Private Payors Against Fraud

by Elizabeth E. Hogue, Esq. | Apr 17, 2026 | Admin, CMS, Home Health, Hospice, Medicaid, Medicare, Regulatory, Waste Fraud and Abuse

by Elizabeth E. Hogue, Esq.

Private Payors Against Fraud

Join Enforcement Efforts

There seems to be a persistent myth among providers of private duty/homecare services that the federal anti-kickback statute applies to Medicare-certified providers only. On the contrary, the anti-kickback statute applies to providers who receive funds from any state or federal healthcare program; including the Medicaid Program, VA, TRICARE, etc. Private duty providers: This means many of you! Lately it has become clear that private payors have joined fraud enforcement efforts.

Guilty

In a recent case, a provider in Detroit pled guilty to conspiring to commit health care fraud. The conspiracy resulted in losses totaling $1.9 million to Medicare, Medicaid, and Blue Cross Blue Shield of Michigan. The investigation was conducted by the FBI and the Office of Inspector General of the U.S. Department of Health and Human Services, the primary enforcer of fraud and abuse prohibitions.

Ghost Services

At the plea hearing, the provider admitted to creating and operating a scheme to submit false and fraudulent claims that were medically unnecessary or not actually provided. In some instances, services billed were not ordered by physicians. The scheme continued for over five years. The provider used the proceeds of fraud for his personal use and to benefit others.

Consequences

After a presentence report is prepared, the provider faces a possible maximum sentence of ten years in prison, a fine of up to $250,000 and up to three years of supervised release following any term of imprisonment.

Federal and Private Prosecution

It is important to note that the provider was criminally prosecuted not only for fraud with regard to claims submitted to Medicare and Medicaid Programs, but also fraud committed against a private payor, Blue Cross Blue Shield.

Your Payor Could Report You

It now appears that providers who receive payments from third party payors must be concerned about fraud enforcement. Consequently, providers of private duty/home care services must develop, implement, and update Compliance Programs.

Compliance Programs

Compliance Programs are specific types of documents that routinely address issues that providers do not usually cover in internal policies and procedures. In addition, providers may not gain benefits related to fraud enforcement if there is no formal document called a Compliance Program.

More than Accreditation

Some providers think that accreditation means they are in compliance. On the contrary, providers may be accredited but fail to meet applicable compliance standards for fraud and abuse. Compliance Programs appropriately address potential fraud and abuse issues. They also include mechanisms for helping to ensure compliance, such as processes for identification and correction of potential problems that are not addressed during the certification process.

It Could Save You

Providers also need to know that developing, implementing, and updating Compliance Programs may make a considerable difference during fraud enforcement actions. If providers have Compliance Programs in place that are current and fully implemented, enforcers may be less aggressive in pursuing potential violations.

Corporate Integrity Agreement

When enforcers discover problems with fraud and abuse in organizations, providers are usually asked to develop and implement a Corporate Integrity Agreement (CIA). This type of agreement is likely to include processes for stringent monitoring on a continuous basis. These monitoring activities can be extremely burdensome to providers in terms of both time and money. Providers with valid Compliance Programs are not necessarily asked to develop and implement CIA’s.

Final Thoughts

Now is the time for all providers, including private duty/home care companies, to recognize and act upon the need to establish and maintain Compliance Programs. “Working on it” is no longer good enough.

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Elizabeth E. Hogue, Esq The Rowan Report

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

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

Medicaid Reform

by Kristin Rowan | Apr 17, 2026 | Home Health, Medicaid, Regulatory, Waste Fraud and Abuse

by Kristin Rowan, Editor

Medicaid Reform

New Efforts to Stop Fraud Before it Happens

As auditors continue to investigate fraudulent activity, new initiatives through Medicare reform aim to stop fraud before it happens. The new initiative, the Combating Deceptive Practices in Assistance Programs Act adds oversight to the Medicaid program.

Preserve Medicaid through Reform

Chairman of the Joint Economic Committee and Chairman of the House Ways and Means Oversight Subcommittee, Rep. David Schweikert, announced the legislation that would tighten eligibility requirements for home health services through Medicaid. The bill requires Medicaid recipients to prove they are unable to perform three or more ADL’s without assistance.

If we seriously want to preserve Medicaid, and provide for the people most in need, we must crack down on fraud. Reaching people that need these services the most should be the top priority of these programs, not growing one of the largest jobs corps in the state. With the U.S. adding almost $87,000 per second to our national debt, making commonsense reforms can save tens of billions of dollars while protecting the truly vulnerable.”

Rep. David Schweikert

Chairman, Joint Economic Committee and House Ways and Means Oversight Subcommittee

Medicaid Waiver Programs

According to the statement from the Joint Economic Committee, the federal waiver programs that allow states to provide at home care for Medicaid beneficiaries are lacking guardrails and oversight. The state policies are “egregious” and lead to waste, fraud, and abuse.

For example, the New York State Medicaid program includes the Consumer Directed Personal Assistance Program (CDPAP) which allows beneficiaries to choose their caregiver. This broad eligibility program allows enrollees to choose friends or family members with no caregiving experience. New York’s Medicaid spending jumped from $2.5 billion in 2019 to more than $9 billion in 2023 with estimates of $12 billion in 2025.

More Information

Read H. R. 7713

Read the accompanying brief from the Joint Economic Committee: From Care to Cash: Correting Misaligned Incentives in Home Health

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

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

Idaho Approves $22M Cut

by Kristin Rowan | Apr 17, 2026 | Advocacy, Medicaid, Partner News

by Kristin Rowan, Editor

Idaho Approves $22M Cut

Provider Reimbursement Rates Slashed

Idaho Governor Brad Little approved House Bill 863 in late March after the bill passed the House and Senate. Little directed the state to balance the budget and sent a recommended list of cuts. Among the recommendations was provider reimbursement rates for residential habilitation services, where lawmakers chose to cut nearly $22 million.

Cut Reverses Raises

The State approved pay raises for providers in 2022. This bill reduces those raises for next fiscal year. Combined with previous Medicaid rate cuts, this amounts to a 10% rate reduction for habilitation providers. Lawmakers say this rate is still 33% higher than four years ago.

An Impossible Decision

Lawmakers say balancing the budget required impossible decisions. For Medicaid, the decision was between cutting the Medicaid expansion, and cutting services for people with disabilities. As evidence of the difficulty of the decision, the proposal was delayed twice and was replaced once with a proposal to repeal Medicaid expansion.

Tighten Your Belt

Co-sponsor of the bill, Senator Julie VanOrden, said to follow the money. “The money [goes] from the state to the provider to the caregiver. Somewhere along there, maybe somebody needs to tighten the belt somewhere…. That might mean, as a provider, I don’t take as much money, but I still pay the people that are doing the work the amount that they need.”

HHAeXchange Responds

The Rowan Report reached out to HHAeXchange president Stephen Vaccaro for a comment.

“Idaho’s recent Medicaid disability-services cuts and Colorado’s proposed reductions point to a broader pattern. When states look for Medicaid savings, home and community-based services (HCBS) are often among the first areas affected. But for people who rely on care at home, these supports are essential. They make it possible for individuals to remain safely in the community, rather than shifting into disruptive, higher-acuity settings.

While cutting HCBS may lower spending in one line item, states can end up shifting costs to more intensive settings, like emergency departments and long-term care facilities. To build a more sustainable Medicaid program, states must look beyond immediate savings and consider the longer-term impact of weakening access to services that help prevent more costly outcomes.

States must continue to address fraud, waste, and abuse to protect the long-term health of Medicaid. However, jeopardizing the critical services that people rely on is not the answer. Oversight and accountability should go hand in hand with preserving access to care at home.”

Stephen Vaccaro

President, HHAeXchange

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California Hospice Fraud

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

by Kristin Rowan, Editor

California Hospice Fraud

Update 04-16-2026

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

Multiple Arrests and Charges

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

Intent to Defraud

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

Location Search

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

The 71 Million Dollar Doctor

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

Task Force Suspends Providers

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

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Accountability and Sustainability in Medicare Advantage

by Kristin Rowan | Apr 10, 2026 | CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Accountability and Sustainability

CMS Finalizes 2027 Medicare Advantage and Part D Changes

As part of its ongoing efforts to reduce unneccessary payments, CMS issued the 2027 Medicare Advantage (MA) and Part D announcement to “improve payment accuracy” in both programs. The changes aim to make MA sustainable, allow beneficiaries to choose the best health coverage for their needs with maximum value, and make Medicare coverage more affordable.

“CMS’ vision for Medicare Advantage and Part D is clear: a great choice for seniors and a smart deal for taxpayers. The Rate Announcement improves payment accuracy and strengthens competition based on quality—not on coding practices—helping put the program on a more sustainable path for the long term.”

Chris Klomp

Director of Medicare and Chief Counselor, U.S. Department of Health and Human Services

Rate Changes for MA Risk Adjustment Model

The Rate Announcement policy changes address coding differences between MA and traditional Medicare. MA is moving toward a risk adjustment system guided by:

Reducing administrative burdens for plans and providers
Equalizing competition for all MA plans regardless of size or resources
Achieving payments that accurately reflect health risk
Facilitating the efficient use of healthcare resources, enhanced program integrity, and greater accountability

CMS will continue using the 2024 risk adjustment model in pursuit of these changes. However, CMS will exclude diagnosis information from unlinked chart review records from risk score calculation. There is an exception from the exclusion for beneficiaries who switch MA providers. The exclusion does not apply to PACE organizations, which will continue to use a blend of the 2017 and 2024 risk adjustment models. CMS expects this change to lower payments to MA plans by more than $7 billion in 2027.

Part D Risk Adjustment Model

Deductible

Part D beneficiaries cover 100% of the costs of their prescriptions, except insulin and recommended vaccines, until the deductible is met. The 2027 deductible will increase from $615 to $700.

Out-of-pocket maximum

After sunsetting the coverage gap phase in 2025, beneficiaries no long have an initial coverage limit. The initial coverage phase lasts until the annual out-of-pocket (OOP) maximum is reached. CMS is also using the API indexing method to establish the annual OOP threshold. The annual OOP will increase from $2,100 to $2,400 in 2027.

Calculation method

CMS can use one of two methods to update the annual deductible amount. The annual percentage increase (API) measures the average plan expenses per beneficiary. The Consumer Price Index (CPI) measures the annual percentage increase of all items across the U.S.

The 2026 API is 9.37%. The 2026 CPI is 2.31% CMS chose to use the API indexing method to set the 2027 deductible.

Accountability and Sustainability API and CPI 2027 Medicare Advantage Part D

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Worthy is Worthy of Consideration

by Kristin Rowan | Apr 10, 2026 | Advocacy, HIPAA, Interoperability

by Kristin Rowan, Editor

Worthy is Worthy

Markovich Calls for Healthcare Overhaul

Worthy is an initiative aimed at nonpartisal healthcare policy reform. Introduced by Ascendiun CEO Paul Markovitch. Worthy calls upon industry players to back major reform in the healthcare system that addresses long-standing problems. According to Markovitch, a 30-year veteran in healthcare, the industry is dysfunctional and in need of a major overhaul.

“The healthcare system is bankrupting and failing us. It requires systemic reform. Those reforms are unlikely to come from the industry itself. Therefore, we need the federal government to step up and make those reforms happen. The status quo is unacceptable. We need bold, systemic reform urgently, so that is what Worthy is.”

Paul Markovich

CEO, Ascendiun

Worthy Outline

Worthy comes from the idea that our healthcare system ought to be “worthy of our family and friends,” Markovitch said. The overhaul program is built on strategic pillars:

Providing every consumer and patient with a comprehensive, real-time digital health record
Breaking the “do more, get paid more” fee-for-service model and instead start paying for health outcomes.
Make prescription drugs accessible and affordable by eliminating kickbacks in the form of rebates, fees and spread pricing.
Put the entire healthcare system on a budget

More than Strategy

Beyond the written initiative, Worthy provides an interactive framework for patients. The website houses podcasts, issue analysis, and videos complemented by social media posts, media commentary, and in-person forums to help consumers and patients understand the changes that need to happen and how to get there.

Additionally, it seems as though the Worthy plan is not merely speculation. The first phase of the plan focuses on prescription drug reform. The plan is already active inside Blue Shield of California. The insurer changed its pharmacy model, moving away from the pharmacy benefit management (PBM) structure. Instead, Blue Shield of California partners with Amazon Pharmacy, Mark Cuban Cost Plus Drug Company, and Prime Therapeutics, among others. That change became the foundation for the Worthy initiative.

Plan in practice

Blue Shield of California rolled out a Digital Health Record (DHR) program, also now part of the Worthy Initiative, that improves care coordination and transparency. The DHR program in California includes sharing all patient data across providers and with the patient, giving patients a complete and real-time health record. According to Markovitch, interoperability is a meaningless term that allows providers to congratulate themselves for sharing slightly more data than before. His goal is to have a national standard for comprehensive digital health records that eliminates the need for any provider or patient to request records.

Working Together

Worthy presumes that the strategic pillars work together. Total reform doesn’t happen without each piece. Markovitch advocates for the responsible use of artificial intelligence to automate what can be automated. This includes, according to Markovitch, prior authorization, billing, provider directory updates, claims settlements, and routine patient questions.

Shared decision-making

The clinical model that the plan implies is one of shared decision-making. It involves both patient and physician having complete health records together with AI and other technology to gather all available information about a health condition. From there, the patient, loved ones, and all treating physicians work together to form a care plan. Markovitch calls for stronger legislation to move toward this kind of comprehensive care plan.

Worthy Vision

Patients over Profits

“Worthy will be advocating for passing a series of laws and enacting regulations that will force all the players to put patients over profits, that is, to do the right thing on behalf of each patient, every time, in order to have a health care business and to earn an income.”

– Paul Markovitch, CEO Ascendiun

Final Thoughts

We don’t know if the Worthy Initiative will gain any ground at the federal level. Likewise, we don’t know if Worthy will make substantive changes to the broken healthcare system. What we do know is that Worthy is, at a minimum, worthy of consideration as a means to overhaul a system that hasn’t truly been effective for a long time. If you agree, here are some links to get more information:

Worthy Podcast

Healthcare Overview

Pharmacy Reform

Blue California Pharmacy Care Reimagined

This is Worthy

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WISeR Model Not so Wise

by Kristin Rowan | Apr 3, 2026 | Artificial Intelligence, CMS, Medicare, Medicare Advantage

by Kristin Rowan, Editor

WISeR Model

Dangerous and Troubling

WISeR model is not as wise as CMS had hoped. For many months, we have been reporting on the waste, fraud, and abuse initiatives from HHS and CMS. From stricter oversight to fewer new agencies to broad investigations, the crackdown on wasteful spending of the Medicare Trust Fund has increased steadily. One initiative, the Wasteful and Inappropriate Service Reduction (WISeR) model, launched in Arizona, Ohio, Oklahome, Texas, New Jersey, and Washington. As the name implies, the model aimed at reducing unnecessary services by using an AI powered prior authorization algorith.

Sounds like Medicare Advantage

The WISeR model includes a limited number of procedures that require prior authorization. Even before the model launched, some were concerned that the preauthorization requirement would delay or deny necessary care, much like the prior authorization requirements in Medicare Advantage plans. The Center for Medicare Advocacy testified in opposition to the WISeR model. The spokesperson for CMA, David Lipschutz, supported three bills discussed during that hearing, including one that would stop the WISeR model altogether and prohibit using or testing any payment models for prior authorization in traditional Medicare.

Foresight was 20/20

Three months before the WISeR model launched, CMS founder Judy Stein said the program would create barriers between physician orders and approved procedures. She cautioned:

“Adding prior authorization requirements to traditional Medicare will create costly problems and barriers to necessary care. Instead, to truly address waste and abuse in Medicare, CMS should look to the dramatic overpayments and unreasonable denials in Medicare Advantage.”

Judy Stein

Founder & Senior Advisor, Center for Medicare Advocacy

Early Reports

Physician struggles

Just three months into the WISeR model demonstration, early reports from providers and patients are discouraging. The Washington Post analysis of the model didn’t include a lot of positive feedback. Physicians report challenges with the approval process. Patients wait in pain until needed care is approved. Issues with the technology include problems with online portals as well as struggles with coordination and communication with tech firms and claims processors. Physicians also report denials for care that is within coverages guidelines and decisions that take longer than federal guidelines allow.

Unintended consequences

Part of the model intended to reduce unnecessary spending is a built-in incentive program for cost savings. The tech companies handling the AI algorithms are paid partly on the savings realized after denying medical services. This creates an inherent goal of adjusting the algorithm to deny more services, even if those services are necessary. The model supposedly balances this with pay adjustments for quality measures that include accuracy in decision-making. These tech companies are not staffed by medical professionals and it is unclear what they use as the basis for their decision-making algorithm.

Exemptions

Officials from Medicare say they intend to offer exemptions to physicians with a high authorization rate. These physicians would no longer be subject to the AI prior authorization if, over time, most of their submitted services are authorized. Taking this to its logical conclusion:

Physicians may dial back on recommended procedures until they get the exemption
Once exempt, physicians can circle back and get the procedures for their patients without prior approval
Tech companies may increase denials to ensure continued work
AI oversight of federal health spending could increase if the pilot program saves money, regardless of patient outcomes

Writing was on the Wall

Long before the WISeR model existed, AI algorithms for care authorizations had denied needed care. Insurance companies started using AI to process prior authorizations in 2020. Both UnitedHealth Group and Humana used nH Predict AI for care authorizations for Medicare Advantage. The family of an elderly couple sued UnitedHealth after their care was denied and the couple died. A class action suit against Humana claimed nH Predict AI Model predictions are highly inaccurate and are not based on patients’ medical needs. In February of 2024, CMS clarified the use of AI cautioning that “compliance is required with all of the rules at § 422.101(c) for making a determination of medical necessity, including that the MA organization base the decision on the individual patient’s circumstances.”

Unclear Future

After only a few months, officials have not indicated whether the WISeR model could expand into additional states or to cover additional procedures in the future. Beneficiaries say they stayed with the traditional Medicare plans specifically to avoid the prior authorization hurdles inherent in Medicare Advantage plans. CMS may have additional information by July, when the program has more data.

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Hospice CARE Act

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

by Kristin Rowan, Editor

Hospice CARE Act

Congress breathes new life into hospice protection

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

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

Program Integrity and Payment Reform

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

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

Linda T. Sanchez

Congresswoman, D-CA

Program Integrity

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

Specifically, the bill:

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

Payment Reform

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

Specifically, it:

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

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

Mark Warner

Senator, D-VA

Industry Support

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

American Academy of Hospice and Palliative Medicine

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

– Kristina Newport, CMO for AAHPM

Center for Medicare Advocacy

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

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

National Alliance for Care at Home

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

-Jennifer Sheets, CEO for The Alliance

LeadingAge

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

-Katie Smith Sloan, President and CEO for LeadingAge

National Partnership for Healthcare and Hospice Innovation

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

– Tom Koutsoumpas, Founder and CEO of NPHI

More Information

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

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

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

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

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

Fraud and Abuse Misunderstandings

by Elizabeth E. Hogue, Esq. | Apr 3, 2026 | Clinical, Legal, Regulatory, Waste Fraud and Abuse

by Elizabeth E. Hogue, Esq.

Medicare and Medicaid Fraud and Abuse

Common Misunderstandings

Providers are generally familiar with prohibitions against fraud and abuse in the Medicare and Medicaid Programs, including Medicaid waiver programs, and other state and federal health care programs, such as the VA and TriCare. Private insurers now often enforce the same prohibitions applicable to federal and state programs. But there are at least two common misconceptions about fraud and abuse.

Intent

Enforcers must prove intent in order to show that providers engaged in fraud, but providers may not understand what the government can use to show “intent.”

Premeditation

Many providers seem to think that the only way to show intent is to prove that they sat down at their desks on a Monday morning and decided to commit fraud, but court decisions tell a very different story! They say that if enforcers can prove that providers knew or should have known of a pattern of fraudulent conduct, enforcers may conclude that providers had intent. Other court decisions say that when providers show reckless disregard for a pattern of fraudulent conduct regulators can show intent necessary to prove fraud.

When providers grasp these crucial standards, it is clear that they must become vigilant to prevent patterns of fraud and abuse. This is necessary in order to prevent government enforcers from concluding that they had intent necessary to prove fraud and/or abuse.

Personal Responsibility

Many providers also may not understand that every provider, regardless of position, is personally responsible for fraud and abuse compliance.

It Rests on You

It is extremely tempting to think that fraud and abuse compliance is management’s responsibility, or the exclusive job of the Administrator/Chief Executive Officer or the organization’s Compliance Officer. On the contrary, the Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services, the primary enforcer of fraud and abuse prohibitions, is quite clear that every practitioner has personal, individual responsibility for fraud and abuse compliance.

The problem of fraud and abuse will never be solved until every practitioner takes individual responsibility for it. Enforcement action is often taken against individual practitioners, as well as members of management and owners.

Complete Compliance

When providers understand these two basic points, they are well along the road to active participation in fraud and abuse compliance efforts.

Final Thoughts

Providers must remember that fraud and abuse compliance is now a permanent part of the health care landscape across the nation. Compliance is not a fad that will blow over or disappear! Providers must be prepared to actively work to prevent or correct fraud and abuse for as long as they work in the healthcare industry.

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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.

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

©2026 by The Rowan Report, Peoria, AZ. All rights reserved.

The Home Care Show: A Review

by Kristin Rowan | Feb 26, 2026 | Editorial, Product Review

by Kristin Rowan, Editor

The Home Care Show

We attend a lot of events. As care at home professionals, nurses, agency owners, regulatory bodies, advocacy groups, and software solutions providers, we travel sometimes more than we are at home. As a general rule, these events comprise networking opportunities, vendor displays, educational panels, and activities. Most of the events are of good quality, well organized, and informative. After a while, they all seem to blend together and we can’t remember which event we attended last or who met at each one. Every now and again, something new comes along.

Local Event Goes National

The Home Care Show started as a regional event in New York, hosted by GlattHealth. After a few years of tri-state success, the group added The Home Care National in Miami in 2025. The Rowan Report became aware of the event through some trusted colleagues who are now on the board of the national event.

Education

After a morning networking block with several options to connect with attendees, The Home Care Show kicked off with an impressive “State of the Industry” panel. The panel included Denise Bellville, Executive Director of the Home Care Association of Florida, Damon Terzaghi, Vice President of Medicaid Advocacy & Programs for the National Alliance for Care at Home, and Eric Reinarman, Vice President of Government Relations for the Home Care Association of America.

Breakout sessions ranging from marketing to IT, led by some of the brightest minds in the industry, followed the state of the industry address. Additional panel topics included AI, payer diversification, navigating risk, optimizaing growth, and mergers & acquisitions.

Growing Pains

Any event that changes its structure, location, or size will have some growing pains. The hiccups at The Home Care Show were minor and easily overcome. There was some overlap in the schedule that disrupted the flow on Tuesday. Navigating the website on a mobile device was tricky. The registration booths were strategically placed in front of the vendor hall and panel room, seemingly to keep attendees out of those rooms before they opened. But drinks and snacks were also behind registration and not obviously available to attendees. The vendor area was heavily leaning to the insurance/financial investment/consultant/advisor variety with few exceptions. Seating in the vendor hall was limited, which made lunch on Wednesday tricky.

Nailed It!

Much of this two-day conference could be considered a home run. In fact, most of it was pretty fantastic.

The education was timely, relevant, professionally moderated, well-planned, and had a mix of representation from home care agencies, consultants, software solutions partners, and investors. One attendee said, “I learned more in that session that I did in three days at the last event.”

The networking events were varied enough to appeal to everyone. After registering, attendees had the option to play pickleball at the host hotel, enjoy the beautiful pool, or relax at the coffee shop. Tuesday evening, GlattHealth and other sponsors hosted a rooftop dinner with live music.

The vendor room kept all sponsors in the same size booth, requiring them to use their product and service to woo attendees rather than the cost of their setup. The layout allowed for movement through the hall, and lunch and cocktail hours were inside the hall, giving vendors more face-time with attendees.

Final Thoughts

As Care at Home events go, this one ranks near the top. The education is well-worth the trip. The opportunities to get concrete information from industry experts to launch your agency no matter the direction you’re taking makes this event stand apart. Whether you’re near Miami or have to travel, put The Home Care Show National on your calendar for 2027.

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

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

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

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