Purpose-Built AI for Care at Home

by Rowan Report | Jan 15, 2026 | Artificial Intelligence, Home Health, Hospice, Outcomes

by Isaac Greszes, Eleos

Purpose-Built AI for Care at Home

How Care at Home leaders can move beyond AI pilots

Care at Home is increasingly turning to AI to address documentation burden, clinician burnout, and regulatory pressure. While AI has the potential to address these issues and more, practical results remain uneven, leaving agencies with a lot of experimentation, but little clarity on actual value.

Evaluating AI solutions should focus on real-world outcomes, how the solution fits into your existing workflow, whether the software is scalable, and how it handles changing regulations. You should also look for AI solutions that are built for care at home (purpose-built). This series of articles will help you make informed, risk-aware decisions about AI adoption.

AI is Coming Fast

Home health and hospice leaders are navigating a difficult balance: persistent workforce shortages, rising provider burnout, expanding documentation requirements, and increasing regulatory scrutiny — all within thin operating margins.

At the same time, AI has moved quickly from experimental to strategic. Many organizations are now evaluating AI not just for productivity, but for operational and administrative efficiency, clinician experience, compliance readiness, and financial performance.

And the stakes are high

Early results across the market have been inconsistent. Some organizations report meaningful reductions in administrative burden and a clear return on investment. However, others struggle to find value after adoption. The difference often lies not in whether AI was adopted, but how it was designed, supported, and governed.

The pilot problem

As AI adoption accelerates, many organizations find themselves caught in extended pilot cycles — testing multiple tools without committing to the operational changes required for scale. While pilots can validate technical feasibility, they rarely provide the consistency or measurement discipline needed to demonstrate sustained ROI in regulated care at home environments.

Quality over Quantity

Why the right evidence matters

In today’s AI market, product demonstrations are easy to produce. Documented outcomes are not.

Executive leaders should expect vendors to demonstrate real-world impact, supported by customer data, third-party validation, or peer-reviewed research. Credible AI partners should be able to explain how their results translate to care at home — and where limitations exist. The challenge is not the lack of information from pilots, but the lack of evidence those pilots results can be reproduced, measured, and sustained, in a care at home setting.

Objective Evidence that Matters

When evaluating AI platforms, leaders should look for evidence related to:

Documentation efficiency, such as reduced time per visit or faster note completion
Operational ROI, including quicker billing readiness or reduced rework
Compliance support, such as documentation completeness or audit preparedness
Provider experience, including reduced perceived administrative burden
Care outcomes, including patient engagement and satisfaction

AI solutions can impact efficiency and burnout. But, these outcomes are highly dependent on whether the solution was built for care at home, the quality of implementation, how easily it will integrate into your workflow, and governance. If a vendor cannot explain how results were achieved and whether they are reliable and repeatable outside the pilot, the vendor and the solution should be evaluated carefully.

General Purpose AI

And inconsistent results

Many AI tools marketed to healthcare organizations rely on general-purpose language models designed for tasks like summarization, chat, or content generation — not for producing structured clinical notes aligned to regulatory and reimbursement requirements.

Home health and hospice documentation often includes:

Clinical observations made in non-clinical environments
Structured requirements tied to reimbursement and regulation
Risk-sensitive language related to safety, decline, or end-of-life care
Significant variation across disciplines, visit types, and patient contexts

Where generic AI breaks down

In these settings, AI tools based on general-purpose language models introduce risks related to accuracy, hallucinations, bias, privacy, and workflow fit — because they were not designed to operate within structured clinical, regulatory, and reimbursement frameworks.

In practice, organizations report that the additional oversight required to validate or correct AI-generated output can reduce — or even negate — anticipated efficiency gains, limiting adoption and ROI. As a result, organizations often remain stuck in pilot mode — investing time and effort in validation without achieving the scale or consistency required for meaningful return.

The right question

When evaluating an AI solution, the right question is not whether the AI tool can record a conversation and translate it into notes or whether the tool can reduce documentation, but whether it can consistently support high-quality clinical documentation at scale without increading burden or creating compliance risks.

Purpose-Built AI

What it means and why it drives operational impact

In care at home environments, purpose-built AI should be evaluated less as a point solution and more as foundational infrastructure — one designed to support regulated clinical workflows consistently over time.

Many AI platforms label themselves as “purpose-built,” but leaders must look past marketing language to truly scrutinize the way the technology is designed and deployed. In regulated clinical environments, purpose-built AI typically incorporates:

Domain-specific clinical intelligence, informed by real documentation patterns
Provider involvement in defining structure, logic, and validation criteria
Structured outputs aligned to required note components, in addition to free-text summaries
Grounding mechanisms that reduce fabricated or misattributed content
Privacy-conscious data handling, with explicit limits on data retention and reuse

Research consistently shows that providers prefer AI systems that function as collaborative tools — preserving human oversight while reducing administrative load — rather than fully automated systems that completely bypass clinical judgment. These characteristics directly affect whether AI improves documentation time, supports compliance workflows, and earns provider trust — all prerequisites for driving ROI.
These design choices are what allow AI systems to move beyond experimentation and begin delivering durable efficiency, compliance support, and clinician adoption at scale.

# # #

This article is part 1 in a 4-part series. Come back next week for “Scalability, Security, and Governance.”

About Eleos

At Eleos, we believe the path to better healthcare is paved with provider-focused technology. Our purpose-built AI platform streamlines documentation, simplifies compliance and surfaces deep care insights to drive better client outcomes. Created using real-world care sessions and fine-tuned by our in-house clinical experts, our AI tools are scientifically proven to reduce documentation time by more than 70% and boost client engagement by 2x. With Eleos, providers are free to focus less on administrative tasks and more on what got them into this field in the first place: caring for their clients.

©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

What can Providers Give to Patients, Part 7

by Elizabeth E. Hogue, Esq. | Dec 12, 2025 | Admin, Clinical, Legal

by Elizabeth E. Hogue, Esq.

What Providers can Give to Patients

Providers, including marketers, are tempted to give patients and potential patients free items and services. While providers usually have good intentions, they must comply with applicable requirements.

Read Parts 1-6

OIG Advisory Opinion

This article provides an example from OIG Advisory Opinion No. 09-11 that shows how the OIG applies exceptions described in this series of articles.

A Case Example

The request for this Advisory Opinion was submitted by a hospital that provides free blood pressure checks to anyone who requests the service during certain hours. The hospital said that it does not advertise free blood pressure checks, which are provided by a member of the nursing staff who follows specific guidelines and procedural checklists.

The hospital also said that free blood pressure checks are not conditioned on use of any other goods or services from the hospital or any other particular provider. No discounts are offered for follow-up services. Recipients of blood pressure checks are advised to see their own practitioners when results are abnormal. The hospital does not bill any payor, including the Medicare and Medicaid Programs, for this service.

OIG Analysis

In its analysis, the OIG first referenced the exception for preventive services described in Part 5 of this series.

The OIG then pointed out that the fair market value of this service, especially if recipients use the service more than once, may exceed the limits of $15 per service or $75 per year described in Part 2 of this series. Therefore, said the OIG, the services may constitute a kickback.

According to the OIG, blood pressure checks are preventive services. The key question, however, is whether the free care promotes the provision of other, non-preventive care reimbursed by the Medicare and/or Medicaid Programs.

Is It Promotional?

In this case, the OIG said that it is unlikely that free blood pressure checks will result in the provision of other services. The factual basis for this conclusion in the Advisory Opinion was that the hospital did not:

Make appointments with its practitioners for individuals with abnormal results
Offer individuals discounts for additional covered services
Otherwise promote its particular programs

Crafted with Care

“In sum,” said the OIG, “the Arrangement is appropriately crafted so as to avoid improper ties to the provision of other services…For these same reasons, we conclude that we would not impose administrative sanctions arising in connection with either the anti-kickback statute or the CMP on the Hospital in connection with the Arrangement.”

Final Thoughts

The 7 parts of this series describe and summarize the laws and exceptions to providing incentives, gifts, and help to patients in accordance with the Anti-Kickback Statute and the Civil Monetary Penalties Law. As long as you are following these regulations, providers should certainly use all of the exceptions available to them to provide better quality of care for 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.

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

Hospice Carve-In is Out

by Rowan Report | Nov 25, 2025 | Advocacy, Hospice, Medicare, Medicare Advantage, Partner News, Regulatory

FOR IMMEDIATE RELEASE

Contact: Hannah Kristan
communications@allianceforcareathome.org
202-355-1647

Sen. Marshall and Sen. Whitehouse Issue Letter to Senate Leadership Expressing Bipartisan Support for Policies that Preserve Medicare’s Hospice Benefit Under Original Medicare

Alexandria, VA and Washington, D.C., November 24, 2025. On November 20, Senator Roger Marshall (R-KS) and Senator Sheldon Whitehouse (D-RI) sent a letter to Senate leadership expressing strong bipartisan support for policies that preserve the Medicare Hospice Benefit under Original Medicare, including for Medicare Advantage (MA) beneficiaries, which has protected their access to high-quality, timely end-of-life care for nearly three decades.

Repeal Special Rule

As Congress considers potential reforms to the MA program, the letter urges Senate leadership to maintain this critical safeguard and oppose any proposals that would include hospice in the Medicare Advantage program, including repeal or alteration of the Special Rule for Hospice (the Special Rule), also known as hospice carve-in.

Hopice in MA

Despite years of attempts from Congress, the Alliance strongly opposes efforts to integrate hospice into Medicare Advantage (MA). Past attempts have revealed challenges such as administrative burdens, difficulty creating networks, and delayed payments for claims. Bringing hospice under Medicare Advantage would undermine patient choice, adversely impact timely access to care, and fragment the hospice experience for patients and families at a highly vulnerable time.

View the full letter here.

Excerpt

“MA enrollees who elect hospice currently retain the freedom to choose any Medicare-certified hospice provider, free from network limitations or prior authorization requirements. More than half of hospice beneficiaries pass away within 14 days of election, making delays in care both harmful and unacceptable. Integrating the hospice benefit into MA plan design would jeopardize this access by layering additional managed care terms (or policies) on top of an already managed and coordinated benefit.”

Marshall and Whitehouse

U.S. Senators

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“The Alliance thanks Sen. Marshall and Sen. Whitehouse for listening to the concerns of the care at home community and taking action to protect our nation’s most vulnerable patient population by defending the Hospice Benefit under original Medicare,” said Scott Levy, Chief Government Affairs Officer at the Alliance. “The Alliance will continue to lead on this important public policy priority for hospice providers nationwide by advocating to preserve this sacred promise established by Congress and kept on behalf of the American people for over four decades.”

# # #

About the National Alliance for Care at Home

The National Alliance for Care at Home (the Alliance) is the leading authority in transforming care in the home. As an inclusive thought leader, advocate, educator, and convener, we serve as the unifying voice for providers and recipients of home care, home health, hospice, palliative care, and Medicaid home and community-based services throughout all stages of life. Learn more at www.AllianceForCareAtHome.org.

© 2026. This press release originally appeared on the National Alliance for Care at Home Website and is published with permission. For additional information or for permission to print, please see press contact above.

What Can Providers Give to Patients, Part 5

by Elizabeth E. Hogue, Esq. | Nov 25, 2025 | Admin, Clinical, Legal

by Elizabeth E. Hogue, Esq.

What Can Providers Give...

Recap

Providers, including marketers, are tempted to give patients and potential patients free items and services. While providers usually have good intentions, they must comply with applicable requirements.

Part 1

As Part 1 of this series indicates, there are two applicable federal statutes: the Anti-Kickback Statute (AKS) and the Civil Monetary Penalties Law (CMPL). Part 1 also makes it clear that there are a number of exceptions. If providers meet the requirements of applicable exceptions, they can give patients and potential patients free items and services that would otherwise violate applicable requirements.

Part 2

Part 2 describes an exception for items and services of nominal value with a retail value of no more than $15 per item or $75 in the aggregate per patient on an annual basis that may be given by providers to beneficiaries. Providers may not, however, give cash or cash equivalents.

Part 3

Part 3 describes the circumstances under which providers may give free items and services to patients with demonstrated financial need.

Part 4

Part 4 summarizes recent guidance from the Office of Inspector General (OIG) about giving incentives to promote vaccination against COVID-19.

Care & Services

According to the OIG, providers may also give patients free preventive care items or services. The definition of remuneration under the CMPL regulations excludes incentives given to patients/potential patients to promote the delivery of preventive care services so long as the delivery of such services is not directly or indirectly related to the provision of other services reimbursed in whole or in part by the Medicare Program or other state and federal healthcare programs. Preventive services include:

Prenatal services or postnatal well-baby visits, or specific clinical services described in the current U.S. Preventive Services Task Force’s Guide to Clinical Preventive Services
Services that are reimbursable in whole or in part by the Medicare Program, or other federal and state care programs

Incentives

However, incentives related to preventive services may not include:

Cash or instruments convertible to cash
Incentives of value that are disproportionally large in relationship to the value of the preventive care services in terms of either the value of the services or the future health care costs reasonably expected to be avoided as a result of preventive care

Preventive

Any tie between provision of exempt covered preventive care services and covered services that are not preventive may, therefore, violate the CMPL and the AKS.

The OIG has stated that some free or discounted services may fit within the preventive care exception described above. These services may include free blood sugar screenings and cholesterol tests.

Anti-Kickback Exceptions

The AKS does not include an exception similar to the provisions of the CMPL described above. In commentary to Supplemental Compliance Guidance for Hospitals, however, the OIG said:

From an anti-kickback perspective, the chief concern is whether an arrangement to induce patients to obtain preventive care services is intended to induce other business payable by a Federal health program. Relevant factors in making this evaluation would include, but not be limited to: the nature and scope of the preventive care services; whether the preventive care services are tied direct or indirectly to the provision of other items or services and, if so, the nature and scope of the other services; the basis on which patients are selected to receive the free or discounted services; and whether the patient is able to afford the services.

Final Thoughts

Based upon the above, the OIG is unlikely to challenge the provision of free preventive services given to patients and potential patients, under either the CMPL or the AKS, so long as the above requirements are met.

# # #

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

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

What Can Providers Give to Patients, Pt 3

by Elizabeth E. Hogue, Esq. | Oct 30, 2025 | Legal

by Elizabeth E. Hogue, Esq.

What Can Providers Give to Patients

Part 1 & 2 Recap

Providers, including marketers, are tempted to give patients and potential patients free items and services. While providers usually have good intentions, they must comply with applicable requirements.

As Part 1 of this series indicates, there are two applicable federal statutes: the Anti-Kickback Statute (AKS) and the Civil Monetary Penalties Law (CMPL). Part 1 also makes it clear that there are a number of exceptions. If providers meet the requirements of applicable safe harbors or exceptions, they can give patients and potential patients free items and services that would otherwise violate applicable requirements.

Part 2 describes an exception for items and services of nominal value with a retail value of no more than $15 per item or $75 in the aggregate per patient on an annual basis that may be given by providers to beneficiaries. Providers may not, however, give cash or cash equivalents.

Exceptions to the Rule

The OIG also says that providers may give free items and services to patients with demonstrated financial need. The exception based on financial need does not include cash or cash equivalents. Cash equivalents include checks, gift certificates, and gift cards.

The CMPL says that the following requirements must be met to qualify for this exception:

- - The items or services are not offered as part of any advertisement or solicitation.
  - The offer to give items or services is not tied to the provision of other items or services reimbursed in whole or in part by the Medicare or Medicaid Programs.
  - There is a reasonable connection between the items or services and the medical care of the patient.
  - Providers give items or services after a determination has been made in good faith that patients are in financial need.

The AKS does not include a similar safe harbor or exception, but the OIG has stated that the AKS does not prohibit discounts to uninsured patients who are unable to pay for items and services.

Good faith determinations that patients are in financial need are key. Determinations should be based on policies and procedures that providers consistently apply to make these decisions. Policies and procedures should include requirements to document financial need. Such policies and procedures are often referred to as policies on “charity care.”

Determining Need

Providers have discretion to take a variety of factors into account to determine financial need. Such factors may include:

- - - Patients’ income, assets and expenses
    - Amounts due for services and items provided

Accuracy Matters

Needless to say, providers should avoid inflated income guidelines that result in free items or services given to beneficiaries who are not really in financial need.

Providers may ask patients to provide documentation of their financial status. Decisions about financial need may also be based on other reasonable methods, such as documented interviews with patients and questionnaires.

Policies and procedures that govern free items and services given to patients should also require periodic review of patients’ financial status, since it may change over time. Providers should recheck patients’ needs at reasonable intervals to help ensure that their financial status has not changed significantly.

Final Thoughts

The key to using this exception is undoubtedly consistent application of a policy and procedure to make determinations about financial need. Now is the time to review or develop and implement policies that cover free items and services given to patients.

This is part 3 of a 5-part series. Come back next week for part 4.

# # #

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

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

Interoperability: The Unreachable Dream

by Kristin Rowan | Oct 17, 2025 | Interoperability

by Kristin Rowan, Editor

Interoperability

The Unreachable Dream

Healthcare and care at home have been reaching for interoperability for decades. When I started working in the care at home industry, there was a learning curve for terminologies, abbreviations (oy! with the abbreviations already!), and the pain points experienced by agencies and vendors. Interoperability was at the top of that list. 2009, the first full year I worked in care at home, was the year Congress mandated EHRs and data exchange. The mandate did not accomplish much. Incompatible data structures limit post-acute care data to the most recent health event, not the patient’s full medical record.

Data Exchange

Following the EHR mandate, Congress continued to add regulations and rules to advance data exchange. Starting with HIPAA in 1996, interoperability advanced as follows:

Health Insurance Portability and Accountability Act ensures patient data stays private both within a healthcare system and during data exchange

Congress mandated the use of EHRs throughout healthcare

HITECH Act launched Health Information Exchanges (HIEs) that support secure exchange of information between health systems

Health Level 7 (HL7) designed a framework that establishes protocols for data exchange

Fast Healthcare Interoperability Resources (FHIR), an updated of HL7, enables processes in 84% of hospitals and 61% of clinician offices

21st Century Care Act allows patients to access their own medical information and requires developers to publish APIs and ensure all data in the patient health record is accessible through that API

Trusted Exchange Framework and Common Agreement (TEFCA) lists principles, terms, and conditions to standardize data

CMS Interoperability Framework pushes interoperability nationwide through improved data quality; advanced technology; data aggregation; and alignment of data, tools, and measures

Following the EHR mandate, Congress continued to add regulations and rules to advance data exchange. Starting with HIPAA in 1996, interoperability advanced as follows:

Health Insurance Portability and Accountability Act ensures patient data stays private both within a healthcare system and during data exchange
Congress mandated the use of EHRs throughout healthcare
HITECH Act launched Health Information Exchanges (HIEs) that support secure exchange of information between health systems
Health Level 7 (HL7) designed a framework that establishes protocols for data exchange
Fast Healthcare Interoperability Resources (FHIR), an updated of HL7, enables processes in 84% of hospitals and 61% of clinician offices
21st Century Care Act allows patients to access their own medical information and requires developers to publish APIs and ensure all data in the patient health record is accessible through that API
Trusted Exchange Framework and Common Agreement (TEFCA) lists principles, terms, and conditions to standardize data
CMS Interoperability Framework pushes interoperability nationwide through improved data quality; advanced technology; data aggregation; and alignment of data, tools, and measures

Thirty Years Later

Despite the laws, regulations, frameworks, and mandates, interoperability is not much better than it was in 1996. I had an experience this year that both enlightened and infuriated me. I switched health insurance plans for a variety of reasons. My new plan didn’t cover most of the doctors, hospitals, and health systems I had been using for many many years. So in February, I found a new PCP and had the standard start of care visit to establish my health history: current conditions, past conditions, past surgeries & procedures, current medications, etc. I requested referrals to new specialists and updates to prescriptions. My PCP performed a “complete physical” that was nothing more than a cursory overview. And then I waited.

The Waiting Game

And waited…and waited…. I thought all these organizations and standards were supposed to make this easier. Still, I waited.

I waited for an “invitation” to my PCPs portal to see my visit notes and test results
I waited for my PCP to send referrals to new specialists
I waited for my health insurance provider to inevitably tell me the specialist wasn’t covered under my plan
I waited for a new referral from my PCP
I waited for appointments, results, and recommendations
I waited for access to new patient portals
I waited for the portal to figure out how to give me access to three different providers in the same app
- (spoiler alert: I have to log in to the same app three different ways to access three different providers; my providers can see all the information in one place, but I can’t)
I waited for test results to appear in each portal; some I had to call and request, some I’m still waiting for

Data Exchange "Advancements"

According to my research, 84% of hospitals and 61% of clinicians are currently using FHIR, designed to improve interoperability between different health systems using standard data formats and APIs.

Last month I had an appointment. Correction: I thought I had an appointment for an imaging scan. I thought this because the scheduling nurse called me to confirm the appointment day, time, and location. When I arrived, the check-in nurse couldn’t find me in their system.

It wasn’t just that she didn’t see my appointment. No, it was that she couldn’t find me at all. (We later discovered it was still pending because the imaging department never confirmed the appointment after the scheduling nurse added it.)

She could see no current or future appointments. She could see no past appointments because they were booked a different way. She couldn’t find any record of me at all. You see, my record started in the next building over.

Error 404: Not Found

Every one of these facilities is in the same healthcare system. (Think ACME hospital, ACME imaging, ACME specialist doctor, and ACME lab) Every office is part of the same healthcare system and none of them can see each other’s information. ACME hospital can’t see the schedule for ACME imaging and can’t schedule imaging appointments outside the hospital. For that, I have to call ACME imaging.

But wait! The doctor wrote my referral for ACME hospital, not ACME imaging. I need a new referral.
But wait! Neither the healthcare system nor the specialist can write a new referral. My payer will only accept a referral from my PCP.
But wait! My PCP has no idea what the referral is for, how it was written, or where it’s supposed to go because my PCP can’t access my records from the healthcare system.

This is advanced data exchange using FHIR, HIE, TEFCA, and QHIN. My health system uses our local HIE and CommonWell Health Alliance, an interoperability network designated as a federal QHIN. Apparently, this ensures the health system can share data with participating providers, but not with themselves.

Home Health is Even Further Behind the Curve

After so many years, so many advancements, and so many regulations, interoperability is no more “solved” than it was in 2009. Even the health systems that are using all the tools aren’t even internally interoperable.

Home Health has an even harder time attaining interoperability.

It is more difficult for HHAs to access patient information, which usually has to be manually imported into the home health EHR
Patient consent is required, but HHAs often deal with patients who don’t have the capacity to consent
Despite the requirement of APIs, most health information is spread out across multiple systems and the HHA only get information from the referring facility
Nearly 80% of HHAs use an EHR
Only 28% of HHAs are electronically exchanging information with outside facilities
Only 18% can integrate shared data into automated workflows
HHAs did not receive the financial incentives that larger healthcare systems got to push interoperability
TEFCA participation is not mandatory, slowing down the process of approving a data connection and exchange

Many legacy EHRs have met significant challenges moving into interoperability. Competitors in the space had no financial incentive to create standard languages and formatting designed to share information. HHAs are left with two choices:

The costly, time-consuming task of reviewing, selecting, and onboarding an entirely new EHR –or–

Piece together workarounds with multiple 3rd party or internal solutions haphazardly strung together to resemble interoperability

Time is Up

The call for interoperability started in 1996. With little advancement and not much hope on the horizon, we (your patients) are looking for other ways to get what we need. Next week, I’ll talk about my predictions for how interoperability will progress for the next generation.

# # #

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

What Can Providers Give to Patients, Pt 2

by Elizabeth E. Hogue, Esq. | Oct 17, 2025 | Admin, Clinical, Legal

by Elizabeth E. Hogue, Esq.

Provider Kickbacks

Exceptions

Providers, including marketers, are tempted to give patients and potential patients free items and services. While providers usually have good intentions, they must comply with applicable requirements. As Part 1 of this series indicates, there are two applicable federal statutes: the anti-kickback statute and the civil monetary penalties law. Part 1 also makes it clear that there are a number of exceptions or “safe harbors. If providers can meet the requirements of an applicable safe harbor or exception, they can give patients and potential patients free items and services that would otherwise violate applicable requirements.

Limit Increase

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services, the primary enforcer of fraud and abuse prohibitions, announced that; effective on December 7, 2016; the limits on free items and services given to beneficiaries increased. Specifically, according to the OIG, items and services of nominal value may be given to patients or potential patients that have a retail value of no more than $15 per item or $75 in the aggregate per patient on an annual basis. The previous limits were $10 per item or $50 in the aggregate per patient on an annual basis.

Undue Influence

Under section 1128A(a)(5) of the Social Security Act, persons who offer or transfer to Medicare and/or Medicaid beneficiaries any remuneration that they know or should know is likely to influence beneficiaries’ selection of particular providers or suppliers of items or services payable by the Medicare or Medicaid Programs may be liable for thousands of dollars in civil money penalties for each wrongful act. “Remuneration” includes waivers of copayments and deductibles, and transfers of items or services for free or for other than fair market value.

In the Conference Committee report that accompanied the enactment of these requirements, Congress expressed a clear intent to permit inexpensive gifts of nominal value given by providers to beneficiaries. In 2000, the OIG initially interpreted “inexpensive” or “nominal value” to mean a retail value of no more than $10 per item or $50 in the aggregate per patient an annual basis.

Needed Items, not Cash

The OIG also expressed a willingness to periodically review these limits and adjust them based on inflation. Consequently, effective on December 7, 2016, the OIG increased the limits of items and services of nominal value that may be given by providers and suppliers to beneficiaries to a retail value of no more than $15 per item or $75 in the aggregate per patient on an annual basis.

Providers may not, however, give cash or cash equivalents.

These amounts may still seem paltry to many providers. According to the OIG, providers who see that patients need items worth more than these limits should establish relationships with charitable organizations that can provide items and/or services that are not subject to these limits. In other words, work together to meet the needs of patients!

Final Thoughts

With time and the emotional context inherent in home health and hospice, clinicians may want to offer gifts to their clients. Low reimbursement rates and workforce shortage may cause HHAs to consider gifts and incentives as a way to keep clients and get referrals to new ones. If you find yourself in this situation, make sure you’re staying under the legal threshold, and engage 3rd parties to fill larger needs.

This is part 2 of a 4-part series. Come back next week for the third installment.

# # #

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

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

MACPAC Rate Setting

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

FOR IMMEDIATE RELEASE

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

MACPAC Rate Setting

The Alliance Expresses Concerns Regarding MACPAC Approach to HCBS Rate Setting

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

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

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

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

MACPAC Rate Setting Report

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

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

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

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

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About the National Alliance for Care at Home

The National Alliance for Care at Home (the Alliance) is the leading authority in transforming care in the home. As an inclusive thought leader, advocate, educator, and convener, we serve as the unifying voice for providers and recipients of home care, home health, hospice, palliative care, and Medicaid home and community-based services throughout all stages of life. Learn more at www.AllianceForCareAtHome.org.

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

Bill Dombi Presents

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

by Kristin Rowan, Editor

Bill Dombi Presents...

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

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

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

Bill Dombi

President Emeritus, National Alliance for Care at Home

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

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

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

What's in Store for Care at Home?

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

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

Final Thoughts - Dombi's Care at Home Forecast

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

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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

Medicare Advantage Excess Payments

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

by Kristin Rowan, Editor

Medicare Advantage Excess Payments

Investigational Study

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

Carve-out to VBID to Carve-out

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

Carve-out Hospice Benefit

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

Medicare Advantage Spending and Payments

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

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

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

Study Conclusion

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

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

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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