Three Choices at the End of Life

by Rowan Report | Aug 7, 2026 | Clinical, Hospice

by guest author Barbara Karnes, RN

Cure, Life-Sustaining, or Comfort Care

When someone is facing a life-threatening illness, they and their loved ones are often asked to make medical decisions they never expected to face. Unfortunately, most of us don’t fully understand the choices before us. Knowing the difference between cure, life-sustaining treatment, and comfort care can help you make decisions that honor the kind of life – and death – you want.

Cure, life-sustaining treatment, and comfort care. These are the three paths available when we are faced with a life-threatening illness.

Cure

Cure means providing a return to a “normal” functioning life. I put normal in quotes because the word can be misleading. What is normal for one person may not be normal for another. Cure implies being able to participate in and enjoy the activities of everyday living. It means the malady is gone or controlled.

Life-Sustaining Treatment

Life-sustaining treatment means keeping the physical body alive by whatever means are deemed necessary. Many people refer to these treatments simply as “life support.” They can include artificial nutrition and hydration, ventilators, dialysis, respirators, and other advanced medical procedures. The goal becomes preserving life, even when the quality of life is greatly diminished.

Quality Improvement Project Hospice Domains

Comfort Care

Comfort care focuses on the quality of the life you are living rather than simply the length of that life. It includes physical care along with emotional, mental, and spiritual support. Comfort care addresses what is most important to your well-being now that your body is no longer able to meet all of your needs. It also guides and nurtures your family and those closest to you as everyone prepares for the end of life while continuing to live fully each day.

"Fix" or Provide Care?

We often get so caught up in getting “fixed” at any price that we lose sight of what our goal really is. Treatment does not necessarily mean cure. Yet most of us assume that if we do everything possible, we will get better. Sadly, too often we sacrifice the quality of the life we have today while pursuing a cure that may no longer be possible.

When deciding between cure, life-sustaining treatment, or comfort care, information and knowledge are vital components to making decisions. We need honest conversations about the likely outcome of treatment, the chances of success, life expectancy, and quality of life. Once you’ve had those conversations and decided what kind of living is most important to you, share those wishes with your physician, your family, and those closest to you—and put your decisions in writing.

There is no right or wrong choice. There is only the choice that best reflects your values and how you want to live the time you have.

# # #

Barbara Karnes, RN, is an award-winning end-of-life educator, award-winning nurse, NHPCO Hospice Innovator Award winner 2018, and 2015 International Humanitarian Woman of the Year

While at the bedside of hundreds of people during the dying process, Hospice Pioneer Barbara Karnes noticed that each death was following a near-identical script. Each person was going through the stages of death in almost the same manner, and most families came to her with similar questions. These realizations led Barbara to sit down and write Gone From My Sight, the “Little Blue Book” that changed the hospice industry.

Gone From My Sight is the original, and remains the most widely used, patient/family educational booklet on the signs of approaching death. It has been in print continuously since 1985 and has sold over 35 million copies worldwide. With its publication and distribution, Barbara created one of the most important tools in the end-of-life movement today.

©2026 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

NGS Shutters Valid Hospice

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

Will a Typo Shut Down Your Agency?

by Tim Rowan, Editor Emeritus

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

July 24 Update

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

It Was Supposed to be Routine

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

No ownership change

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

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

NGS received the message…and ignored it.

What is PPEO Fraud Prevention?

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

Yet that is exactly what happened, he told us.

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

Grounds for denial bordered on the frivolous:

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

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

The Clinical Reality NGS Ignored

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

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

Deadly consequences

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

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

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

Widely Known, Ongoing Issue

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

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

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

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

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

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

Sound Familiar?

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

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

United front

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

More to Come

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

# # #

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

©2026 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Fraud in Hospice

by Elizabeth E. Hogue, Esq. | May 29, 2026 | Hospice, Waste Fraud and Abuse

By Elizabeth E. Hogue, Esq.

Fraud in Hospice Today

Between a Rock and a Hard Place

The crackdown on fraud in the hospice industry has begun and will undoubtedly continue for some time. Many believe that this crackdown is way overdue. Efforts to eliminate fraud are likely to negatively impact the hospice industry; causing significant damage or even destruction of its credibility. The result may be that patients are no longer willing to receive hospice care. These negative effects could spill over to other types of services provided in patients’ homes, such as home health services.

Examples of Fraud in Hospice

Placed in Hospice Care Without Knowledge

A former Louisiana resident was sentenced to 6 years in prison for conspiracy to commit health care fraud and 3 counts of health care fraud. Evidence presented at trial demonstrated that 24 patients were admitted to the hospice who had not been diagnosed with a terminal condition. Many of the patients and their families never knew they had been placed in hospice care. A patient testified at trial that Medicare refused to cover a procedure he needed because, without his knowledge, he was a patient of a hospice.

Fake Charts

A defendant in California told prospective patients that they did not have to be dying to receive hospice services. After collecting identifying information from prospective patients who were not terminally ill, the hospice billed the Medicare Program for services provided to the patients. When the Medicare Program requested additional information to support claims submitted, the owners directed employees to create fake patient charts that were submitted to Medicare.

Make the Patient go "Bye-Bye"

A Texas hospice owner sent employees a text that said, “You need to make this patient go bye-bye.” Giving the owner every benefit of the doubt and allowing for misunderstandings that may arise from text messages, it seems impossible to justify this communication.

Another owner of a hospice in Texas sent a text message to a hospice nurse telling her to take over for nurses who weren’t doing their jobs. The owner went on to say: “I told this chick that if she would just give her 1 ml of Ativan and turn her she would die,” and “[expletive] woman is still alive…I need boots on the ground.” After the nurse took over the care of the patient, as instructed, the owner then texted “nice work.”

Hospice Without a Terminal Illness

A physician was the medical director of several hospice companies. He fraudulently certified that patients of these hospices had terminal illnesses when they did not. In 2015, the physician was listed as the attending physician for more hospice claims paid by the Medicare Program than any other doctor in the country.

Kickbacks

The medical director of another hospice with dozens of locations certified unqualified patients for hospice care. In addition to payment for his services as medical director, he received other perks, including luxury trips and bottle service at exclusive nightclubs.

Final Thoughts

The need for enforcement action is clear, but what effect will these efforts have on the general public and the public’s willingness to use hospice and other services? The backlash from learning that providers who are supposed to care for patients and their families in their dying moments actually engaged in fraudulent conduct may be horrendous – even catastrophic – in terms of utilization of hospice services. Even compliant hospices and other types of providers may feel severe adverse effects. So sad for everyone.

# # #

Elizabeth E. Hogue, Esq The Rowan Report

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

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

California Hospice Fraud

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

by Kristin Rowan, Editor

California Hospice Fraud

Update 04-16-2026

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

Multiple Arrests and Charges

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

Intent to Defraud

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

Location Search

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

The 71 Million Dollar Doctor

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

Task Force Suspends Providers

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

# # #

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

Hospice CARE Act

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

by Kristin Rowan, Editor

Hospice CARE Act

Congress breathes new life into hospice protection

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

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

Program Integrity and Payment Reform

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

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

Linda T. Sanchez

Congresswoman, D-CA

Program Integrity

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

Specifically, the bill:

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

Payment Reform

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

Specifically, it:

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

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

Mark Warner

Senator, D-VA

Industry Support

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

American Academy of Hospice and Palliative Medicine

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

– Kristina Newport, CMO for AAHPM

Center for Medicare Advocacy

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

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

National Alliance for Care at Home

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

-Jennifer Sheets, CEO for The Alliance

LeadingAge

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

-Katie Smith Sloan, President and CEO for LeadingAge

National Partnership for Healthcare and Hospice Innovation

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

– Tom Koutsoumpas, Founder and CEO of NPHI

More Information

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

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

# # #

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

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

©2026 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

LEAD Replaces REACH

by Kristin Rowan | Jan 9, 2026 | CMS, Hospice

by Kristin Rowan, Editor

LEAD Replaces REACH

CMS Launches 10-Year Model Test

LEAD replaces REACH in new 10-year CMS model. The Long-term Enhanced ACO Design (LEAD) model is scheduled to launched at the end of 2026, following the end of ACO Realizing Equity, Access, and Community Health (REACH). LEAD is a voluntary model that will run January 1, 2027 thorugh December 31, 2036, the longest CMS has ever run a test.

Key Takeaways

CMS provides the following information:

Problem: Many health care providers have not historically participated in or dropped out of ACOs because of financial and administrative obstacles to success.

Solution: LEAD is designed to address such barriers to support both established and newly created ACOs by providing them enhanced, flexible cash flow payments; and greater freedom and tools to support spending time with and meeting patient needs, including those with specialized care needs.

Outcomes: Through ACOs, health care providers will be empowered to deliver coordinated, accountable care and preventive services — keeping patients healthier and helping to reduce health care costs and unnecessary emergency room visits and hospitalizations.

Strategy: LEAD advances the Innovation Center’s commitment to 1) building opportunities for independent health care providers and practices to be rewarded for delivering better care, 2) promoting and empowering patient choice in both coverage and sites of care, and 3) making it easier for health care providers and patients to engage in preventive care that supports healthier living.

LEAD Goals

According to CMS, the LEAD Model will improve care coordination among a broad range of healthcare providers, including hospices. The model will also appeal to providers with specialized patients and those who are newer to ACOs like small, independent, or rural-based practices. The LEAD model intends to incentivize providers downstream such as home health agencies, palliative care, and hospices, to engage with the providers upstream. It is particularly aimed at complex patients with high needs.

CMS has outlined a 3-part framework for its goals:

Increase the scope of ACOs to include rural, small, and independent providers and health centers

Enhance evidence-based prevention and care coordination for more patients

Empower patient choice and encourage patient participation in care

Planning Phase

The LEAD Model will begin its planning stage in March of 2026 and run through December of 2027. During that time, CMS will identify two states to partner with for developing the framework for Medicaid partnerships. The framework will include how ACOs and Medicaid organizations can share data and coordinate care.

CARA

Among the more prominent changes in the LEAD Model is the CMS Administered Risk Arrangements (CARA). CMS will assist LEAD ACOs in designing episode-based risk payment arrangments with other health care providers. According to CMS, CARA will facilitate stronger preferred provider relationships. Building these strong care networks and partnerships between ACOs and hospice and palliative care providers will improve care for high-needs patients.

Hospice and palliative care organizations will need to demonstrate partnership value to ACO organizations by supporting smooth care transitions, reducing unnecessary hospitalizations, and ensuring patients receive the right care at the right time, according to a statement from The Alliance.

Final Thoughts

This new model may provide some opportunities for hospice agencies. It may also pave the way for a reimbursement model for palliative care. Although the statements from CMS focus on hospice and palliative care, there may be opportunities for home health agencies as well. These opportunities may become more apparent once the model demonstration begins in 2027. If they are not immediately apparent, we have 10 years to figure them out.

Applications for participation will open in March. To stay connected and receive updates from CMS, join the LEAD Model List or contact the LEAD Model team.

# # #

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

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

©2026 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Appeals Court Filing

by Kristin Rowan | Dec 4, 2025 | Advocacy, Clinical, CMS, Hospice, Legal

by Kristin Rowan, Editor

Appeals Court Filing

Hospice ALJ

A hospice claim may fall under review either before or after the claim has been paid. A hospice agency with a denied claim must file appeals until the claim is approved or the appeals are exhausted. First, they file a written request to reconsider. Then, they file an appeal to a Qualified Independent Contractor (QIC) who employs medical professionals to assess the case. Next, they file an appeal to an Administrative Law Judge (ALJ).

The ALJ is meant to review the documentation to determine whether it satisfies Medicare requirements. That’s all. There are two sets of criteria: the Medicare requirements and the patient record. If they match, the claim is paid. However, a recent ALJ decision and subsequent challenge suggests that the ALJ ignored expert testimony and decided independently that the patient did not qualify for hospice care.

Request to File

The hospice agency in this case filed suit against the ALJ, arguing that physician expertise should be shown deference in these cases. The National Alliance for Care at Home (the Alliance), joined by the American Academy of Hospice and Palliative Medicine (AAHPM), represented by William A. Dombi of Arnall Golden Gregory (AGG), has requested the right to file an amicus brief. An amicus brief provides extra information in a court case from an individual or group that is not part of the lawsuit, but has a vested interest in the outcome.

The Dispute

The Alliance puts at the heart of the case several issues, including:

Predicting death is inherently difficult

Physicians are the experts and their opinion should carry more weight

Oversight from non-qualified third parties add confusion, increase costs, and limit care

The Argument

The wording in multiple parts of the hospice benefit recognizes the expertise and importance of the physician. It is the physician who determines terminal illness. Physicians must have a face-to-face for continued eligibility. And it is the physician’s clinical judgment makes these determinations based on a patient’s individual circumstances, not an arbitrary set of standards.

If an ALJ, or any non-medical person, can overrule the treating physician’s assessment of a patient, they are effectively usurping the role of the doctor in providing a treatment plan. Medical care is subjective, which is why CMS has repeatedly considered and rejected defined criteria that would overrule a physician.

Broader Implications

The brief argues that medical professionals are better able to make care determinations. Further, the brief includes the complexity of health care prognosis, particularly in terminal illnesses. Previous court decisions have noted that “clinical judgments must be tethered to a patient’s valid medical records….” which already eliminates the need for this oversight. The Alliance stated a high probability that the decision in this case will carry substantial weight and influence both in the Sixth Circuit and in courts nationwide.

In fact, the implications may be farther reaching than that. Payors in and out of hospice deny claims deemed “unnecessary” regularly. Claims denials range from about 19% in the ACA Marketplace to as much as 49% from private payers. Even though about 80% of appeals are later accepted, only about 1% of denied claims are appealed.

Not only could this case help more patients get the hospice care they need, it could also lay the groundwork to require insurance companies to rely more heavily on the treating physician’s recommendation. We could see lower denials from prior authorization requests, unconventional treatment plans, VA benefits, and more.

Final Thoughts

The Rowan Report supports the Alliance’s efforts in this case and wholeheartedly agrees that a physician knows better the care his patient needs than a judge ever could. We are hopeful that Bill Dombi and his team at AGG will be successful in this case and that hospice providers can get back to the business of patient care. Read the statement from the Alliance here.

# # #

Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.

She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Government Shutdown

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

by Kristin Rowan, Editor

Government Shutdown Threatens Care at Home

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

UPDATE: Shutdown, Day 16

–As of October 16, 2025–

What it Means for Care at Home

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

Telehealth

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

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

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

Payments

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

Surveys

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

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

–As of October 9, 2025–

The Disagreement

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

Push to Extend

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

Priced Out

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

Photo Credit – The New York Times

Counter

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

Open Enrollment

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

Care at Home Impact

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

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

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

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

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

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

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Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.

She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

AI Eases Clinician Burnout

by Rowan Report | Sep 25, 2025 | Artificial Intelligence, Caring for the Caregiver

by Curantis Solutions

AI in Hospice and Palliative Care

Eases Clinician Burnout and Drives Retention

In hospice and palliative care, clinicians are your most valuable and most vulnerable resource. They’re the heart of care delivery, and often the largest expense line item on your budget. But today, many are walking a tightrope between compassion fatigue and after-hours documentation burnout. Hospice organizations can’t afford to lose them. And with AI-powered tools, you don’t have to.

Clinician burnout Is a crisis and a cost center

Hospice nurses and interdisciplinary team members are burning out at unsustainable rates. The emotional weight of their work is immense, but it’s the after-hours charting, documentation delays, and system inefficiencies that often push them over the edge. The cost of clinician turnover is staggering. Onboarding and training a new hospice nurse takes time, money, and trust, and patients feel the impact, too.

AI bridges the gap without replacing the human touch

Curantis Solutions is leading the way with AI that lightens the load. Our embedded AI assistant, EVA, supports clinicians in real-time, reducing documentation friction and eliminating the need to chart late into the evening.

How AI may help

Voice-to-text documentation

captures patient-specific details naturally, as they happen

Smart prompts and reminders

prevent missed data points and reduce rework

Less screen time after shifts

improves work-life balance and job satisfaction

Clinicians feel more supported and less likely to leave

Retain the staff you've worked so hard to hire

When your staff hears that another organization doesn’t have modern tech or AI tools? They stay. Providing intuitive, hospice-specific tools isn’t just about efficiency. It’s about creating a culture that respects their time, honors their energy, and values their expertise.

AI as a strategic investment in care and culture

Hospice leaders are being called to solve two problems at once:

Deliver exceptional, person-centered care

Do it with fewer resources and higher costs

AI-powered software like Curantis helps close this gap. By streamlining documentation and workflow, we help you preserve the well-being of your clinicians, which, in turn, protects your operations and your outcomes.

Imagine this...

No more nurses charting late into the night

Fewer resignations and higher morale

Patients receiving care from clinicians who aren’t drained, but present and energized

# # #

Let's make clinician burnout a thing of the past

Explore how Curantis Solutions empowers your team and strengthens your bottom line. Contact us today to schedule a demo and see how we are making your software experience refreshingly simple with ChartBoost AI.

Contact us today to see a demo and learn how we are making your software experience refreshingly simple.

© 2025 This blog article originally appeared on the Curantis Solutions website and is reprinted with permission. For more information, please contact Curantis Solutions directly.

AI in Hospice: 3 Questions Before Adopting

by Rowan Report | Sep 18, 2025 | Artificial Intelligence, Hospice

by Curantis Solutions

AI in Hospice

3 question to ask before adoption

AI in healthcare

Artificial intelligence (AI) is transforming healthcare. From voice-to-text documentation to predictive analytics, AI promises to streamline operations, reduce clinician burden, and improve outcomes. However, in hospice and palliative care, where care is deeply personal and the margin for error is razor thin, adopting AI cannot be treated as just another trend. It must be thoughtful, mission-aligned, and clinically appropriate.

AI in hospice

Hospice leaders are under pressure. Staff shortages are real. Regulatory demands like Hospice HOPE are intensifying. Vendor inboxes are flooded with promises of automation, optimization, and return on investment (ROI). It is easy to feel like you must adopt AI quickly just to keep up.

But the truth is, not all AI is ready for hospice and palliative care. And not all hospice organizations are ready to implement it effectively. The stakes are too high to rush.

If your hospice or palliative care organization is exploring AI, here are three critical questions to ask before making a decision:

1. Is the AI built for the way hospice and palliative care work?

Hospice and palliative care are fundamentally different from other healthcare environments. The workflows are interdisciplinary. Much of the documentation relies on narrative detail. Clinicians manage complex emotional, spiritual, and medical needs at the same time. Care is not episodic or transactional. It is longitudinal, values-driven, and highly individualized.

Many AI tools on the market today were built for hospitals or outpatient clinics. They may offer efficiencies in acute care but fail in hospice because they do not understand the subtleties of team-based care, psychosocial documentation, or end-of-life symptom management.

Ask the vendor: Has your AI been developed specifically for hospice or palliative care? Or are you expecting our team to adapt to your tool?

Healthcare isn't hospice

Some hospices have tried generic AI dictation tools and found them inadequate. They could not capture the nuance of hospice documentation, especially when it comes to describing spiritual distress, family dynamics, or legacy work. Other teams tried predictive tools that produced frequent, non-actionable alerts that distracted the clinical team and created more work, not less.

Hospice AI must be purpose-built. It needs to support interdisciplinary team meetings, comply with documentation standards like HOPE, and align with Medicare Conditions of Participation. If the tool does not understand your workflow, it will only add friction.

2. Will this AI solution actually save time, or will it create more work?

AI should make your clinicians’ lives easier, not harder. Unfortunately, many solutions promise time savings but fail to deliver because they are poorly implemented or require too much manual oversight.

Here is where hidden costs show up. If your team needs to log into separate platforms, copy and paste information, or manually verify AI-generated content line by line, the benefits quickly disappear. Add in the time it takes to train staff, troubleshoot bugs, and manage updates, and you might find you are investing more time than you are saving.

Ask the vendor: What does your implementation and training process look like? What kind of support do you provide after go-live?

Responsible AI vendors should provide more than software. They should offer a clear rollout plan with defined milestones, retraining sessions for staff turnover, and a roadmap for future enhancements. Without this, even the most impressive AI tool will fail to achieve meaningful ROI.

You also want to ensure that your team can trust the AI. If it produces content that needs to be heavily edited or raises questions about accuracy, clinicians will disengage. The best AI makes documentation feel intuitive, not burdensome.

Ultimately, the right solution should reduce charting time, improve documentation quality, and give your clinicians more time for direct patient care. Do not just ask

what the AI can do. Ask what the experience of using it will be like for your team on day one, day 30, and day 365.

3. Does the AI preserve your mission and center the patient?

This is perhaps the most important question of all. Hospice care is defined by its human connection. Patients and families count on your team to be present, compassionate, and attentive during the most vulnerable moments of life. Any technology you introduce must uphold that standard.

Ask yourself: Does this tool enhance our ability to serve patients meaningfully? Or does it get in the way?

AI should never replace the clinician’s presence. It should support that presence by taking on administrative tasks, summarizing clinical notes, or preparing IDG summaries. It should make care feel more personal, not less.

There is a real risk in adopting tools that do not align with your mission. Some AI solutions are focused solely on efficiency. Others may depersonalize care by reducing complex human experiences into checkboxes or canned phrases. If the technology distances your team from the bedside, it is not the right fit.

Ethical, mission-aligned AI empowers your team. It helps clinicians spend less time documenting and more time connecting. For chaplins, it supports spiritual care providers in crafting better notes. It assists social workers in capturing family dynamics. Finally, it helps the entire team stay informed without increasing their cognitive load.

Final Thoughts

Thoughtful evaluation and the right questions make all the difference

The conversation about AI in hospice and palliative care is just beginning. There is enormous potential to reduce burnout, improve quality, and strengthen compliance. But realizing that potential requires more than excitement. It requires asking the right questions, involving the right stakeholders, and choosing tools that are built for this environment.

Before you adopt AI, pause and evaluate:

Is this solution designed for how we deliver care?

Will this save time or increase workload?

Does this align with our mission and center the patient?

If you can answer yes to all three, then you are on the path to responsible, effective AI adoption.
Hospice and palliative care deserve nothing less.

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