Treatment in Place from Emergency Medical Services

by Elizabeth E. Hogue, Esq. | Feb 14, 2025 | Clinical, Medicare Advantage, Regulatory

by Elizabeth E. Hogue, Esq.

Treatment in Place

Providers of services to patients in their homes are anecdotally familiar with situations in which patients need help at home, but do not qualify for home health services and have not arranged for or are unable to afford home care/private duty services. These patients need assistance, but do not need transport.

The Problem

The problem for Emergency Medical Services (EMS) is nonpayment for services if patients are not transported for services.

Can EMS Charge Without Transport

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services has weighed in on whether local EMS can meet this need and bill patients’ insurance for treatment in place (TIP) services. The OIG has “blessed” the provision and billing of these services in Advisory Opinion No. 24-09 issued on November 21, 2024.

Treatment in Place Requirements to Bill Insurance

Specifically, the OIG says that EMS may provide services to patients in their homes or TIP services and bill Patients’ insurers if the following requirements are met:

Charges to patients’ insurers would be limited for emergency responses only.
Charges for TIP services must be based on the level of care furnished to patients and cannot exceed amounts currently claimed for payment for the same levels of care furnished in connection with ambulance transports.
Charges are made regardless of whether patients are enrolled in commercial insurance plans or federal health programs.
EMS accepts payment for TIP services from patients’ health insurances as payment in full.
Patients will not be billed for any cost-sharing amounts under patients’ health insurance, including federal health care programs for covered TIP services, regardless of whether they are residents or nonresidents of the county where TIP services are provided.
EMS cannot later claim cost-sharing amounts waived as bed debts for payments under federal health care programs or otherwise shift the burden of cost-sharing waivers onto federal health care programs, other payors, or individuals by, for example, balance billing.

Cost-Sharing

In light of the above, the OIG first acknowledged that the prohibition on waivers of cost-sharing under the federal anti-kickback statute (AKS) is applicable and that the requirements of a safe harbor that addresses waivers of cost-sharing amounts for municipally owned ambulances are not met by the proposed arrangement. The OIG also said that the proposed arrangement would result in remuneration in the form of cost-sharing waivers for TIP services and TIP services provided at no charge to patients. Consequently, remuneration provided implicates both the AKS and the Beneficiary Inducements CMP.

Risk

Nonetheless, the OIG concluded that the arrangement involves a low risk of fraud and abuse. In addition to the above requirements, the OIG concluded that neither Medicare Part B nor the State Medicaid Program currently covers TIP services; only a handful of Medicare Advantage Plans and some Medicaid Programs currently cover TIP services. This means that, in most circumstances, the arrangement will result in no costs to federal health care programs and, in fact, may reduce costs by avoiding ambulance transport or subsequent hospital care. Patients may also receive care more quickly and efficiently, and at more appropriate levels of care when they receive TIP services.

Treatment in Place Cost-sharing Waivers

Finally, according to the OIG, waivers of cost-sharing for TIP services or the provision of free TIP services are unlikely to affect patients’ decisions to use future emergency ambulance services reimbursed by federal health care programs.

Providers are increasingly aware that patients need a variety of services in their homes. The OIG has opened another door!

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

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

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

Is Medicaid Down for the Count?

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

by Kristin Rowan, Editor

Medicaid Payment System Goes Dark

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

The Memo

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

Exclusions

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

Immediate Lawsuits

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

Temporary Freeze on the Temporary Freeze

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

Then Comes the Thaw

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

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

Final? Ruling

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

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Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news .She also has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

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

Medicare Advantage Lowers Home Health Care Use

by Kristin Rowan | Feb 6, 2025 | Hospice, Medicare Advantage

by Kristin Rowan, Editor

End-of-Life Care in Medicare Advantage vs Traditional Medicare

Using research from CMS, researchers from Mt. Sinai in New York and Brown University in Rhode Island studied the data of adults aged 66 and older who passed away and had Medicare coverage in their final year of life. Included in the study were people potentially eligible for home health care and not in a nursing facility, hospital, or hospice care setting. Data from close to 1.8 million people was analyzed. The researchers identified whether the participants received home health care and how many days of end-of-life care they received.

Home Health Higher in Traditional Medicare

Of the nearly 1.8 million participants, the average age was 82. 51.5% were female and 36.5% were enrolled in Medicare Advantage. In the final year of life, home health care use was recorded at 37.5% for MA enrollees and 41.7% for traditional Medicare.

When the researchers looked at different demographic groups within the data sets, home health care usage was higher in traditional Medicare in most groups. However, among American Indian and Alaska Native groups, Medicare Advantage had a slightly higher rate of home health use at 37.9% compared with 37.1% in Traditional Medicare.

Conversely, in the Asian or Pacific Islander demographic, home health use rate was 32.6% in MA and 41.8% in TM. Similarly, the rate of use among the Hispanic group was 33% in MA and 44% in TM. Following a similar trend, in the non-Hispanic Black group home health usage in MA was 38.8% compared with 42.9% in TM. Likewise, among the non-Hispanic White group, home health use in MA was 37.9% versus 41.5% for TM. For those of unknown race, usage was 36.1% in MA compared with 40.1% in TM.

Days of Care Lower in Medicare Advantage

Home health users across all racial and ethnic demographic groups enrolled as Medicare Advantage beneficiaries had fewer days of care in home health than those enrolled in Traditional Medicare. The stand-out group in this part of the research was those of Hispanic descent, who averaged 81.9 days in home health care in Medicare Advantage compared with 111.9 days in Traditional Medicare.

Implications

The researchers indicated some limitations in the study, namely that data was pulled from pre-covid patients because of the changes in home health during covid. The study should be repeated with post-covid data. One of the researchers received personal fees while serving as a senior advisor to CMS. Another received personal fees as a section editor for UpToDate. A third researcher reported receiving personal fees from Abt and UpToDate.

Despite these limitations, the implications of the study show that end-of-life care is not the same between Medicare and Medicare Advantage patients. Medicare Advantage is largely operating on a Value-Based Purchasing Model. The fewer services the beneficiary receives, the more money the primary doctor, hospital, and payer keep. It is not surprising, therefore, that MA patients get fewer services for less time. Patients who switch from Traditional Medicare to Medicare Advantage, especially if they are your patients, should be informed that they are still eligible for home health care and hospice care, but they may have to ask for it.

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Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news .She also has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

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

Medicare Advantage Increase for Payers, not Providers

by Kristin Rowan | Jan 23, 2025 | Artificial Intelligence, Breaking News, CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

CMS Announces Medicare Advantage Pay Hike

On January 13, 2025, CMS announced its plans to increase payments to Medicare Advantage plans by 4.33%. Policy changes for Medicare Advantage and Part D include changes in how the agency calculates payments to health plans. A spokesperson from CMS said that the policy change provides access to affordable, high-quality care. The changes, however, don’t increase payments to the people actually providing the care, only to the payers.

Opposition

While major health plans across the U.S. were thrilled with the announcement and saw substantial stock price hikes immediately after, not everyone is on board. The American Medical Association (AMA) outlined how physicians who treat Medicare patients are getting pay cuts from CMS for the fifth year in a row. Meanwhile, HHS OIG released a report finding that MA insurers profited $7.5 billion from risk-adjusted payments in 2023.

“It’s unbelievable they’re giving insurance companies that had record profits an increase while at the same time cutting payment to physician practices that are struggling to survive. This contrast highlights the urgent need for Congress to prioritize linking payment to physician practices to the cost of providing care.”

Bruce Scott, M.D.

President, American Medical Association

Out-of-Pocket Cost Increase

In addition to the higher payments, the advance proposal includes an increase in the Part D deductible from $590 to $615. With this proposal, the out-of-pocket maximum will increase from $2,000 to $2,100 as well. Cost sharing after the deductible is reached but before the out-of-pocket max is reached will also increase. There is no increase for beneficiaries whose income is less than 100% of the Federal Poverty Level.

Coverage Increase

The CMS advance proposal calls for coverage and policy changes. Medicare and Medicaid programs will now cover anti-obesity medications. The plan imposes stricter rules on MA policies to prevent denial of reasonable and necessary services that would be covered under Medicare Part A and B. Finally, imposed guardrails on the use of AI. The guardrails will ensure AI systems are unbiased in patient care decisions. Additionally, the guardrails will ensure they do not perpetuate existing inequity in access to and receipt of medical services. The American Hospital Association appplauded this last change.

“The AHA commends CMS for taking important steps to increase oversight of 2026 Medicare Advantage plans to help ensure enrollees have equal access to medically necessary health care services. The AHA has previously raised concerns about the negative effects of certain Medicare Advantage practices and policies…that are more restrictive than Traditional Medicare and can compromise enrollee access to Medicare-covered services.”

Ashley Thompson

Senior Vice President, American Hospital Association

Changes are not Definite

Even though CMS has announced these changes to start in January, 2026, they are not set in stone. As of January 20, 2025, we are operating under anew administration and the changes under Trump have already started. CMS intends to continue it’s three-year plan to update the MA risk adjustment model and the implementation of the Inflation Reduction Act. However, it seems likely that the Inflation Reduction Act will be replaced with a different plan for inflation.

Jeff Davis, director of health policy at McDermott+ believes it is likely that Trump’s team will throw out the updates to MA and Part D as well as Biden’s proposed staffing mandate for SNFs. In the first 24 hours of his Presidency, Trump revoked both Biden’s “Strengthening Medicaid and the Affordable Care Act” and “Continuing to Strengthen Americans’ Access to Affordable, Quality Health Coverage” executive orders. He also rescinded the Drug Pricing Model executive order that covered obesity drugs, lowered the price of some drugs, and accelerated FDA approval for drugs that address unmet medical needs.

As Yet Unknown

As was to be expected, many of Trump’s initial 78 executive orders are already facing lawsuits from various entities. There are as of yet no definitive answers to changes in Medicare, Medicare Advantage, or other policies that impact healthcare and care at home. The Rowan Report will continue to follow these stories as they unfold.

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Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news. She also has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

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

Care at Home Coming to Medicaid?

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

by Elizabeth E. Hogue, Esq.

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

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

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

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

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

Support for Olmstead

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

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

Consequently, the decision applies to

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

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

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

Final Thoughts on Brown v D.C.

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

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

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

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

Whistleblower Case Impedes Lawsuits

by Kristin Rowan | Jan 16, 2025 | CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Whistleblower Action

A United States District Court in Tampa, Florida ruled against a whistleblower action under the False Claims Act (FCA) against her former employer. In 2019, a family care physician filed a whistleblower, or qui tam, action against her employer for increasing the risk adjustment scores of Medicare Advantage patients in order to receive higher payments.

Whistleblower Protection

When an employee or person with information about a company’s wrongdoing, they can file a lawsuit against that company. Whistleblowers are protected under OSHA, EEOC, and several federal and state regulations against retaliation from their employer. A whistleblower, the person who brings evidence of wrongdoing to the court, is called a “relator.”

Before the Ruling

The False Claims Act is the first and one of the strongest whistleblower laws in the U.S. Under the FCA whistleblower rules, any private citizen can sue any individual, company, or other entity that is defrauding the government and recover damages and penalties on the government’s behalf. Whistleblowers also receive compensation when these suits are settled between 15% and 30% of the total proceeds. As the FCA has expanded since its passing in 1863, the law made it possible for anyone to serve as a whistleblower.

The Ruling

In the case noted above, the court ruled that FCA whistleblowers act as officers of the United States when they sue on behalf of the federal government. The decision reasoned that whistleblowers are appointing themselves as officers of the federal government by bringing these lawsuits.

Article II, Section 2, Clause 2 of the Constitution states that the President can appoint officers and officials to the government and that they require Senate approval for some of these. Cabinet appointments, judicial appointments, and other high ranking positions are often the subject of news stories during Senate hearings to confirm these appointments.

The court ruled that an FCA whistleblower becomes an officer of the federal government through self-appointment, violating the Appointment Clause of the Constitution. The court further ruled that the False Claims Act in itself is a violation of the Constitution, effectively nullifying the FCA, at least in Florida for now.

Widespread Implications

Any company who has lost a False Claims Act suit may now be able to challenge those rulings, using this case as precedent. However, there are some hoops they would need to jump in order to do so, depending on how this case is interpreted. Ironically, this case states that whistleblowers cannot be officers of the government without appointment, but if that’s true, then all False Claims Act decisions become easier to challenge.

If this decision stands and is adopted as precedent across the U.S., it could completely nullify the False Claims Act. It may even be considered for a Supreme Court ruling. In 2023, the U.S. government recouped $2.6 billion from FCA suits, nearly $2.3 billion of which were claims brought by whistleblowers.

Care at Home Implications

Medicare and Medicare Advantage are rife with fraudulent claims, “coding intensity“, upcoding, and predatory marketing. In 2024, CMS announced changes to the risk adjustment model in the Risk Adjustment Validation Final Rule after seeing higher-than-expected risk scores. The changes could help CMS recoup up to $4.7 billion in the next ten years.

MedPAC estimates that Medicare Advantage plans received as much at $88 billion in excess payments in 2024. The lowest share of overpayment reimbursement through the Fraudulent Claims Act would give whistleblowers a combined $13.2 billion. Eliminating the FCA may discourage employees and contractors from reporting fraudulent claims and overbilling through Medicare and Medicare Advantage.

Final Thoughts

A safeguard for people trying to do the right thing, a means to save the federal government billions of dollars that can be spent elsewhere, and ultimately better care for patients are all at risk if the FCA is struck down. A law that has been in place for more than 150 years should carry more weight than the ruling of one district court who applies a new definition to a long-standing term.

Whistleblowers and the federal government have generally been considered co-defendants in these suits. Two parties with separate interests in the same suit, acting independently, not a joint case like a class action suit would be. I anticipate an appeal on this decision and hopefully a panel of judges who better understand the necessity of the False Claims Act and the Whistleblower provisions.

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Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news .She also has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

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

Congress Allows Medicare Advantage to Deny Coverage

by Kristin Rowan | Jan 9, 2025 | Advocacy, Editorial, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Medicare Advantage Bill Dies in Congress

The 118th United States Congress, ran from January 3, 2023 to January 3, 2025. This Congress’s first law was passed on March 20, 2023, much later than most previous congressional sessions. In its first year, it passed only 34 bills. In the two years of this congressional run, the 118th passed 209 public laws, almost half the average since 1989. Among the many bills that died on the floor before time ran out was the Improving Seniors’ Timely Access to Care Act (H.R. 8702/S. 4532). Senate and House members introduced the bill on June 12, 2024.

Improving Seniors' Timely Access to Care

In June of 2024, senators and representatives introduced bipartisan legislation that would have curbed Medicare Advantage’s ability to deny claims. The bill included language that allowed CMS the authority to establish standard timeframes for electronic prior authorizations requests including expedited requests and real-time decisions for routinely approved services. The bill also included requirements for transparency and reporting, including:

- establishing an electronic prior authorization process
- establishing a process for real-time decisions for routine services
- providing more detailed reports on use of prior authorization including
  - rates of approvals
  - denials
  - average time for approvals
- pressing Medicare Advantage providers to incorporate input from health care providers on their authorization processes and decisions
- adopting prior authorization programs that adhere to evidence-based medical guidelines
- requiring Medicare Advantage providers to report on the percentage of denied claims that were later overturned

Overwhelming Support

At the time this bill was reintroduced to Congress in June, 135 House co-sponsors and 44 Senate co-sponsors signed on. By the end of July, the bill had been read, sent to the House Ways and Means Committee, and passed. Representative Mike Kelly (R-PA) noted that more than 500 organizations had endorsed the act.

Urgent Need for Change

In early 2024, an audit from the Office of the Inspector General (OIG) at the U.S. Department of Health and Human Services (HHS) revealed that Medicare Advantage plans eventually approve 75% of authorization requests for services that were initally denied. More recently, HHS OIG released a report showing that MA plans incorrectly denied services to beneficiaries even though they met the requirements for coverage. Following the report, HHS OIG made the following recommendations to CMS:

- issue new guidance on the use of MAO clinical criteria in medical necessity reviews
- update audit protocols for Medicare Advantage to address the issues of MAO use of clinical critera and examining service types
- direct MAOs to indentify and address the causes for manual review errors and system errors.

CMS agreed with all three recommendations.

Dead in the Field

Despite the bipartisan, bicameral support of this much needed overhaul of Medicare Advantage providers, the bill is currently in pile of unaddressed issues that the 118th Congress just didn’t get to. Despite having it in front of them for five months, and despite passing nearly half the legislation of the 17 most recent congressional sessions, the bill that would keep MA beneficiaries from waiting inordinate amounts of time for routine care will have to wait for the next session to resume. Let’s hope the 119th Congress is more productive.

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Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news .She also has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

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

HH Accessibility Report

by Rowan Report | Dec 19, 2024 | Partner News, Regulatory

FOR IMMEDIATE RELEASE

Contact: Lauren Corcoran

press@trellahealth.com

Trella Health Launches Special Report on Home Health Accessibility for Medicare Fee-for-Service (FFS) Beneficiaries

An analysis of the key trends shaping access to care for Medicare patients

ATLANTA, Dec. 16, 2024. Trella Health, the leading provider of market intelligence and integrated customer relationship management (CRM) solutions to the post-acute care industry, released its Special Edition Report on Home Health Accessibility Among Medicare Fee-for-Service (FFS) Beneficiaries.

Access to Services

This report investigates trends shaping home health accessibility, revealing how the expanding Medicare-eligible population – and other factors – continues to strain access to home health services.

Below are a few key insights from this special report:

- 49.9% of counties had five or fewer home health agencies per 1,000 square miles in 2023.
- 94.1% of counties experienced either a decrease or no change in the number of skilled home health agencies treating more than 10 FFS patients in the post-pandemic period.
- 83.3% of counties experienced a decrease in the number of FFS home health admissions per 1,000 beneficiaries in the post-pandemic period.
- 87.4% of counties experienced a decrease in the average number of home health visits in the post-pandemic period, and the number of home health visits per patient day decreased by 17.3% between 2017 and 2023.

Urgent Need for Change

“Our analysis of Medicare Fee-for-Service claims indicates a concerning trend: decreasing accessibility to skilled home health care at a time when we are experiencing the largest growth in the Medicare population,” stated Carter Bakkum, Senior Data Analyst at Trella Health. “This report underscores the urgent need for healthcare leaders to address these disparities and ensure that Medicare beneficiaries receive the care they need.”

# # #

About Trella Health

Trella Health‘s unmatched market intelligence and purpose-built CRM allow post-acute providers, HME, and Infusion organizations to drive more effective performance and growth. Trella’s solutions allow post-acute, HME, and Infusion organizations to identify the highest-potential referral targets, evaluate new market opportunities, and monitor performance metrics. Paired with CRM and EHR integrations, business development teams can better manage referral relationships to advance their organizations with certainty by improving their sales and marketing strategy.

This press release was submitted by Trella Health and was reprinted by The Rowan Report with permission. For more information, or to request permission to use this content, please use the press contact above.

Updates on UnitedHealthcare CEO Shooting

by Kristin Rowan | Dec 12, 2024 | Breaking News, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Last Week

As most of the U.S. now knows, last week, UnitedHealthcare CEO Brian Thompson was shot and killed outside a hotel in Manhattan just hours before the UnitedHealth Group Investor Event. The Rowan Report provided the breaking news story with the information available at the time.

Manhunt

According to reports, after the shooting, a man fled the scene on foot and then rode an e-bike toward Central Park. Police were in pursuit based on early descriptions of the shooter and later on video footage of the shooting. The suspect was wearing a hoodie in the images of the shooting. Further investigation found a photo of the suspect in the lobby of a hostel where it is believed he stayed, smiling. Police followed the suspect into Central Park, where it is believed he got into a taxi and left the park.

He was later spotted at a bus station near the George Washington bridge.

Conflicting Images

Images obtained of the suspect taken inside the hotel show a man appearing to be in his 20s, wearing a dark jacket with the hood up and a black face mask resting under his chin. An image of the suspect at a nearby Starbucks puts the suspect in a dark jacket with a black mask covering his mouth. Twenty minutes after the shooting, he is spotted getting into a taxi wearing a black jacket and a white surgical mask covering his mouth and nose. Conspiracy theories about why he would change his mask started circulating quickly.

Ongoing Investigation

A video shows the suspect entering the bus station near the George Washington Bridge. There is no video of him exiting the station. Police believe he got on a bus.

Meanwhile, police found a backpack in Central Park they believe belonged to the suspect. The investigation also discovered a cell phone that may be linked to the shooting. Early on Monday, December 9, police returned to Central Park with dive crews to search for evidence.

Delay, Deny, Defend

Delay Deny Defend by Jay M. Feinman is a book criticizing health insurance companies. The sub-title, “Why Insurance Companies Don’t Pay Claims and What YOu can Do About It,” supports the description of the book indicating that Feinman explains how to be more custios when shopping for policies and what to do when you have a disputed claim. Feinman also includes a play for the legal reforms he feels are needed to end the abuse.

NYPD officers found writing on the three shell casings left at the scene of the shooting. Initially reported as “Deny, Defend, & Depose”, police have now clarified that the permanent marker found on the casings read “Deny, Delay, & Depose.”

Former FBI agent Brad Garrett said he believes the shooter is “trying to send a message.” Police have not commented on what they think the words might mean. Meanwhile, “Deny Defend Depose merchandise appeared overnight, followed quickly by the corrected “Deny Delay Depose.”

Person of Interest

Around the time the dive crews arrived to search for clues in Central Park, a man entered a McDonald’s in Altoona, PA, nearly 280 miles away. An employee recognized him as the man from the photos and alerted local police. The person of interest, now identified as Luigi Nicholas Mangione, had a weapon, a mask, and writings that linked him to the shooting. The writings suggest he has issues with corporate America in general, and named several other people in the document in addition to Brian Thompson. He also had a fake ID that matches the one used to check in to the hostel in New York. Mangione has now been charged with Thompson’s murder.

Mangione was taken into custody by local police. Several members of the NYPD were later seen entering the police station in Altoona. As of Monday afternoon, Mangione was refusing to talk to police and did not have an attorney.

A DNA swab was taken and will be compared with DNA from a Starbucks cup found near the scene. Reports indicate Mangione will be extradited to New York. Mangione was denied bail and will remain in the Pennsylvania prison while he and his attorney fight the extradition to New York.

Additional information about Mangione surfaced on December 11. Mangione’s grandfather founded Lorien Health Services. The company, based in Maryland, operates six ALFs and eight nursing homes. Mangione often volunteered with the company in high school. Additionally, Mangione’s former roommate said in an interview that Mangione recently had surgery that was “heinous” and left him with multiple screws in his body.

Public Outcry

The customary sentiments of comfort, sympathy, and condolences were pointedly absent in the days after Thompson’s death. Instead, stories of denied claims, limitations on access to care, and other frustrations with the industry flooded social media. Of the 60,000 reactions to the UnitedHealth Group post about Thompson’s death, 57,000 were laugh emojis.

Many industry professionals noted that the incident has brought up bigger issues with healthcare insurance in general. The Rowan Report previously wrote about UnitedHealthcare using AI in place of medical professionals to determine medical necessity. This resulted in a much higher than expected denial rate and more than 90% reversal of denials on appeal.

For more information on how healthcare might change after the shooting death of Brian Thompson, please see our complimentary article this week, “Will Thompson’s death change healthcare?”

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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

Health Insurance Impact after Thompson’s Death

by Kristin Rowan | Dec 12, 2024 | Advocacy, Editorial, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Will Thompson's death change healthcare?

It's all Relative

On the same day that Brian Thompson died, Blue Cross Blue Shield announced a reversal of an earlier planned policy change. In November, the insurance giant announced it would change its process for anesthesia claims. The change would start in three states and begin on February 1st, 2025. The new process would limit the amount of time the company would cover anesthesia for surgeries and other procedures that called for anesthetization.

The announcements said the company would deny any claim for a surgery or procedure needing anesthesia that goes beyond the time limit they established. Reportedly, the policy would not apply to people under 22 or any maternity related care. A press release from the American Society of Anesthesiologists criticized the policy. It said BCBS “will no longer pay for anesthesia care if the surgery or procedure goes beyond an arbitrary time limit, regardless of how long the procedure takes.”

The new policy was confusing. Some reports indicated there would be a time limit set by the insurer and all claims over that time limit would be denied. Another interpretation said the company would initially approve the claim but would only cover the anesthesia up to a point, leaving the balance to the insured. Yet another report implied BCBS shield would still pay for the surgery, surgeon, and facility, but not for any of the anesthesia.

Reversal of Fortune

Though the initial announcement received backlash from anesthetists, surgeons, insured patients, and Connecticut Senator Chris Murphy, the policy was not widespread news. That is, until the shooting of Brian Thompson shed light on all health insurance company policies. Citing “misinformation” the company announced on Thursday, December 4, that it would not proceed with the policy change.

To be clear, it never was and never will be the policy of Anthem Blue Cross Blue Shield to not pay for medically necessary anesthesia services. The proposed update to the policy was only designed to clarify the appropriateness of anesthesia consistent with well-established clinical guidelines.

Spokesperson

Anthem Blue Cross Blue Shield

Social Media Backlash

The New York Times referred to the reactions to Thompson’s death as “morbid glee.” Comments on social media posts, videos, and news stories include:

“Thoughts and deductibles to the family.”

“Unfortunately my condolences are out-of-network.”

“I pay $1,300 a month for health insurance with an $8,000 deductible. When I finally reached that deductible, they denied my claims. He was making a million dollars a month.”

“Cause of death: Lead poisoning! It’s a pre-meditated condition. Payout denied.”

UnitedHealth Group Responds

UnitedHealth Group CEO Andrew Witty called the media interest in Thompson’s death “aggressive” and “frankly offensive.” In a video to UnitedHealth Group employees, Witty said, “I’m sure everybody has been disturbed by the amount of negative and in many cases citriolic media and commentary…particulary in the social media environment.” Witty noted there were few poeple who had a “bigger positive effect” on the U.S. healthcare system than Thompson.

From Bad to Worse

Witty’s leaked internal video compounded the negativity towards health insurance companies. Witty decryied the media and public vitriol. He then praised Thompson’s impact on healthcare and defended the company policy.

“Our role is a critical role, and we make sure that care is safe, appropriate, and is delivered when people need it,” Witty said, “What we know to be true is the health system needs a company like UnitedHealth Group.” Witty followed his seemingly innocuous statement with, “We guard against the pressures that exist for unsafe care or for unnecessary care to be delivered in a way which makes the whole system too complex and ultimately unsustainable.” Public outcry was amplified after the video was leaked, with insured persons using this as proof that the company’s policy is to deny care.

Experts Weigh In

Ron Culp, a public relations consultant at DePaul University said if the attack is related to health insurance policies it “could cause companies in the sector to make some changes,” noting that, “empathy and potential alternative solutions will play greater roles.”

Fortune predicts that the incident will cause fewer people to aim for the corner office.

While disgruntlement with corporate America is not new, The Wall Street Journal said this incident is “tinged with class rage and anti-corporate venom….[The] current outpouring is on a grander scale….”

Loss of Faith in Insurance Stock

Between close of business on Tuesday, December 3, the day before Thompson’s shooting, and Tuesday, December 10, major insurance stocks have dropped more than 6%. This includes UnitedHealth, CVS Health, and Cigna, three of the largest private health insurers in the country.

Jared Holz, a health-care equity strategist, said the stock performance appears to be in response to the rhetoric condemning health insurance business models that include denied claims in deference to higher profits.

Final Thoughts

After just one week, the public is still uncovering and pronouncing issues with the healthcare insurance industry. The long-term health insurance impact regarding company policies, denial rates, or anything else remains to be seen. The Rowan Report will never condone violence against another person. However, if Thompson’s death brings about changes in the corruption of for-profit insurance companies, we will all be the better for it.

This is an ongoing story. The Rowan Report will continue to provide updates as they become available.

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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