hospice Archives - Page 7 of 19

Home Health in a Post-Chevron World

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

by Elizabeth E. Hogue, Esq.

The "Wicked Witch" Chevron is Gone

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

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

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

What Does it Mean for Providers?

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

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

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

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

# # #

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

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

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

What are You Hiding?

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

by Elizabeth E. Hogue, Esq.

Bring on the Fraud Enforcers

We Have Nothing to Hide!

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

Here’s why:

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

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

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

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

Here are some common examples:

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

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

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

# # #

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

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

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

Home Health and Hospice Face Another Election Year

by Tim Rowan | Sep 20, 2024 | Editorial

by Tim Rowan, Editor Emeritus

Home Health Hospice and the Election

It happens every four years. Once the Olympic torch has been extinguished, Americans turn their attention from athletics to politics, specifically to choosing their next President. While watching the Harris/Trump debate this week, my thoughts turned to the dilemma faced by Home Health, Hospice, and Home Care owners, managers, and field staff.

U.S. voters can make their voting decision after taking into consideration the policy proposals of each candidate and analyzing which policies might better benefit themselves or their businesses. Voters can also vote along party lines, regardless of the candidate or their policies. And then, there is always a percentage who set their personal advantages aside and vote for the candidate they believe to be better for the nation as a whole.

Choice 2024

This may be where our healthcare sector finds itself this year. Is what is best for the country also best for Home Health, Hospice, Palliative Care, and Home Care? Or might the needs of one diverge from the needs of the other? If the latter, which choice is the higher calling?

In this week’s debate, the broad healthcare issue merited little more than a mention and some vague promises. Post-acute care was apparently unimportant or unknown to both candidates. Had a clever writer been tasked with summarizing that moment, it might have read, “Unhealthy Healthcare Debate Fails to Heal.” What did we learn, and where does it leave us?

Balancing Your Responsibilities

Voters have twin responsibilities, each as simple as it is profound. First, to decide whether to base their choice on party alone, on personal or business gain, or for the benefit of all. This includes whether the same vote will accomplish both or whether it is necessary to pick one or the other. The second responsibility is to research the issues and each candidate’s position on each issue. An informed voter is a patriotic voter.

Taylor Knows Best?

Once a voter has committed to the basis for their choice, the second responsibility is met by reading. Oddly, this retired grandfather cannot express that idea any better than a 34-year-old pop singer. In her September 10 endorsement statement, Taylor Swift said:

“Now is a great time to do your research on the issues at hand and the stances these candidates take on the topics that matter to you the most. As a voter, I make sure to watch and read everything I can about their proposed policies and plans for this country. I’ve done my research, and I’ve made my choice. Your research is all yours to do, and the choice is yours to make.”

History May Repeat Itself

Home Health and Hospice are deeply dependent on government spending. In the immediate future, MedPAC and CMS can be counted upon to continue to squeeze profit margins as they shift their gaze from services to outcomes. For more than two decades, CMS has enacted rules that shrink the total number of Home Health agencies. This happened across four administrations with different political ideologies. The result is agencies serving the same number of beneficiaries with the same number of nurses while supporting fewer executives.

The meeting of self-interest and national interest may be stronger in the Home Care sector. Caregiver shortage pushes higher hourly pay rates, which pushes higher hourly fees, which decreases the number of clients willing and able to pay. An economy that creates more spendable income or savings means the threshold between “can’t afford it” and “we’ll make it work” lowers.

No, This is not an Endorsement

I guess the bottom line is that I agree with the young pop singer. Like her, I have done my research and made my decision. I urge you to do the same. Read everything you can from the source, if you can. Avoid the temptation to rely on anyone else’s summaries of candidate positions and plans. Think “patriotism” first and “what’s in it for me” second. When in doubt, revisit the words of speechwriter Ted Sorensen, whose brilliant poetry was etched permanently into American history through the voice of John F. Kennedy. “And so, my fellow Americans, ask not what your country can do for you; ask what you can do for your country.”

# # #

Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

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

NonCompete Agreements and What to do About Them

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

by Elizabeth E. Hogue, Esq.

What to do About Noncompete Agreements

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

Requirements of the rule included:

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

There are a number of exceptions to the rule.

In the meanwhile, litigation

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

But...

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

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

Another but...

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

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

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

So...

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

Stay tuned for more!

# # #

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

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

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

Hospice Fraud Oversight

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

by Kristin Rowan, Editor

CMS Oversight in Fraud-Ridden States

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

Churn-and-Burn

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

Program Integrity Strategy

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

Enhanced Oversight

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

Nationwide Pilot Project

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

Regulatory Changes

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

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

Prepayment Review Expanded

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

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

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

# # #

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

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

Meet Dr. Steve Landers, MD

by Rowan Report | Aug 29, 2024 | Admin, Breaking News

Get to know the new NAHC-NHPCO Alliance CEO

Dr. Steve Landers

Dr. Landers named CEO for joint NAHC NHPCO. A recognized leader and innovator in home health, primary care and aging services, Dr. Steven “Steve” Landers brings almost two decades of experience as a physician, executive leader and public health policy advocate to lead The Alliance as its first Chief Executive Officer.

Physician

As a board-certified physician in family medicine, geriatric medicine, and hospice and palliative medicine, Dr. Landers has dedicated his career to seeking home- and community-based solutions for ill and aging Americans. He is a champion of the impactful role home care and hospice play in the health and lives of communities, acknowledging that as an aging nation, providing compassionate, dignified and cost-effective systems of care to patients is critical.

Education

Dr. Landers graduated from Case Western Reserve University School of Medicine, where his training included a family medicine residency at Case Western and a geriatric medicine fellowship at the Cleveland Clinic. He also attended the Johns Hopkins Bloomberg School of Public Health, where he focused on health policy and management. He received a bachelor of arts in political science from Indiana University in Bloomington.

Early Career

Early in his career, Dr. Landers based his clinical practice on providing health care through house calls and has made thousands of home visits, primarily to low-mobility patients. While in this setting, he saw the need to better connect home care and hospice to the broader health care system and medical community. He understood that to improve patient care, he would need to understand and play a leading role at the intersection of clinical work, health policy and systems of care. He pursued a master’s degree in public health, which contributed to his passion for influencing federal and state policy to improve health care delivery to vulnerable patients.

On The Board

Dr. Landers has served on numerous boards and committees in the home-based care policy space, including past appointments to the boards of directors of the National Association for Home Care and Hospice, American Academy of Home Care Medicine, the Partnership for Quality Home Health, and the Alliance for Home Health Quality and Innovation (now Research Institute for Home Care). He has represented these organizations by engaging policymakers, including meeting with members of Congress; providing committee testimonies for Congress and state legislatures; and discussing home care policies and regulations with the U.S. Secretary of Health and Human Services, the administrator of the Centers for Medicare & Medicaid Services, Medicare Payment Advisory Commission officials, and federal agency staff.

Home Care

Prior to joining The Alliance, Dr. Landers served in several executive leadership roles. He was the director of home care at the Cleveland Clinic, and for more than 11 years was the president and CEO of the Visiting Nurse Association Health Group, Inc. — one of the oldest, largest and highly respected home health, hospice and community health organizations in the country.

As a renowned author and thought leader in the care at home sector, his work has been published in the New England Journal of Medicine, the Journal of the American Medical Association and the Huffington Post. The work of Dr. Landers and his team to prioritize at-home vaccines for homebound seniors during the COVID-19 pandemic also has been featured by major news outlets such as ABC’S Good Morning America and CBS Mornings with Gayle King.

Personal Life

Steve lives in Little Silver, New Jersey, with his wife, Allison, and their three sons. His hobbies include golfing, fishing, hiking, traveling, enjoying good food and watching horse racing. When he is not taking part in these activities, you can find him cheering on his sports teams — the Browns, Cavaliers, Guardians and Indiana Hoosiers.

This bio originally appeared on the NAHC-NHPCO Alliance web site. It is reproduced in The Rowan Report by permission. It may be freely reproduced.

It’s Official! NAHC NHPCO Alliance Name New CEO

by Rowan Report | Aug 29, 2024 | Admin, Breaking News

WASHINGTON D.C. Steven Landers, MD, MPH, has been named the inaugural Chief Executive Officer of the newly merged NAHC-NHPCO Alliance (The Alliance). A recognized national leader and innovator in home health, primary care and aging services, Dr. Landers brings almost two decades of experience as a physician, executive leader and health policy advocate to The Alliance, which represents care at home and community providers across the country. (Read more about Dr. Landers at our accompanying article in this week’s issue.)

Dr. Landers has dedicated his career to seeking home- and community-based health care solutions for people of all ages. As a board-certified physician in family medicine, geriatric medicine, and hospice and palliative medicine, he is a champion of the impactful role health care at home plays in the health and wellbeing of communities, acknowledging that as an aging nation, providing compassionate, dignified and cost-effective systems of care to patients is critical.

“The Alliance members provide a wide range of high-quality home- and community-based services that promote comfort, dignity and independence. I’m so proud to become a part of this organization, and am eager to serve,” said Dr. Landers. “I’ve had the opportunity in my career to see the health care industry from many vantage points, and in this new role with The Alliance, I will use all that I have learned to make a difference for our members as we continue to expand to meet the growing public needs for our care.”

Prior to joining The Alliance, Dr. Landers served in several executive leadership roles. He was the director of home care at the Cleveland Clinic, and for more than 11 years was the president and CEO of the Visiting Nurse Association Health Group, Inc. — one of the oldest, largest and highly respected home health, hospice and community health organizations in the country. During his most recent tenure as the president and CEO of Hebrew SeniorLife, he led an organization known for superior senior living, geriatric health care, research and teaching.

Dr. Landers has served on numerous boards and committees in the care at home space and has represented organizations by engaging policymakers, including meeting with members of Congress; providing committee testimonies for Congress and state legislatures; and discussing home care policies and regulations with the U.S. Secretary of Health and Human Services, the administrator of the Centers for Medicare & Medicaid Services, Medicare Payment Advisory Commission officials, and federal agency staff.

“Providing leadership around policy and advocacy efforts is critical to our mission at The Alliance,” said Transition Board Chair Ken Albert. “Throughout his career, Dr. Landers served the field as an effective policy advocate, shaping policy at both the state and federal levels. We are thrilled to welcome him as our inaugural CEO, and I know he will build an extraordinary team to offer value for our members.”

Early in his career, Dr. Landers based his clinical practice on providing health care through house calls and thousands of home visits, primarily to low-mobility patients. While in this setting, he saw the need to connect home care and hospice to the broader health care system and medical community. He understood that to improve patient care, health care providers need to explore and thrive at the intersection of clinical work, health policy and systems of care. He pursued a master’s degree in public health, which contributed to his passion for influencing federal and state legislation to improve health care delivery to home-based patients.

“Dr. Landers’ rich and diversified experience makes him the ideal candidate to lead our membership as our organization evolves,” said Alliance Transition Board Vice Chair Melinda Gruber. “Working alongside community health workers and within our patients’ homes, he understands what we need as frontline caregivers and advocates.”

Dr. Landers is a graduate of Case Western Reserve University School of Medicine, where his training included a family medicine residency at Case Western and a geriatric medicine fellowship at the Cleveland Clinic. He also attended the Johns Hopkins Bloomberg School of Public Health, where he focused on health policy and management. Additionally, he received a bachelor of arts in political science from Indiana University in Bloomington.

# # #

About the NAHC-NHPCO Alliance

The NAHC-NHPCO Alliance brings together the National Association for Home Care & Hospice (NAHC) and the National Hospice and Palliative Care Organization (NHPCO), two organizations with more than 90 years of combined experience serving providers of quality care in the home to form one new association. This historic alliance creates a national organization representing providers of home care, home health, hospice, and palliative care, forming the most powerful voice and resource the care-at-home community has seen. The integration process underway is expected to continue through the beginning of 2025. While leadership explores a permanent name, the new organization is operating under the interim name the NAHC-NHPCO Alliance.

Keep track of updated news on the NAHC and NHPCO websites.

This news release originally appeared in The Rowan Report. by permission of the National Association for Home Health and Hospice. It may be freely reprinted.

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

by Kristin Rowan | Aug 23, 2024 | Regulatory

by Kristin Rowan, Editor

False Claims Act Violations

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

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

Whistleblowers

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

Allegations

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

More Allegations

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

Settlement

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

Repeat Offender

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

2014: a class action suit alleged unpaid wages.

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

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

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

Not Alone

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

Evolution Health LLC

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

Halo Home Healthcare

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

Atlantic Home Health Care

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

Speak Up, Speak Out

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

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

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

More Rural Providers Say ‘No’ to MA

by Tim Rowan | Aug 23, 2024 | Artificial Intelligence, Caring for the Caregiver, Clinical, CMS

by Tim Rowan, Editor Emeritus

O

ne just does not know whom to believe anymore. This week, we were sent three opinions of the pros and cons of Medicare Advantage programs. One says they reduce costs and improve patient satisfaction for rural residents. Another says rural hospitals are turning away MA customers at a growing rate. The third says MA customers utilize healthcare services at a lower rate than traditional Medicare beneficiaries. Let’s take a look at each opinion.

The Pro

Better Medicare Alliance is a non-profit advocacy group that promotes Medicare Advantage. They describe themselves and the genesis of their recent report this way:

“Better Medicare Alliance engaged ATI Advisory to understand Medicare beneficiaries who live in rural areas and how they are served across Medicare Advantage and Fee-for-Service (FFS) Medicare. Understanding geographic differences in beneficiary experiences is important to both the Medicare Advantage and FFS Medicare program. This research can help policymakers and stakeholders identify opportunities to improve access to and quality of rural health care.”

That sounds good so far. Let’s look at their conclusions.

- 30 percent fewer MA client live in rural areas compared to cities and suburbs
- rural MA enrollees are more likely to be Black or LatinX but health needs are consistent across all rural demographics
- satisfaction is the same between rural MA clients and traditional Medicare beneficiaries, though MA enrollees use preventive services more and outpatient services less
- rural MA enrollees spend less in premiums and out of pocket costs than traditional Medicare beneficiaries

Rural Hospitals Tell a Different Story

Healthcare Uncovered, an online publication with a patient advocacy slant, describes BMA as “an active front group for the health insurance industry and perhaps the country’s greatest champion of Medicare Advantage plans.” and “with a well-stocked, industry-financed war chest to promote insurers’ premier product.”

Writing for Healthcare Uncovered, longtime healthcare journalist Trudy Lieberman added perspective to the BMA-sponsored report:

More places say no to medicare advantage

There was evidence last fall that Medicare Advantage was under attack when several hospitals announced they were reviewing their arrangements with Advantage plan sellers and were not accepting some or all plans. The CEO of the Brookings Hospital system in Brookings, South Dakota, told me, “The difference between original Medicare and Medicare Advantage is vast. Advantage plans pay less, don’t follow medical policy, coverage, billing, and payment rules and procedures, and they are always trying to figure out how to deny payment for services.”

In 2023, Becker’s Hospital Review began reporting on hospitals that were dropping some or all of their contracts with Advantage plans. The August 20, 2024 update indicates 18 more hospitals have or will drop MA plans this year.

Ms. Lieberman went on to report that MA plans frequently limit in-plan physicians. When they eliminate a physician in a rural community, patients often must travel miles to reach an approved doctor.

“Another damning report, this one issued by the Nebraska Rural Health Association, also revealed the pitfalls of joining an Advantage plan. The report warned that Nebraskans with Advantage plans ‘have created such a financial burden for rural residents’ that when they get sick, those with Medicare Advantage coverage ‘represent the largest growing segment of charity care for Nebraska’s rural hospitals.’ I’d bet few if any seniors are told they may end up on charity care if they choose an Advantage plan.”

A hospital in 23,000-resident North Platte, Nebraska has stopped accepting all MA patients. CEO Ivan Mitchell told Ms. Lieberman that transfers to nursing home and Home Health are denied 13 percent of the time. “Hospital stays are 40 percent longer for MA patients. They are stuck in the hospital two or three days waiting for approval to be transferred, and we need those beds for sicker patients.”

Home Health Weighs In

The Research Institute for Home Care awarded a grant to Tami M. Videon, PhD, and Robert J. Rosati, PhD, of the VNA Health Group, the honored Home Health not-for-profit in New Jersey. The researchers divided beneficiaries into three groups: Traditional Medicare, MA with a premium, and MA without a premium. Their findings resonated with the experiences of rural hospitals more than those of the MA advocacy group.

Research Findings

- Traditional Medicare (TM) beneficiaries were more likely to utilize outpatient, inpatient, and home health care services than beneficiaries in Medicare Advantage (MA) plans, regardless of whether the plan had a monthly premium or not.
- Beneficiaries who reported being in zero premium MA plans were substantially less likely to use dental, hearing, and vision services compared to other beneficiaries.
- Rates of utilization of hearing and dental services were relatively similar for beneficiaries reporting they were in MA plans with a premium and those enrolled in TM. Access to vision services was greatest among beneficiaries reporting being in MA plans with a premium.

In their research briefing, the researchers stated:

“Consistent with the literature, this study found beneficiaries enrolled in MA plans had lower utilization for services required to be covered by Medicare (outpatient visits, inpatient admission, and home health care use) than beneficiaries enrolled in TM. The observed lower rate of home health care utilization among MA beneficiaries may result from restrictions in inpatient care. However, prior research indicates when analyses are restricted to similar patient populations (a subset of diagnostic codes), MA beneficiaries are less likely to receive home health care than TM beneficiaries.”

Where Does the Money Go?

We have often reported on the lawsuits that various federal departments have lodged against the largest health insurance companies for their Medicare Advantage practices. With their payments from the Medicare Trust Fund based on patient assessments, they have been caught exaggerating illnesses, adding chronic conditions that do not exist, and conducting periodic home visits to “update” their data on the health condition of their customers. These nurse visits to the home frequently “identify” serious health conditions that the person did not know they had, or in most cases did not have at all.

As a consequence of this practice, coupled with denying care that Traditional Medicare would have covered, the program has been determined by government audits to cost 119 percent of what Traditional Medicare costs.

Final Thoughts

Should Home Health follow the lead of so many rural hospitals and begin to Just Say No? Our guess is that this will be a prominent topic at this October’s NAHC Conference in Tampa.

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Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com Tim@RowanResources.com ©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Product Review: AI Comes to Data Analytics

by Kristin Rowan | Aug 16, 2024 | Product Review

by Kristin Rowan, Editor

Artificial Intelligence has existed in basic forms for many years and has recently advanced to include augmented intelligence and generative intelligence. The Rowan Report has provided several examples of quality AI usage and even more examples of AI applications that are fraudulent, improperly applied, and/or poorly executed. As we continue our journey of AI discovery, we are seeing more companies researching how to effectively use AI to enhance existing software solutions as well as new solutions entirely based on AI. We’ve reviewed AI software for point of referral, talk to text documentation, employee recruitment and retention, and now data analytics.

The Rowan Report recently met the founder of a data analytics AI software solution, Skyra.ai. “Our goal is to advance the industry to be technology forward,” said Skyra founder Mickel Mirchandani, “we imagined a future were technology empowers home care agencies to focus on what matters – serving patients.”

Data Analytics: From What to Why

Care at Home agencies have no shortage of access to reports through various tech solutions. Hours worked and earnings from payroll reporting, average length of visit and number of patients per week from EMR and EVV reports, average daily census, employee turnover rate, and the list goes on. These reports are useful in telling us what is happening within our agency, with our staff, and with our partners. Once you have this information, what do you do with it? Does it tell you why your top clinician saw five fewer clients last week? Does it explain the decrease in referrals from area hospitals and physicians? Can the reports tell you whether the recent trends will continue? Why are these things happening in your agency? And what’s more, how do I fix them?

Give Your Home Health Agency a Much-Needed Tune-Up

Like the warning light on your dashboard, data is meaningless until it is diagnosed. That warning light that tells you your referral numbers dropped last week might indicate new competition in your area, a drop in confidence in your agency by hospitals and physicians, too many NTUCs on your scorecard, or simply a glitch in paperwork or your website. The data tells you the numbers have dropped. Skyra.ai tells you why.

Skyra is a data analytics solution that connects to your EMR, payroll, accounts payable, scheduling, and quite literally almost any other piece of your tech stack that has useful data you want to see.

With a standard dashboard containing the most relevant and popular queries, and the ability to create custom insights, Skyra makes understanding the volumes of data collected simple and easy. Once you understand the “why” behind the numbers, you can make adjustments in your operating, scheduling, ordering, and operations to improve the overall health of your agency.

Features

Standard Dashboard
Insights for each Team (Sales, Executive, Clinical)
Two-Month Data Trends
Custom Insights Page
Pinned Query that refreshes itself daily
Understands multiple languages
Zero Percent Hallucination
HIPAA Compliant with multiple security layers applied vertically and horizontally

“Ask Sky” – the Generative AI assistant you can tap into for custom insights into your agency
Compliance Monitor to avoid payment penalties by ensuring accuracy and timeliness of submissions
Control Tower for key metrics and alerts

Platform Agnostic

Data analytics is difficult enough without using multiple tech solutions. Even worse is when you’ve decided that a particular solution no longer works for your agency and you find yourself shopping for a new payroll, scheduling, or EMR solution. How do you preserve the years of data from your legacy systems without interruption?

Skyra.ai’s unique process stores all your data as though it comes from the same source, in the same language. Switching from solution to solution is a seamless process that keeps your data intact and reduces the opportunity cost of changing systems.

Future Plans

The team at Skyra is not content with one of the most advanced AI applications in the space. With a recently redesigned website, and new partners, Skyra is now looking to the future. Look for a two-way communication solution over a secured system with encrypted messages. The messaging system will connect caregivers to patients, patients to care teams, and caregivers, to care teams. The solution will reduce triage costs, reduce rehospitalizations rates, assist with marketing efforts, and increase CHAP scores. Skra Connect will launch sometime in 2025.

But, first, Skyra is focusing its development efforts on an application for sales teams and marketers. An alternative to a traditional CRM that requires large amounts of useless data input and doesn’t help close a deal, Skyra’s sales solution will provide a CRM solution that sales people actually want to use and will free up their time to spend on customer-facing activities.

The Rowan Report will provide a separate review of each of these new products as they become available.

Overall Impression

A Familiar Problem

Skyra.ai found Mickel tells a familiar story about the idea for his solution. Familiar, at least, to those of us who grew up in the 80s. When our favorite band released new songs, we ran to the nearest music retail store to buy a cassette tape. If your favorite song on the tape was track 3, you know the pains of fast forwarding and rewinding to get the tape to the perfect spot at the beginning of the song, only to have to do it all over again when the song ends. Today, we ask “Alexa” or “Siri” or “Google” to play our favorite song and it starts at exactly the right second every time. Mickel strove to make accessing and understand data as easy as asking Alexa to play your favorite song. Ask Sky removes the fast forward and rewind buttons and lets you understand your data faster.

A Consolidated Solution

As a small business, and even as an individual, I know how many applications I have to log in to daily to see my business analytics and personal information. Skyra houses all of your business information in one place for easy access and provides an open-ended query so each agency gets the information they need most to help the agency operate at its fullest potential. The possibilities that will exist as the AI technology advances is near endless.

As we have mentioned before, there are a lot of misuses for artificial intelligence, and a lot of misunderstanding. Now, it seems, we have found at least one more company doing AI well.

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

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