to disabled persons when such services are:

- Appropriate;
- Unopposed by disabled persons; and
- Reasonable accommodations taking into account resources available to public entities and the needs of other disabled individuals receiving services from the entity.

This decision gave a tremendous boost to the provision of home and community-based services of all types. Since Olmstead was decided in 1999, there have been more court decisions that require services to be provided at home based on this opinion.

Support for Olmstead

One recent decision is Brown, et al v. District of Columbia (Brown v D.C.) that was decided on December 31, 2024. The Court decided that the District of Columbia violated the rights of D.C. residents with disabilities under the Americans with Disabilities Act (ADA) and the Rehabilitation Act. According to the Court, D.C. failed to inform nursing facility residents who receive Medicaid that they could leave nursing facilities and receive home health services in their communities and failed to assist them to do so. The D.C. government also failed to help them access community-based services and housing options needed to transition back to the community.

The Court recognized that individuals living in nursing facilities often need help learning about and applying for available community services to help them transition out of the institution and into their own homes. Even when residents learn about services, navigating the complicated Medicaid-funded long-term care program can cause confusion and anxiety that sometimes causes facility residents to lose hope that they can live in their own homes again.

Consequently, the decision applies to

“All persons with physical disabilities who, now or during the pendency of this lawsuit: (1) receive DC Medicaid-funded long-term care services in a nursing facility for 90 or more consecutive days; (2) are eligible for Medicaid-covered home and community-based long-term care services that would enable them to live in the community; and (3) would prefer to live in the community instead of a nursing facility but need the District of Columbia to provide transition assistance to facilitate their access to long-term care services in the community.”

Brown v D.C. Says That D.C. Must

- Develop and implement a working system of transition assistance for [nursing home residents that], at a minimum
  - informs DC Medicaid-funded residents, upon admission and at least every three months thereafter, about community-based long-term care alternatives to nursing facilities
  - elicits DC Medicaid-funded nursing facility residents’ preferences for community or nursing facility placement upon admission and at least every three months thereafter
  - begins DC Medicaid-funded nursing facility residents’ discharge planning upon admission and reviews at least every month the progress made on that plan
  - provides DC Medicaid-funded nursing facility residents who do not oppose living in the community with assistance accessing all appropriate resources available in the community
- Ensure sufficient capacity of community-based long-term care services for [residents] under the EPD, MFP, and PCA programs and other long-term care service programs, to serve [residents] in the most integrated setting appropriate to their needs, as measured by enrollment in these long-term care programs.
- …[D]emonstrate [its] ongoing commitment to deinstitutionalization by, at a minimum, publicly reporting on at least a semi-annual basis the total number of DC Medicaid-funded nursing facility residents who do not oppose living in the community; the number of those individuals assisted by [DC] to transition to the community with long-term care services [described above]; and the aggregate dollars [DC] saves (or fails to save) by serving individuals in the community rather than in nursing facilities.

Final Thoughts on Brown v D.C.

As indicated above, there continues to be a clear mandate for Medicaid Programs to provide services to individuals in the community, which is a significant impetus to provide services to patients in their homes. This mandate, however, does not directly address practical aspects of implementation, such as reimbursement at appropriate rates for providers or availability of staff to provide services at home. Nonetheless, the Olmstead and Brown cases provide an important basis for further development of in-home services of all types to meet the needs of disabled persons.

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

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.

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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

VitalCaring Pulls Agreement

Breaking News

by Kristin Rowan | Jan 9, 2025 | Breaking News, Regulatory

by Kristin Rowan, Editor

Just as we were setting the article on UnitedHealth Group and Amedisys for publication, we received the following breaking news story:

VitalCaring Divestment Agreement Cancelled

VitalCaring entered into the agreement on June 28, 2024, just after the merger announcement and initial pushback from the Department of Justice. The DOJ approved the divestiture, despite some misgivings about the quality of care. VitalCaring said at the time that it believed the merger and the divestment were in the “best interest of patients and stakeholders.”

VitalCaring has been under its own scrutiny since 2022 when Encompass Health and its home health and hospice arm, Enhabit, Inc. accused VitalCaring CEO April Anthony of using unethical practices to establish the company. Anthony is the founder of Encompass Home Health & Hospice, the previous owner and CEO of Liberty Health Services, and founder and former CEO of Homecare Homebase.

She Who Shall Not be Named

Encompass Health filed an injunction against April Anthony, and her partners Vistria Group and Nautic Partners in 2021 for violation of the terms of her employment agreement, non-competition agreement, non-solicitation, and misappropriation of trade secrets.

Anthony and her partners purchased a small home health agency in Louisiana and started plan for its growth while Anthony was still CEO of Encompass. Additionally, Anthony recruited employees of Encompass to work at her new venture using a fake recruiter to cover her tracks. Anthony used fake names, spouses’ phones, and her personal laptop to remain undetected during this time. Anthony asked her partners and recruits to refer to her as Voldemort.

Judgment Day

In August of 2022, a judge called the actions of Anthony and her partners “willful misconduct” and agreed with almost all of Encompass’s allegations. The judge found that Anthony was in violation of her non-compete agreement and that she was actively running a direct competitor while still serving as CEO of Encompass. The judge stated, “These are not the actions of a person complying with her contractual obligations.” Although Encompass’s injunction asked to have the non-compete agreement extended, the judge only enforced the existing non-compete agreement, and found that that Anthony had violated the covenant.

Pay the Piper

The Delaware Court of Chancery, in December of 2024, agreed with the earlier findings of the court and found that Anthony, two former senior officers of Encompass, and the investment companies were complicit in their miconduct and that VitalCaring was a result of their deceit.

The court awarded an upfront payment for mitigation damages of $1.62 million dollars plus attorneys’ fees. The court also imposed a trust entitling Encompass Health and Enhabit to 43% of al of VitalCaring Group’s future profits, paid quarterly as well as 43% of proceeds if and when the company is sold.

Divorce Proceedings

Depending on the source, each of the companies involved in the divestiture agreement are claiming credit for filing for divorce.

An equity analyst for UnitedHealth Group said, “UNH has abandoned VitalCaring as a divestiture buyer after the Delaware Chancery decision against VitalCaring’s executives.”
An article from a hospice website stated, “Amedisys has halted the divestiture of some of its home health and hospice locations to Texas-based VitalCaring.
A stock market website reported “VitalCaring Group cancelled the acquisition of certain home health care centers from UnitedHealth Group, Inc.”

Regardless of who filed for divorce, UnitedHealth Group and Amedisys are courting new partners to acquire the home health centers that need to be divested before their marriage can be blessed by the DOJ.

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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

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

Good News for Veterans and Care at Home

Advocacy

by Kristin Rowan | Jan 9, 2025 | Advocacy, Hospice, Regulatory

by Kristin Rowan, Editor

Biden's Final Acts

With only a short number of days left in office, President Joe Biden has been making headlines. Not all of his final decisions have been met with absolute approval, but his latest one will make a difference for our veterans wanting Care at Home. On Thursday, January 3, 2025, President Biden signed into law the Senator Elizabeth Dole 21st Century Veterans Healthcare and Benefits Improvement Act.

The Dole Act

The Elizabeth Dole Act improves upon much of the benefits, programs, and services provided by the Department of Veterans Affairs (VA). Some of these changes include providing protections for care agreements between veterans and clinicians, modifications to educational assistance programs and benefits, expansion of the Native American Direct Loan program, increases per diem rates for veteran transitional housing, and various administrative and oversight tasks.

Elizabeth Dole Home Care Act

The Elizabeth Dole Home Care Act is a bill within the larger act specific to home- and community-based services (HCBS). The home care act aims to enhance veterans’ access to the Program of All-Inclusive Care for the Elderly (PACE) nationwide. The new law also allows the VA to increase funding for HCBS. Prior to this, the VA was able to allocate 65% of nursing home care to home care services.

Additionally, the home care bill will provide support and benefits to caregivers of some disabled veterans, start a pilot to provide non-medical supportive care at home to veterans with limited access to home health aides, and increase access to HCBS for Native American Veterans.

The Industry Responds

The National Alliance for Care at Home responded to the landmark legislation, specifically siting section 301 of the bill, known as Gerald’s Law. Gerald’s is so named for a Michigan veteran who was denied his non-service related burial and plot benefit after he died at home while under VA hospice care. Gerald’s Law requires the VA to provide a burial and funeral allowance for veterans who were receiving VA hospice care in a home or other setting outside a hospital or nursing home.

“We are deeply grateful for the bipartisan support of Gerald’s Law and its inclusion in the Dole Act. This legislation ensures that Veterans and their families can choose hospice care in the setting that best meets their needs without risking the loss of crucial burial benefits. We thank Senators Moran, Tester, and Hassan, Representatives Ciscomani, Bost, Brownley, and Takano, and many others for their leadership, as well as President Biden for signing this important bill into law.”

Dr. Steve Landers

CEO, The Alliance

HCAOA, Leading Age, National PACE Association (NPA), and many others joined the Alliance in applauding Biden for signing the bill into law. They noted that providing care at home and in the community improves the quality of life for veterans and their caregivers. HCBS also come at a much lower cost than hospital and institutional care.

HCAOA said in a statement that the bill is “…a crucial victory for both veterans and their caregivers.” The President and CEO of NPA said the bill would dramatically increase options for veterans who want to age in place and that Congress can “…easily implement PACE for hundreds of thousands of additional seniors and their families.”

The VA has found that HCBS can delay or remove the need for nursing home or assisted living admission. Care at Home also reduces the risk of preventable rehospitalizations.

Final Thoughts

Once again, it seems the world is “discovering” that which we have known for ages: Home based care is better, cheaper, and more effective than institutional care. In the last few years, doctors and hospitals have figured this out and implemented hospital at home care. Now, the VA has finally figured it out as well. When this law takes effect, we as an industry will breathe a collective sigh when our veterans see better outcomes, their caregivers are better supported, the cost for their care decreases, and especially when our veterans enjoy a better quality of life in their final days without sacrificing the benefits to which they are so richly entitled.

One small step for veterans, one giant leap for Care at Home.

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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