An Interview with Dr. Steven Landers, Part 2

Advocacy

by Kristin Rowan | Oct 25, 2024 | Advocacy, CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Medicare Advantage is Killing Us...Literally

This is part 2 of 2 in the interview with Dr. Steven Landers. You can read part 1 here.

Medicare Advantage article by Dr. Landers

Earlier this week, Dr. Landers published an article in the NAHC Report. The article cited three studies and analyses on the number of enrollees in both Medicare and Medicare Advantage who do not receive the care to which they are entitled. During our recent interview with Dr. Landers, he addressed this article.

Dr. Steven Landers: On the Record

The Rowan Report:

You wanted to address something you recently wrote. Is this the same topic you mentioned the opening session, or is this something else?

Dr. Steven Landers:

No, this is a focused piece on the emerging research that we’re seeing around when people miss out on home health. It’s a life and death issue. I want to be sure that we, as an alliance, I, as a physician, and us, as advocates, that we are conveying that these issues around home health cuts and barriers are potentially deadly. This is not a trivial matter. It’s not an administrative or technical financial issue. It’s about people’s lives.

RR:

The article mentioned a study that said that the numper of people not getting the home care that they’re entitled to is almost double with Medicare Advantage enrollees over traditional Medicare.

Steve:

That was from a study that’s referenced there from a few years ago. The Partnership for Quality Home Health Arcadia Analysis that came out this year actually showed that those trends are worsening. We know that they’re not getting the needed care in Medicare Advantage and traditional Medicare.

In both cases it’s too high, but it’s higher in Medicare Advantage. It’s more common that people don’t get the prescribed care in Medicare Advantage. And we also know that that’s going up in both traditional Medicare and Medicare Advantage. The access has gotten worse because of the Medicare home health policy and because of the way that Medicare Advantage has grown and handled these issues.

Interviewer:

I guess the big giant question is what do we do, especially when margins for both traditional Medicare and Medicare Advantage are so low?

Steve:

One, we’ve got to start improving access to home healthcare. And the way that we do that is we end this march of payment cuts that are being set forward by Medicare. I mean, right now the leaders of Medicare are in their rulemaking process and they have choices to make. They can either do things that reverse this trend and put us on a path to better access or I think continuing these cuts will hurt beneficiaries.

And the other piece is the Medicare advantage front. We need more scrutiny and evaluation and potentially oversight here to make sure Medicare Advantage beneficiaries have access to high quality home healthcare.

“The results of this study demonstrate that among MA members referred to home health after acute hospitalization, those who did not receive home health services experienced higher mortality and lower readmissions than those who received these services.”

Unfulfilled Home Health Referrals Lead to Higher Mortality Among Medicare Advantage Members

Elan Gada, MD, Paul Pangburn, MHA, Chris Sahr, MS, MBA, Chad P. Schaben, MPH, Richard Young, MS

RR:

Where does the problem lie?

Steve:

People don’t get home health when it’s prescribed and mortality rates are substantially higher. There could be [anecdotal] reasons that this is happening. I’ve tried to think of them. I can’t really come up with them when you see it in three different analyses, especially one done within the Medicare Advantage plan. They have great data. It was well thought out and this is serious business and it really should be a kitchen table discussion for families like ‘what’s going here?,’ because obviously home healthcare is a beloved service that families care deeply about.

We’ve seen home care become a presidential campaign issue because it’s good policy and also because the folks running, Vice President Harris, who brought it up, and former President Trump, who chimed in sort of a me too, being enthusiastic about the concept. They’ve got to know that this polls well, that the families care about this stuff.

Editor Emeritus Tim Rowan provides an analysis of the study from UnitedHealth Group here.

# # #

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

Introducing “The National Alliance for Care at Home”

Admin

by Tim Rowan | Oct 25, 2024 | Admin, Advocacy, Regulatory

by Tim Rowan, Editor Emeritus

National Alliance for Care at Home

The merger of the National Association for Home Care and Hospice and the National Hospice and Palliative Care Organization, which was inked on July 1, became official this week in Tampa, Florida. The new National Alliance for Care at Home said farewell to retiring NAHC President Bill Dombi and gave a rousing welcome to incoming Alliance CEO, Steven Landers, MD. Both Bill’s farewell address and Dr. Landers’ introduction speech ended with the same theme. We do what we do for the good of our patients. Yes, there is money. Yes, there are politics. In the end, our legacy and our future are about people.

Dr. Steven Landers

Integrity, Quality and Compliance

That future will begin with a commitment to patient care excellence. Dr. Landers closed his opening address with an announcement. From now on, every member, upon beginning or renewing their annual membership, will be asked to sign an attestation pledging their company and themselves personally to commit to Integrity, Quality, and Compliance. “Our members will be known to the world as the best in the industry,” he proclaimed. “They will assure patients, families, and payers that they participate in Medicare and Medicaid quality performance standards.”

In a press conference the next day, Dr. Landers elaborated that NAHC and NHPCO have always worked with public and private payers and law enforcement agencies to rid our industry of those who are not in it for noble reasons. Those cooperative efforts will continue, he told the reporters. The new attestation will further assure the world that members of The Alliance publicly join that mission. One is reminded of a code of conduct common to all our national military academies. “We will not lie, steal, or cheat, nor tolerate among us anyone who does.”

Emphasis on Advocacy

The Alliance is new, and Dr. Landers candidly admits he is gradually learning his new role as he goes along. But he is guided by a commitment to care in the home that has been with him since medical school. “I didn’t want to be just another cog in the system,” he told 2,000+ attendees. “The first time I went along on a home visit, I immediately realized that this is what I wanted to commit my career to.” Through his years at the VNA and Cleveland Clinic, he saw the power of in-home care, including its ability to extend live expectancy and reduce the total cost of care.

Bill Dombi

A Semi-Farewell at Best

National Alliance for Care at Home Dombi

Bill Dombi will serve the new Alliance through the end of this year before fully entering retirement. Following his closing address on the last day of the conference, during which he summarized his 38 years with NAHC (years that began with a promise to his wife Lynn that they would only have to leave their home in Connecticut for the DC area for three to four years), I asked him what he planned to do that first day in January. He said that he accumulated a ton of frequent flyer miles during his career and that they would love to travel somewhere other than state and national association conference cities.

He also mentioned the ongoing legal actions he initiated to force CMS to develop more honest formulae for calculating Home Health reimbursement and added, “It is very difficult to change litigators in the middle of a lawsuit.” Draw your own conclusion but take it from one who knows how difficult it is to completely walk away from this mission and its people. We may not have heard the last of William A. Dombi.

# # #

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. homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com

UnitedHealth Group Sees Q3 Growth

CMS

by Kristin Rowan | Oct 18, 2024 | CMS, M&A, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

UnitedHealth Group Earnings Show Strong Q3 Revenue Growth

For most of 2024, and even going back into 2023, The Rowan Report has written about UnitedHealth Group and its acquisitions, its over diagnosing patients for financial gain, its dropping of Medicare Advantage plans, and, of course the Change Healthcare cyberattack.

Despite all the negativity, UnitedHealth Group continues to grow. The company’s revenue grew more than 9% over last year’s Q3 numbers. Even after the cyberattack, Optum grew by more than $2 billion. According to UnitedHealth Group CFO John Rex, the growth is due to an increase in both the number and type of care services offered. Optum operates three subsidiaries, OPtum Health, OptumRx, and OptumInsight, with total revenue of $63.9 billion.

CyberAttack did not Impact Earnings

According to the Q3 financial statement, per share earnings of $6.51 include the cyberattack impacts. The annual adjusted net earnings outlook for 2024 is between $27.50 and $27.75, in line with earlier projections. The 2024 net earnings outlook reflects both the selling of South American properties and the impacts from the Chnage Healthcare cyberattack. Net earnings outlook is $15.50 to $15.75 per share.

More UnitedHealth Group Acquisitions on the Horizon

UnitedHealth Group CEO Andrew Witty said the company is using a five pillar growth strategy. They will continue to spend money acquiring companies for United Healthcare, value-based care, pharmacy businesses, financial services, and what he called “technology-ed opportunities.

Meanwhile...

While UnitedHealth Group and Optum post higher revenue and cash flow and their shareholders se an increase in per share earnings, subscribers to UnitedHealth insurance plans are losing. Monthly premiums and annual deductibles for Medicare Part B increased from 2023 to 2024. Part B standard premiums are expected to increase by almost 6% in 2025. For seniors with higher income, the adjustment amount will go up to $74 per month, making monthly premiums jump to $259. The base beneficiary premium for Part D also increased in 2024 and will again for 2025.

Keeping it in the Family

Effective September 1, 2024, UnitedHealthcare started requiring prior authorization for Medicare Advantage member to receive PT, OT, and ST services when performed outside of the home. Not surprisingly, United Health owns multiple practices that offer PT, OT, and ST at home. Those services don’t require prior authorization. UnitedHealth Group is enjoying higher revenue, higher net income, and is funneling the money from insurance premiums back into its own pocket.

Go for the Gold

This announcement came just after UHC announced a gold card program to reduce prior authorization requirements. The gold card program started October 1st and was supposed to reduce the prior authorization request volume for provider groups. Providers groups who are in-network, have a minimum number of prior authorizations for two years, and have at least a 92% approval rate qualify for gold status.

Final Thoughts

Home health agencies are struggling to survive with lower payment rates from Medicare plans and operating in the negative under Medicare Advantage plans. Physician practices, surgery centers, urgent care, and pharmacy benefit managers are operating under UHC for even greater profits. More patients are seeing delays in care due to increased prior authorization requirements, unless the patient is seeing a caregiver owned by UHC. Shareholders are getting increased per share revenues. Perhaps there’s a solution hidden in the math there somewhere.

# # #

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

Patient Preference by Race or Nationality

Admin

by Elizabeth E. Hogue, Esq. | Oct 10, 2024 | Admin, Clinical, CMS, Regulatory

This article provides updated information about a discrimination case filed against a home care agency by the EEOC. The Rowan Report published the initial press release and article last year.

by Elizabeth E. Hogue, Esq.

What to do When Patients Don't Want Caregivers of Certain Races or Nationalities

The Equal Employment Opportunity Commission (EEOC) sued ACARE HHC, Inc.; doing business as Four Seasons Licensed Home Health Care Agency in Brooklyn, New York. The EEOC claimed that the Agency removed home health aides from work assignments based on their race and national origin to accommodate clients’ preferences in violation of the Civil Rights Act of 1964 [EEOC v. ACARE HHC d/b/a/ Four Seasons Licensed Home Health Care, 23-cv-5760 (U.S. District Court for the Eastern District of New York)].

This case recently settled, and Four Seasons will pay a whopping $400,000 in monetary relief to affected home health aides! The Agency must also update its internal policies and training processes related to requirements of the Civil Rights Act, stop assigning home health aides based on clients’ racial or nationality preferences, and provide semi-annual reports to the EEOC about any reports or complaints received about discrimination.

Aides Removed from Assignments

According to the EEOC, Four Seasons routinely responded to patients’ preferences by removing African American and Latino home health aides based on clients’ preferences regarding race and national origin. Aides removed from their assignments would be transferred to new assignments, if available, or, if no other assignments were available, would lose their employment altogether. The lawsuit asked for both compensatory and punitive damages, and for an injunction to prevent future discrimination based on race and national origin. The EEOC says that “Making work assignment decisions based on an employee’s race or national origin is against the law, including when these decisions are grounded in preferences of the employer’s clients.”

As many providers know, patients’ preferences for certain types of caregivers are common. Experienced managers have been asked by patients not to provide caregivers who are, for example, “foreign.” Such requests should generally be rejected, especially when they involve discrimination based upon race, national origin, religion, or any other basis commonly used to treat groups of people differently. Legally and ethically, providers should not engage in such practices.

Exception to the Rule

There is one exception to this general rule that occurs when patients ask for caregivers of the same sex as the patient based upon concerns about bodily privacy. It is then acceptable to assign only same-sex caregivers to patients who have made such requests.

Risk Management

In addition to concerns about discrimination, providers must also be concerned about risk management when they honor such requests. Especially in view of increasing staff shortages, limitations on available caregivers may mean that patients’ needs cannot be met by staff members who are acceptable to patients. In view of staffing shortages, the fewer caregivers who are permitted to care for certain patients, the more likely it is that patients’ needs will go unmet. Unmet patient needs are, in turn, likely to significantly enhance the risk associated with providing care to patients.

Preferences at Home

Perhaps the pressure to honor patients’ requests is at its greatest when patients receive services at home. Patients who will accept any caregiver assigned to them in institutional settings somehow feel that they have the right to decide who may provide services in their homes. On the contrary, with the exception noted above, staff assignments should be made without regard to client preferences for services rendered at home, just as assignments are made in institutional settings.

Agency Response

How should managers respond when patients tell them not to assign any “foreign” nurses to them? First, they should explain that the organization does not discriminate and that to avoid assignments based on cultural or racial background may constitute unlawful discrimination. Then staff should explain that if limitations on caregivers were acceptable, the provider may be unable to render services to the patient at all because they may not have enough staff. The bottom line is that staff will be assigned without regard to patient preferences in order to prevent discrimination and to help ensure quality of care.

Patients’ requests and managers’ responses must be specifically documented in patients’ charts. Documentation that says patients expressed preferences for certain caregivers or rejected certain types of caregivers is too general. Specific requests and responses of management must be documented.

Monitoring the Patient

After patients have expressed what may amount to prejudice against certain groups of caregivers, managers must follow up and monitor for inappropriate behavior by patients directed at caregivers who are not preferred. Managers should be alert to the potential for this problem and should follow up with patients and caregivers to help ensure that caregivers are receiving the respect they deserve. Follow-up activities and on-going monitoring should also be specifically documented.

From the EEOC

“Employers cannot make job assignment decisions based on a client’s preference for a worker of a particular race or national origin. It is imperative for employers to have policies, training and other safeguards in place that help prevent a client’s prejudices from influencing their employment decisions.”

-EEOC Representative

Final Thoughts

Caregivers are a scarce commodity. Providers cannot afford to lose or alienate a single caregiver based upon discrimination or inappropriate behavior by patients.

# # #

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.

©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

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

Home Care Patient Dies in Care: Aide Arrested

Clinical

by Kristin Rowan | Oct 10, 2024 | Clinical, Regulatory

by Kristin Rowan, Editor

Elderly Patient Needs 24-hour Care

In Polk County, FL, an 86-year old man, identified only as Mr. Anderson, was hopsitalized and diagnosed with congestive heart failure. In addition to receiving care from Good Shepherd Hospice, his family hired round-the-clock care through Assisting Hands. The home health aides were caring for Mr. Anderson in 12-hour shifts.

Night Shift

Beatrice Taylor arrived for her night shift at 9 p.m. She noted that Mr. Anderson and his wife were already in bed, but not sleeping. Shortly after the day aide left, Taylor fell asleep on the couch in the living room of the patient’s home. Company policy states she was responsible for the patient’s care and should not have been sleeping.

An Avoidable Tragedy

Taylor was awakened by a “thump” coming from the bedroom. She entered the bedroom to investigate and found Mr. Anderson lying on his side, on the floor, with his head wedged between the nightstand and the bed. Taylor told investigators that she tried to help him back into the bed. He told her not to touch him, so she left him there and went back to sleep on the couch. She did not call 911, as was the policy of Assisting Hands in the event of an emergency. Nor did she call her agency or anyone else to assist.

Four Hours Later

Taylor woke up somewhere between 3:45 a.m. and 4:53 a.m. that morning. At some point, she called her parents and had a 36 minute conversation. During that conversation, she decided to check on the patient and found him still on the floor, but now unresponsive. It was her parents who suggested she call 911.

Contrary to both her parents’ urging and her employer’s policy, Taylor still did not call 911. Instead, she called Assisting Hands and left a message through the company portal. Taylor finally called 911 at 5:37 a.m., more than four and a half hours after Mr. Anderson fell.

The implanted pacemaker found during autopsy showed that Mr. Anderson was still allive at 1:oo a.m. when Taylor initially found him. The autopsy also concluded that he would have survived if Taylor had called 911 right away. His official cause of death was positional asphyxia with pre-existing health conditions listed as contributory causes.

Not actual image from story

Company Policies Broken

During the course of their investigation, detectives reviewed the Assisting Hands employee policies. That investigation uncovered several policies that Taylor violated:

If a patient falls, home aides are required to seek help which may entail calling 9-1-1. Home aides must notify the company as soon as the patient is safe
Home aides are not permitted to sleep during their assigned shift unless it is a “live in” shift
Home aides are required to submit care notes using the company portal throughout their shift to ensure assigned services are being followed appropriately.

The 911 call that Taylor placed at 5:37 a.m. should have been placed at 1:00 a.m.
Assisting Hands confirmed to detectives that this was not a “live in” shift
No information was provided as to whether Taylor submitted care notes during the shift.

Arrested Development

Taylor worked for Assisting Hands for eight months, but did not show up for her shift following the incident with Mr. Anderson. Assisting Hands has since terminated her employment. She was a licensed home health aide, but does not have a medical license, nor is she a nurse.

Taylor was arrested by detectives and made several statements about her innocence. She insisted she had done nothing wrong saying she, “didn’t kill that man.” A paramedic who responded to her 911 call overheard Taylor on the phone say, “he was old anyway so what does it matter.” Taylor remains in custody at the Polk County Jail and is being held without bond.

Polk County Sheriff

“The complete disregard for Mr. Anderson’s life by the person who was employed by his family is completely outrageous, and egregious. I believe someone who was not even being paid to look after this elderly man would have immediately dialed 9-1-1 under these circumstances. Her behavior and attitude are simply deplorable. Mr. Anderson’s family members are in our prayers.”

Grady Judd

Sheriff, Polk County Sheriff's Office

Risk Fall

In 2021, more than 38,000 older adults died from falls. This is the leading cause of injury death for adults aged 65 and older. The death rate increased 41% between 2012 and 2021. You can read more about the risk of falling and what one company is doing to help prevent falls in our accompanying article this week, an interview with Dr. Ann Wells of InnovAge.

# # #

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

CMS Ransomware Attack: Breach of PII

Admin

by Kristin Rowan | Sep 27, 2024 | Admin, Breaking News, CMS, Regulatory

by Kristin Rowan, Editor

CMS Ransomware Attack

In mid-2023, a planned file transfer went awry when Clop claimed to have breached hundreds of companies that they later listed on a data leak site. Among the companies listed were Shell, UnitedHealthcare Student Resources, The University of Georgia, and Putnam Investments. Also compromised were government entities including the U.S. Department of Energy. According to Clop, data from military sources, children’s hospitals, and other .gov sites was also copied. The ransomware group alleges they deleted all information from government, military, and children’s hospital sites.

Unfortunately, there is no way to confirm whether all that information was indeed deleted. Earlier this year, Change Healthcare suffered a similar widespread breach that caused massive payment delays for months. CMS provided guidance during those delays.

Underreporting of Attack

Many of the companies impacted by this attack chose to disclose the breach rather than negotiate with the ransomware attackers to retrieve the stolen data. When Bleeping Computer reached out to those companies immediately following the attacks, a number of them indicated that only a small number of people were effected and that no financial or identifiable information had been stolen. It seems, now, though that not all companies involved in the attack were on the initial list.

Wisconsin Physicians Service (WPS) health insurance corporation was among the companies not listed when news of this attack was first published. WPS provides Medicare administrative services to CMS, including handling Medicare Part A/B claims. In the first week of September, nearly 3-1/2 months after the attack, CMS and WPS started notifying beneficiaries whose protected health information (PHI) or other personally identifiable information (PII) may have been stolen during the attack.

1,000,000 Notifications

On July 28, 2023, CMS estimated 612,000 Medicare beneficiaries may have had PHI and/or PII exposed in the breach. That number has increased to almost 1 million. CMS and WPS are sending notifications to more than 950,000 people whose information has been compromised. The letter explains further:

May 31, 2023, MOVEit disclosed the breach to the public and released a patch.

June 2, 2023, WPS notified CMS of a data breach that occurred sometime between May 27 and May 31, 2023.

According to WPS, they applied the patch but did not observe any evidence of any files having been copied.

July 28, 2023 CMS sends an initial letter to beneficiaries whose information may have been affected.

May 2024, WPS acted on new information that led them to discover copied files from before the patch was deployed.

Of the portion of breached files that WPS studied, none were found to have personal information.

June 8, 2024, a different portion of the files showed personal information was contained in those files. This information includes:

Name
Social Security Number or Individual Taxpayer Identification Number
Date of Birth
Mailing Address
Gender
Hospital Account Number
Dates of Service
Medicare Beneficiary Identifier (MBI) and/or Health Insurance Claim Number

Note: in the initial letter sent to beneficiaries in July of 2023, CMS also listed Healthcare Provider, Prescription Information, Insurance Claims, Policy Information, Subscriber Information, Health Benefits, and Enrollment Information as possibly having been leaked. These items were removed from the list in the September 2024 version of the same letter.

For those who received this notification, CMS and WPS offered a complimentary year of credit monitoring from Experian. CMS also advised members to request their free credit report from each of the credit reporting companies.

The letter also informed members that they would soon receive a new Medicare card with a new Medicare Number. 946,801 people received this notice.

CMS Ransomware Attack Victims Not Notified

On September 24, 2024, Bleeping Computer reported that on the same day CMS sent more than 900,000 letters to members, they also reported to the Department of Health and Human Services that the total number of people with information stolen was 3,112,815. CMS explains the difference by saying the larger number includes Medicare beneficiaries, people who are deceased, and people who were covered by other providers but whose information was included in WPS data collection used for provider audits in their role as Medicare Administrative Contractors (MACs).

New MBIs and What it Means For You

According to a blog post dated September 26, 2024 from SimiTree, starting in mid-October, CMS will issue new Medicare cards with new Medicare Beneficiary Identifiers to the 946,801 Medicare beneficiaries who were previously identified as at risk and were notified of the breach. This may cause undue delays and other issues for home health and hospice providers.

Claim Rejection

If these beneficiaries use their existing MBI after the new one has been issued, providers could see rejections on NOAs, NOEs, OASIS submissions, and claims.

Urgent Reverification

Providers will need to reverify eligibility and update patient records in their EMR systems. Because providers were not notified of which beneficiaries were impacted, agencies will need to verify MBIs for every Medicare patient.

Possible Disruption

The full impact of reassigning MBIs to nearly 1 million Medicare beneficiaries is not yet known. Medicare has not clarified what will happen with claim processing for patients whose MBIs change during the claim processing for active patients. There are possibilities for delayed processing, delayed payments, and incorrect denial of services or payments due to the volume of MBIs changing at once.

How to Prepare

Our friends at SimiTree have some suggestions for how home health and hospice providers can prepare in advance for the MBI change coming around October 15-16, 2024.

Take Immediate Action – start reverifying eligibility for all Medicare patients now
Update Systems – ensure your EMR and other solutions in your tech stack are updated and ready to handle the changes
Train your Staff – make sure everyone on your team knows this change is coming and teach them new verification procedures so their patients aren’t left without care

CMS has not issued a statement about the impact of the MBI changes, but this story is ongoing and we will continue to monitor and report on any updates from WPS and CMS as well as look for additional information on the changes expected with the new MBIs.

# # #

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

BREAKING NEWS: Blumenauer Proposes Hospice Overhaul

Breaking News

by Rowan Report | Sep 27, 2024 | Breaking News, Partner News, Regulatory

FOR IMMEDIATE RELEASE

Contact: Portland District Office
503-231-2300

blumenauer proposes overhaul to hospice benefit

If enacted, the legislation would be the single most significant update to the hospice benefit and payment structure since its inception in 1982

WASHINGTON, D.C., SEPTEMBER 26, 2024 – Today, Congressman Earl Blumenauer (D-OR), a senior member of the Ways and Means Committee, introduced the Hospice Care Accountability, Reform and Enforcement Act (Hospice CARE Act) to modernize Medicare’s hospice benefit, which has remained largely unchanged since its inception in 1982. The proposal comes as egregious reports of fraud and abuse within the benefit persist, despite action from Centers for Medicare & Medicaid Services (CMS). The legislation is the product of years of collaboration between stakeholders, lawmakers, and industry leaders. It builds on Blumenauer’s decades-long commitment to ensure the federal government supports families at a time of great stress and vulnerability: the end of life.

“The United States spends significantly more on health care than other developed nations for worse outcomes. Nowhere is this more egregious than in the hospice industry,” said Congressman Earl Blumenauer. “Patients and families deserve better. We need a reset. It is past time for Congress to act to end the fraud, waste, and abuse within the hospice benefit and bring it into the 21^st century.”

To protect patients and taxpayers, the Hospice CARE Act would institute a number of long overdue reforms to crackdown on fraud while incentivizing high-quality care. Critically, it would:

- Reform the payment structure: The underlying hospice per-diem payment structure—which generally pays hospices for each day of care regardless of if care is provided on a given day—rewards bad actors who exploit the benefit for financial gain. The legislation revises the payment structure to ensure that providers are incentivized to deliver high-quality care and meet the current needs of individuals and their families.
- Bolster program integrity: Additional safeguards and oversight is needed to prevent fraudulent providers from enrolling in Medicare, especially for new hospices. That includes temporarily preventing new hospices from enrolling in Medicare, with exceptions where additional access to care is needed, increasing survey frequency, and increasing ownership transparency

A one-page fact sheet can be found here. Bill text here.

“The hospice benefit, while unique, is ripe for change. This legislation is a first-of-its-kind opportunity to improve it,” said Katie Smith Sloan, president and CEO, LeadingAge, the association of nonprofit providers of aging services, including hospice, on the Hospice Care Accountability, Reform and Enforcement (CARE) Act of 2024. “Revising a benefit that has not been altered significantly since its creation in 1982 is a formidable undertaking – but a necessary one. Done right, changes will expand the benefit to support the realities of modern-day hospice care and address vulnerabilities that are currently being exploited. There is more work to do and we look forward to continuing our productive partnership to ensure this bill achieves these goals.”

“The National Partnership for Healthcare and Hospice Innovation (NPHI) is thankful for the work of Congressman Blumenauer, his staff, and the Ways and Means Committee staff who worked with the hospice and advanced illness community to put forward the Hospice Care Accountability, Reform, and Enforcement (CARE) Act. This legislation is an encouraging and unique opportunity to consider reforms that would strengthen the Medicare hospice benefit by ensuring it continues to support patients, families, and the non-profit providers who were the original foundation of hospice care,” said Tom Koutsoumpas, CEO and founder of NPHI. “We look forward to continuing to work closely with Congress and relevant stakeholders on efforts to modernize the hospice benefit and improve care of those at the end-of-life.

“The Coalition to Transform Advanced Care (C-TAC), truly appreciates the introduction of the Hospice Care Accountability, Reform, and Enforcement (Hospice CARE) Act. We commend Representative Earl Blumenauer (D-OR-3rd) for this important work and for his decades of support for compassionate end-of-life care and for bringing policies to the national stage with bi-partisan support,” stated Jon Broyles, C-TAC CEO. “We have had the privilege to work with the Congressman, his staff, Ways & Means Committee staff and other advocates on this bill and it is an important starting point for ideas that will lead to modernizing the hospice program and improving the lives of people with serious illness and their family caregivers.”

# # #

This press release was issued by the office of U.S. Congressman Earl Blumenauer, representing the 3rd district of Oregon. The original press release can be found here. The Rowan Report has reached out to The Alliance for Care at Home for comment.

Home Health in a Post-Chevron World

Admin

by Elizabeth E. Hogue, Esq. | Sep 27, 2024 | Admin, Advocacy, Audits, Regulatory

by Elizabeth E. Hogue, Esq.

The "Wicked Witch" Chevron is Gone

On June 28, 2024, the U.S. Supreme Court overturned a decision of the Court in 1984 often referred to as “Chevron.” The Chevron case said that Courts must defer to administrative actions that are reasonable interpretations of ambiguous statutory language.

In Loper Bright Enterprises v. Raimondo, however, the U.S. Supreme Court abandoned the decision in Chevron and said that:

- The “deference that Chevron requires of courts reviewing agency action cannot be squared with” the Administrative Procedure Act (APA). The APA “specified that courts, not agencies, will decide ‘all relevant questions of law’ arising on review of agency action…even those involving ambiguous laws – and set aside any such action inconsistent with the law as they interpret it.”
- The framers of the U.S. Constitution envisioned that the final “interpretation of the laws” would be “the proper and peculiar province of the courts.”
- The views of the executive branch should inform the judgment of the judiciary, not supersede it.
- “Chevron’s presumption is misguided because agencies have no special competence in resolving statutory ambiguities. Courts do.”

What Does it Mean for Providers?

The short answer is that we don’t know yet. It is unclear how the new standards of the Loper Bright decision will be applied and affect health care providers. The Supreme Court said that the recent Court decision does not call past cases into question that were based on Chevron, but existing regulations are not insulated from challenges. It is likely that several providers will “swing for the fences” for favorable rulings based on Loper Bright!

One possible “candidate” for disruption is the reliance of administrative law judges (ALJs) on Chapter 8 of the Medicare Program Integrity Manual. This section offers an overview of use of inferential statistics and statistical sampling to estimate overpayments in Medicare audits. Chapter 8 of the Manual is only nine pages long. ALJs routinely use this section of the Manual to hamper providers’ ability to mount a compelling defense that challenges auditors’ methods using widely accepted standards within the statistical community. Challenges to this practice based on Loper Bright may prevent ALJs from reliance on these sections of the Manual.

Another possible target is the use of sub-statutory and even sub-regulatory guidance from the Centers for Medicare and Medicaid Services (CMS) and the Medicare Administrative Contractors (MACs) by fraud and abuse enforcers to make determinations about illegal conduct, especially under the False Claims Act (FCA). Defendants arguably now have a better chance to challenge the basis of claims of illegal conduct in light of Loper Bright.

The story of Loper Bright has not been written by any means. Surely providers should use this significant change in the law to their benefit whenever possible.

# # #

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.

©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

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

What are You Hiding?

Admin

by Elizabeth E. Hogue, Esq. | Sep 20, 2024 | Admin, Regulatory

by Elizabeth E. Hogue, Esq.

Bring on the Fraud Enforcers

We Have Nothing to Hide!

Oh, but you do! Statements like this from providers are cringe-worthy. If you have said it before, please don’t ever say it again.

Here’s why:

First, many providers think that when fraud enforcers are required to show intent they must show that providers sat down at their desks on a Friday afternoon, for example, and decided to engage in fraud. On the contrary, enforcers can demonstrate intent by showing that there was fraudulent conduct that providers knew about or should have known about. This is a game changer! It’s not hard to imagine fraudulent conduct that providers should have known about, but have not identified and corrected.

In addition, George Will points out in his Washington Post column, “Have you committed a felony yet? Probably so.” that the volume of legal requirements has skyrocketed. Here is what Mr. Will says:

“Less than a century ago, …a single volume contained all federal statutes. By 2018, they filled 54 volumes – about 60,000 pages. In the past 10 years, Congress has enacted about 2 million to 3 million words of law each year. The average length of a bill is nine times what it was in the 1950s. Agencies publish their proposals and final rules in the Federal Register, which began at 16 pages in 1936, and now expands by an average of more than 70,000 pages annually. By 2021, the Code of Federal Regulations filled about 200 volumes. And in a recent 10-year span, federal agencies churned out approximately 13,000 guidance documents.”

Mr. Will goes on to point out that ignorance of the law is, therefore, inevitable. Congress has added an average of 56 new federal crimes each year so that there are not more than 5,000 federal statutory crimes. In addition, at least 300,000 regulations of federal agencies include criminal sanctions.

Here are some common examples:

- If you are a discharge planner/case manager in a hospital or skilled nursing facility you may not know about guidance from the Office of Inspector General of the U.S. Department of Health and Human Services that says you can’t accept gift cards from post-acute providers that want referrals.
- If you are a home care/private duty provider and accept payments from the Medicaid Program, you may have repeatedly violated technical requirements, such as recording the time caregivers arrive and leave patients’ homes.
- If you provide home health services and use the services of consulting physicians as Medical Directors, chances are very good that fraud enforcers will demonstrate that you violated at least one of a multitude of requirements that govern these relationships.
- Finally, hospice providers know all too well that enforcers are going to claim that their patients are not terminally ill.

Mr. Will says in his column that James Madison predicted our current situation in which laws are “so voluminous that they cannot be read, or so incoherent that they cannot be understood” and “undergo such incessant changes that no man, who knows what the law is today, can guess what it will be tomorrow.”

So, don’t even think that you have nothing to hide, much less say it!

# # #

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.

©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

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

Another One Bites the Dust

CMS

by Kristin Rowan | Sep 20, 2024 | CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Essentia Drops Medicare Advantage

Essentia Health is an integrated health system with locations in Minnesota, North Dakota and Wisconsin. The health system offers 285 different services across more than 1,700 locations. They employ more than 2,700 doctors. Essentia also includes 14 hospitals, emergency care, same-day care for mental health crises, and multiple specialties.

This is all to say that Essentia Health is not a small player. They contract with the largest payers in the industry.

Re-Evaluation

Recently, the health system began re-evaluating its participation in some Medicare Advantage plans. According to the chief medical officer for population health at Essentia, Cathy Cantor, M.D., M.B.A., too often deny or delay care. Cantor said in a statement:

“This was not a decision we made lightly. The frequent denials and associated delays negatively impact our ability to provide the timely and appropriate care our patients deserve. This is the right thing to do for the people we are honored to serve.”

Essentia informed patients that they will no longer be an in-network provider for MA plans through UnitedHealthcare (UHC) or Humana beginning January 1, 2025. The health system claims that UHC and Humana delay and deny approval of care at more than twice the rate of other Medicare Advantage plans. They are encouraging its patients to choose a different plan during open enrollment that is in-network with Essentia.

UHC Responds

UnitedHealthcare responded to the press release that Essentia issued. According to their statement, the two parties extended their contract just this past July. Negotiations included a number of items on which they agreed to collaborate, but Medicare Advantage was not specified among them.

“Essentia Health didn’t raise concerns regarding its participation in our Medicare Advantage network until last week. We have since met with Essentia on Sept. 9 and are committed to working with the health system to explore solutions with the goal of renewing our relationship. We hope Essentia shares our commitment toward reaching an agreement.”

Following Suit

Essentia’s departure from Medicare Advantage is just one in a recent mass exodus.

Sanford Health of South Dakota ended its Humana MA participation due to “ongoing challenges and concerns that negatively effect patients including ongoing denials of coverage and delays in accessing care.”

HealthPartners out of Minnesota announced over the summer that “UnitedHealthcare delays and denies approval of payment for MA claims at an exceptionally high rate…up to 10 times higher than other insurers…. After over a year of being unable to persuade UnitedHealthcare to change their practices, we’ve determined that we can no longer participate in the UnitedHealthcare Medicare Advantage network.”

Mercy, the official medical provider of the St. Louis Cardinals, announced its year-end departure from the Anthem Blue Cross Blue Shield network. This includes all Medicare Advantage, ACA marketplace, and managed Medicaid plans. They cited administrative tasks that create a barrier to timely, appropriate patient care. Mercy also complained that Anthem has raised its rates for patients and employers, increased its profits, and still has not raised reimbursement rates to providers. Like Essentia, Mercy is encouraging its patients to consider whether the health care plan they choose during open enrollment will list Mercy as one of its in-network providers.

Final Thoughts

CMS reimbursement rates, Medicare Advantage denials, payment delays, and other interruptions are impeding patient care. As Tim mentions in his editorial this week, we are in an election year and we urge you to research how each party might impact our industry.

If more providers and payors continue to drop Medicare Advantage from their offerings, will we see more patients returning to traditional Medicare plans with an affordable Medicare Supplement or MediGap coverage? One can only hope!

# # #

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

NonCompete Agreements and What to do About Them

Admin

by Elizabeth E. Hogue, Esq. | Sep 12, 2024 | Admin, Clinical, Regulatory

by Elizabeth E. Hogue, Esq.

What to do About Noncompete Agreements

The Federal Trade Commission (FTC) published a final rule earlier this year that banned noncompete agreements. The final rule was effective on September 4, 2024.

Requirements of the rule included:

- A ban on new concompete agreements with all workers, including senior executives
- Existing noncompete agreements could remain in force for senior executives if
  - they make more than $151,164 per year including salary, commissions, and performance bonuses but not including benefits, board and lodging; and
  - senior executives have authority to make policy decisions for the entire company
- Existing noncompete agreements with workers other than senior executives are unenforceable after the rule is effective

There are a number of exceptions to the rule.

In the meanwhile, litigation

On July 23, 2024, a federal court in Pennsylvania refused to issue a preliminary injunction to prevent implementation of the final FTC rule. The U.S. District Court for the Eastern District of Pennsylvania said that the statutory authority of the FTC to prevent unfair methods of competition under Section 5 of the FTC Act is not limited to procedural rules for adjudications and extends to substantive rulemaking [See ATS Tree Servs. v. Fed. Trade Comm’n, No. 24-1743 (E.D. Pa. July 23, 2024)].

But...

In early July, a federal court in Texas granted a preliminary injunction that delayed the effective date of the final rule. The Court declined to issue a nationwide injunction [See Ryan LLC v. Federal Trade Comm’n, No. 3:24-CV-00986-E (N.D. Tex. July 3, 2024)].

Then, on August 20, 2024, the Judge issued an order in the Ryan case that included a nationwide prohibition on implementation of the FTC rule. The basis of this decision is that the FTC does not have authority to order a ban, and that the rule was arbitrary and capricious. Based on this ruling, employers may continue to enter into and enforce non-compete agreements with workers.

Another but...

A number of state legislatures have enacted restrictions on use of noncompete agreements. As of August 21, 2024, four states ban the use of noncompete agreements and thirty-three states plus the District of Columbia restrict the use of these agreements.

Providers must comply with applicable requirements in the states in which they conduct business. Providers who fail to do so risk enforcement action.

Comfort Keepers, for example, agreed to pay $500,000 to resolve claims that it unfairly restricted workers’ mobility according to the California Department of Justice. Comfort Keepers’ Client Care Agreement that clients were required to sign before receiving care prevented clients from using, hiring, or soliciting current and former Comfort Keepers’ caregivers for up to one year after the termination of services. Violations required payment of $12,500.

So...

The current bottom line is that the FTC rule banning noncompete agreements is not in effect, but providers must comply with applicable state requirements or risk enforcement action.

Stay tuned for more!

# # #

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.

©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

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

Hospice Fraud Oversight

Admin

by Kristin Rowan | Sep 12, 2024 | Admin, CMS, Hospice, Regulatory

by Kristin Rowan, Editor

CMS Oversight in Fraud-Ridden States

In 2023, The Centers for Medicare and Medicaid Services (CMS) cited research suggesting that hospices profit from fraud far too often. CMS has identified cases of hospices certifying benficiaries who are not terminally ill, providing little to no services, and still billing CMS. Four states have had rapid growth in fraudulent hospices: Arizona, California, Nevada, and Texas.

Churn-and-Burn

Some of the registered hospices had non-operational addresses. This information led to an investigation that resulted in evidence of the fraud dubbed “Churn and Burn.” This scheme involves registering a new hospice and billing for services until there is an audit or the agency maxes out on yearly payments. Then, the hospice closes, keeps the money, registers for a new Medicare billing number, and starts all over again.

Program Integrity Strategy

As a result of the findings of this research, CMS put more effort behing the hospice program integrity strategy to find and address fraudulent activity. Part of the strategy was unannounced visits to hospices nationwide. Hospices not active at listed addresses were deactivated and Medicare billing privileges were revoked. Of the more than 7,000 hospices visited, 400 had potential administrative action pending.

Enhanced Oversight

In the four states identified as having higher instances of fraud, CMS implemented a provisional period of enhanced oversight. During the provisional period, CMS conducted a medical review prior to payment for hospices in these states that have identified problems.

Nationwide Pilot Project

In addition to the provisional period for the four identified states, CMS started a pilot project to review hospice claims after a patient’s intitial 90 days of hospice care. This pilot project was not limited to the four states, but was implemented nationwide. CMS launched the program to help inform medical reviews in determining whether hospices are submitting claims for eligible patients.

Regulatory Changes

CMS also proposed some regulatory changes to combat hospice fraud. Some of these regulatory changes were initially suggested by hospice providers. The proposals include:

- Prohibiting the transfer of Medicare billing privileges of a new hospice for 36 months
- Clarifying the definition of “Managing Employee” to include the administrator and medical director of a hospice
- Implementing a Special Focus Program to increase oversight on poor-performing hospices that have ongoing health and safety deficiencies
- Adding criminal background checks for owners when they initially enroll for Medicare billing privileges.

Prepayment Review Expanded

CMS has just announced that they will expand the prepayment review process in the four states beginning in September, 2024. Information from CMS is limited and states that prepayment review volume will start low to protect compliant hospices, but will increase if a hospice is found to be non-compliant. Consequences for non-compliance includes delays in payment, extended review, or additional administrative actions.

According to preliminary information we received from a hospice consultant, the expanded program puts all new hospices or hospices with ownership changes into prepayment review even if they have not had identified problems.

We have reached out to both CMS and some of our expert hospice consultants to get more information and will update this story as information becomes 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

NHPCO and NAHC Announce New Name and Website

Advocacy

by Kristin Rowan | Sep 12, 2024 | Advocacy, Breaking News, Regulatory

by Kristin Rowan, Editor

The Alliance

Since the announcement that the National Hospice and Palliative Care Organization and the National Association for Home Care and Hospice would merge, the default name for the combined entities has been “The Alliance.” NAHC President Bill Dombi and Interim NHPCO CEO Ben Marcantonio, along with a transition board and other members have been working since August of 2023 on the merger. In June of 2024, the two organizations signed an official affiliation agreement.

Alliance Updates

In the last year, the two organizations have spoken about the work they’ve been doing to create the new affiliation. They jointly hosted a town hall to answer questions, and Bill Dombi has spoken at state and national association meetings about the merger. On August 26, 2024, The Alliance named its inaugural CEO, Dr. Steven Landers.

National Association for Care at Home (NACH)

Our industry loves its acronyms and this one rolls off the tongue like we’ve been using it for years. Although, we may all need to perfect the German guttural sound to differentiate it from NAHC.

In a press release on Sept. 5, 2024, the two associations officially announced that The National Alliance for Care at Home (NACH) is the new name of the combined organizations. Along with this announcement, The Alliance has also launched its new logo (below) and new website at www.AllianceForCareAtHome.org.

From The Alliance

Statements from both organizations outline the path forward and the mission and vision for the new affiliation:

- The National Alliance for Care at Home will Combine the Strengths of the Two Largest National Organizations Representing Healthcare Providers Delivering Care Primarily in Homes
- The Alliance Will Provide Unparalleled Resources and Representation to Support the Care-at-Home Community
- This Alliance will be the leading authority on transforming care in the home. We will implement that mission under a new name that welcomes providers across the care continuum to join – the National Alliance for Care at Home
- The Alliance will be your advocate, your resource, and your network to help you reach your goals

The new logo for NACH is, according to the press release, both an homage to the past and a symbol for the future. It creates a visual representation of both NAHC and NHPCO. The star shape of the logo is representative of the stars on the American flag, part of the NAHC logo. The visual aesthetic of the logo is reminiscent of the lotus flower from the NHPCO logo. The individual sections of the logo represent people holding hands, the visual representation of the coming together of types of care. The white space in the middle is meant to symbolize a house or home.

The logo is based on guidance from a workgroup comprised of members from both organizations, whose input has helped shape the Alliance brand.

About Us

This press release also included a new boilerplate, describing the National Association for Care at Home, rather than two separate descriptions of each organization. This is probably still a temporary description, as it mentions that they are still in the process of combining operations and Communications Officers from both separate organizations are listed as press contacts.

More to Come

Despite the announcement of the new CEO and the new name, the merger is far from over. There are logistical and operational hurdles still to overcome, a new board to enstate, the combining of assets and competencies, and a restructuring of existing employees. We will continue to report on press releases coming from NACH.

# # #

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

HHA to pay Nearly $4 Million after False Claims Act Violations

Regulatory

by Kristin Rowan | Aug 23, 2024 | Regulatory

by Kristin Rowan, Editor

False Claims Act Violations

According to allegations in U.S. es rel. Jones v Intrepid U.S.A. Healthcare Inc. and U.S. es rel. Rigney v Intrepid U.S.A. Inc., Intrepid U.S.A. Inc. (Intrepid) violated the False Claims Act multiple times over five years.

Intrepid is based in Texas and includes more than 80 Personal Care, Home Health, Palliative Care, and Hospice Care agencies across 18 states. Intrepid describes their services as “concierge medical home healthcare, hospice at home, private duty home care, and independent living support.”

Whistleblowers

Whistleblowers filed Civil cases against Intrepid under the whistleblower provisions of the False Claims Act. A former travel nurse and a former Director of Quality and Improvement for Intrepid filed the first case. A former Director of Clinical Excellence and Integrity and a former Regional Manager of Clinical Excellence for Intrepid filed the second. Under the False Claims Act, a private party can file an action against a company on behalf of the United States. Should there be a settlement or resolution, the filing party(ies) receive a portion of any recovery.

Allegations

Each of the cases addresses different lines of business for Intrepid. The first case alleges that Intrepid knowingly submitted home healthcare Medicare claims for patients who did not qualify for the home healthcare benefit, or where services did not qualify for reimbursement. The second case alleges that Intrepid knowlingly submitted Medicare claims for patience who did not qualify for the hospice benefit.

More Allegations

Additionally, the United States claims that from 2016 to 2021, Intrepid submitted claims for services that were not reasonable or medically necessary, services provided by untrained staff, and services that were never provided at all. Separately, the United States alleges that Intrepid admitted patients who were ineligible for hospice benefits because they were not terminally ill and continued providing services to patients who should have been discharged because they no longer met the requirements to qualify for the hospice benefits.

Settlement

The Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, the U.S. Attorney’s Office for the Western District of Kentucky and U.S. Attorney’s Office for the District of Minnesota worked together to investigate and resolve these matters. According to the Department of Justice report, no liability or admission of guilt was determined and the settlement resolved allegations only.

Repeat Offender

It seems this is not the first run-in with the law that Intrepid U.S.A. has faced.

2014: a class action suit alleged unpaid wages.

2019: Intrepid settled a class action suit where employees alleged unpaid overtime.

2021: William Buchanan filed a civil right – employment discrimination suit against Intrepid in Indiana.

Intrepid in Minnesota and North Carolina faced similar Medicare fraud charges as well.

Not Alone

Intrepid U.S.A. Inc. is not the only home health or hospice agency to face these types of allegations.

Evolution Health LLC

In July, 2024, Guardian Health Care, Inc., Gem City Home Care LLC, and Care Connection of Cincinnati LLC, together with their parent company Evolution Health LLC, settled a False Claims Act case in which the Companies were accused of providing illegal kickbacks to ALFs and physicians in exchange for referrals. That settlement totaled almost $4.5 million dollars.

Halo Home Healthcare

Similarly, in June, 2024, the former owner of Halo Home Healthcare pled guilty to billing more than $8.5 million in fraudulent claims to Medicare, Medicaid, and Veterans Affairs from 2015 to 2021. Halo Home Healthcare hired more than 50 employees with criminal backgrounds that should have excluded them from providing home health services, one of whom was charged with a quadruple murder during their employment at Halo. The former owner also hid her ownership of the company because she had been convicted in 2013 of passing forged and fraudulent prescriptions for oxycodone and hydrocodone.

Atlantic Home Health Care

In January, 2024, Atlantic Home Health Care was accused of falsely billing the Energy Employees Occupational Illness Compensation Program. The claim alleges Atlantic charged for in-home nursing and personal care when employees weren’t providing services and paying kickbacks for patient referrals. The Arizona-based company paid almost $10 million to resolve that case.

Speak Up, Speak Out

Fraudulent billing, up-coding, and other illegal acts from home health and hospice agencies put additional strain on the already stretched CMS budget for reimbursement. The millions of dollars recovered just this calendar year is just a portion of fraudulent claims filed. Whistleblower laws protect employees from retaliation by their employers. Fraudulent practices that send money directly to an agency without benefitting a patient hurts the whole industry. The only way the Department of Justice can address and stop these billing practices and keep that money going directly to patient care is with the help of whistleblowers.

# # #

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

HHVBP Model Payments Begin January 1, 2025

Admin

by Kristin Rowan | Aug 23, 2024 | Admin, CMS, Regulatory

by Kristin Rowan, Editor

Background on the HHVBP Model

The Home Health Value Based Purchasing (HHVBP) Model, implemented by CMS in 2016, began in nine states. The goal is “to provide incentives for better quality care, to study new quality and efficiency measures, and to enhance the reporting process.” It may also provide new avenues for payment models.

According to the CMS website, the original HHVBP Model, launched in nine states, improved an average of 4.6 percent HHA performance scores and saved Medicare $141 million. Additionally, the model lowered unplanned hospitalizations for acute care and reduced skilled nursing facility (SNF) stays.

HHVBP Model Expansion

From the initial study, CMS surmised that expanding the model would increase performance, increase savings, and further reduce hospitalizations and SNF stays. Early in 2021, CMS announced the nationwide expansion of the HHVBP Model.

The expanded model started on January 1, 2022. In its first expansion year, CMS provided training and allowed HHAs time to adjust practices based on HHVBP expectations and requirements. During the transition year, HHA performance did not risk future payment rates.

HHVBP Model Performance Year

January 1, 2023 marked the beginning of the performance year, in which all HHA results would impact future payments. CMS will adjust fee-for-service payments based on performance relative to other HHAs. CMS groups HHAs into cohorts determined by beneficiary count the previous year. Cohorts include large- and small-volume for agencies above and below 60 unique HHCAHPS eligible beneficiaries, respectively.

Using data already reported by HHAs through the Home Health Quality Reporting Program (HH QRP) and HHCAHPS surveys, CMS compares an HHAs data to similar agencies. Based on this comparison, CMS adjusts future payments between -5% and 5% for fee-for-service payments.

Interim Performance Report

The Interim Performance Report (IPR) is a quarterly report with performance data for all HHAs participating in the HHVBP Model. Active HHAs that were Medicare certified before January 1, 2022, are eligible for payment adjustment, and meet the minimum threshold of data for at least one quality measure receive the reports. Reports are available at iQIES. Registration on the portal is required.

CMS publishes new reports every quarter and eligible HHAs should receive an email when a new report is available.

Points System

Payment adjustments for the next calendar year are based on an HHAs performance in the last report. For CY 2025, payment adjustments will use the Final Annual Performance Report, published 30 days prior to each payment year.

The process to determine your HHAs ranking in relations to the other HHAs in your cohort can be confusing and has many steps. Payment adjustments are based on “Care Points”, which are calculated on a weighted scale, using the higher of the agency’s earned achievement points or improvement points. An HHA must have at least 20 quality stays for claims-based measures and at least 40 surveys for the HHCAHPS survey-based measure.

Achievement Points

Achievement points are earned by scoring above the median performance on each quality measure (better than half of the agencies in your cohort) and dividing that by the difference between your score and the top 10 percent in your cohort.

Improvement Points

Improvement points are calculated using an HHAs prior year performance measure, current measure and the mean score of the top 10 percent of agencies in your cohort.

Care Points

Care points are the higher of Achievement Points or Improvement Points for each quality measure. Each quality measure is weighted differently in each category of OASIS-based Measures, Claims-based Measures, and Survey-based Measures.

The higher of each agency’s achievement and improvement scores is multiplied by its assigned weight to calculate the weighted score within each measure. Each measure then has its own weight. OASIS- and Claims-based measures each count for 35% of the total score while Survey-based measures make up 30% of the final score.

The HHA score is measured against all HHAs in the cohort to determine your rank. Where your weighted points fall in comparison with the rest of your cohort determines whether your next payment cycle will go up or down by as much as 5 percent.

Public Reporting

Your scores will not only be used to determine your payment increase or decrease. These reports will be made public as well. CMS will publicly report each quality measure’s benchmark and achievement threshold. For every HHA that qualifies for a payment adjustment, CMS will also publish:

- - Measure results and improvement thresholds
  - Total Performance Score and Percentile Ranking
  - Payment adjustment percentage

Scoring well on the Achievement and Improvement markers for each measure may offer an HHA an opportunity to gain more referrals, recruit talented clinicians, and gain a reputation for quality care.

On the other hand, scoring low may hurt an agency irreparably. HHAs who think there is an error in the initial reporting can submit a recalculation request within 15 days of the publishing of a preview report. Based on CMS’s decision, HHAs have 15 days to submit a reconsideration request if they submitted a recalculation request and are not happy with the decision. If the HHA is still not in agreement with the decision of the reconsideration request, they have seven days to submit a request for administrative review.

Next Steps

According to the information we can find on CMS, these reports will be published quarterly. Logically, then, the recalculation requests can also be submitted quarterly along with reconsideration and administrative review requests. We will continue to follow this and provide updated deadlines to submit requests as we find them.

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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