Medicare Prior Authorization

by | Sep 4, 2025 | CMS, Medicare, Regulatory

by Kristin Rowan, Editor

Medicare Prior Authorization

Wasteful and Inappropriate Service Reduction Model

The Centers for Medicare and Medicaid Services (CMS) is launching a pilot program in six states to combat what they deem to be unnecessary treatments. Dubbed the Wasteful and Inappropriate Service Reduction (WISeR) Model, the voluntary program will launch in New Jersey, Ohio, Oklahoma, Texas, Arizona, and Washington beginning January 1, 2026 and ending December 31, 2031. The program will use Artificial Intelligence (AI) and Machine Learning (ML) alongside human clinical review to “ensure timely and appropriate Medicare payment for select items and services.”

The Problem

According to CMS, health care waste harms patients and comprises 25% of healthcare spending. “Low-value” services provide little effectiveness, do not align with specific health conditions, and can lead to additional complications and more wasteful services.

Medicare Prior Authorization Solution

The new WISeR Model is designed to reduce unsupported care. Participating care providers will outsource authorization of a pre-selected list of services to reviewers using technology to “expedite and improve the review process.” These services are those that CMS designated as vulberable to fraud, waste, and abuse.

Reasoning

CMS suggests that the fee-for-service model used in traditional Medicare incentivizes unnecessary treatments, tests, and other care. According to CMS, these items provide little to no benefit for some patients. These include:

  • Skin and tissue substitutes
  • Electrical nerve stimulator implants for obstructive sleep apnea and incontinence
  • knee arthroscopy for knee osteoarthritis
  • Cervical fusion
  • Epidural steroid injections
  • Vertebral augmentation
  • Image-guided lumbar decompression
  • deep brain stimulation for Parkinson’s and essential tremor

Strategy and Outcomes

The WISeR Model is supposed to ensure patients get the most appropriate care for the best outcomes. It is also supposed to lower costs and administrative burden on providers. Patients are supposed to partner with their health care providers to decide on the most appropriate care plan. Eliminating “unnecessary” services and procedures is supposed to save taxpayer dollars and decrease fraud, waste, and abuse. Care providers are supposed to focus on providing care that has the most impact on the well-being of Medicare beneficiaries.

Editorial Comment

I am not a Medicare recipient, but I have many close friends and family who are. I am not a nurse or home health expert, but I am a patient and by my count, I have a PCP and 6 specialists that I see on a regular basis. However, I am now, or will be in the near future, in need of:

  • Electrical nerve stimulator
  • Cervical fusion
  • Steroid injections
  • Lumbar decompression

Personal Experiences

I am already at the mercy of my health insurance provider for pre-authorizations for everything that is not routine visits with my primary care provider. I know first-hand the hoops and red tape my provider(s) go through. Already this year, I have filed two requests to review denials, more than 10 rescheduled visits because my pre-authorization had not been received, and at least one interview that my PCP had to attend with an “expert” who had previously decided that my regularly scheduled follow-up cancer scan was unnecessary.

Predicted Results

Adding prior authorization approval requirements for care and treatment will delay beneficiaries from getting the care they need, prolong the pain they experience daily, and cost more in wasted time and money than it can possibly save in wasted procedures. I sincerely hope there are enough voluntary participants in this experiment to document the additional time, money, and resources required. I also hope these participants send regular surveys to their Medicare beneficiaries to ask whether they feel like getting pre-authorizations for routine procedures has made them feel like they are getting better care.

# # #

Kristin Rowan, Editor
Kristin Rowan, Editor

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

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

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

 

Overtime Changes

by | Sep 4, 2025 | Advocacy, Regulatory

by Kristin Rowan, Editor

Overtime Changes

FLSA exemption to resume

In 1938, the Fair Labor Standards Act (FLSA) established a federal minimum wage, guaranteed overtime, and kept children out of the workforce. Exemptions to FLSA include executive, administrative, professional, computer employee, and outside sales positions. Employers did not pay minimum wage for retail workers, service workers, agricultural workers, or construction workers.

Domestic workers included

An amendment to FLSA in 1974 added domestic workers to those who must receive minimum wage and overtime. The amendment did not include “companionship services” and live-in domestic service employees. A later amendment from 2013 narrowed the definition of “companionship services.” This eliminated the exemptions for workers who provided “care.” Companions could still be exempted from overtime. This stopped home care agencies from claiming exemptions and required overtime pay for home care workers.

Overtime Changes FLSA Exempt

Rolling back the rule

The Department of Labor is considering unraveling the 2013 amendment. There is a concern that they may have misinterpretated the rule. Additionally, requiring overtime for home care workers will increase the cost of care. Supporters of the rule change believe that allowing exemptions for overtime among home care workers would make live-in care more affordable. If the 2013 amendment is removed, employers would not have to guarantee minimum wage or overtime for home care aides.

Industry impact

The DOL argues that this change will make care more affordable and expand access to care at home. However, there is already a workforce shortage in the industry. Lowering pay rates and removing overtime could cause a mass exodus from the industry. As far as we know, DOL did not discuss requiring CMS to increase reimbursements rates or covering non-medical supportive care at home as an alternative.

“Removing basic labor protections from home care workers will only exacerbate the multiple issues buffeting the home care sector, its workers and consumers: serious threats from cuts to federal Medicaid contributions, changing immigration policies and the lack of realistic long-term services and supports (LTSS) options.”

Katie Smith Sloan

President and CEO, LeadingAge

Comments from the industry

The public comments period on this proposed rule change ended on September 2, 2025. The proposed rule received roughly 5,300 comments. Some examples of feedback include:

“…reversing the 2013 protections, the DOL would undermine the wages and economic security of home care workers…exacerbate turnover and workforce shortages…[and] harm older adults and people with disabilities….” – Hand in Hand: The Domestic Employers Network

“This proposed change is a crucial step toward restoring flexibility and affordability in home care services, particularly for families relying on live-in support.” – Owner, Home Helpers Home Care of Larimer County and member of HCAOA and IFA

“…strongly support workforce development and has historically and continues to support thoughtful solutions to our workforce crisis. We strongly support the restoration of the overtime exemption.” – The Virginia Association for Home Care and Hospice and the West Virginia Council for Home Care and Hospice

“Home care workers are also strongly vital for companion care, personal care, home health, nursing, therapy, caring for the disabled and the elderly, and more. The proposed rule that was meant to strip home care workers of wage and overtime protections is absolutely cruel and harmful for home care workers…” – Derek Dinh, CA

“I am not a home care worker, but used a home care worker to take care of my mom when she was unable to do things around the home and then got progressively worse. They need to be paid a living wage and receive overtime. They are professional people who take care of those who need care.” – Wendy Peale, NY

Opposition

  • Among the people and organizations who have publicly expressed opposition to this change are:
  • LeadingAge
  • Autistic Self Advocacy Network
  • American Civil Liberties Union
  • Congresswoman Pramila Jayapal
  • The Commonwealth of Pennsylvania, California, Colorado, Connecticut, District of Columbia, Hawaii, Illinois, Massachusetts, Maryland, Maine, Michigan, Minnesota, Nevada, New Jersey, New York, Oregon, Rhode Island, Vermont, and Washington

Final Rule

The has not issued a final rule. However, neither has the DOL enforced the requirement since July 25, 2025. Home care agencies can currently claim overtime exemptions. There is no set timeline yet for a final decision. We will continue to follow updates on this topic.

# # #

Kristin Rowan, Editor
Kristin Rowan, Editor

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

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

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

 

Imposter Clinicians

by | Aug 28, 2025 | Clinical, Legal

by Elizabeth E. Hogue, Esq.

Imposter Clinicians

Although it is relatively rare, there are individuals who impersonate clinicians! Imposters will inevitably slip through the cracks despite concerted efforts by providers.

The First Offense

For example, Thomasina Amponsah recently admitted to posing as a licensed registered nurse at more than forty facilities in Maryland. Beginning in about September 2019 through approximately August 2023 Amponsah used stolen nursing credentials and false educational and professional histories to secure employment at multiple facilities. She was employed primarily at rehab facilities and nursing homes. She earned at least $100,000 in wages with her false credentials.

Amponsah used a Maryland nursing license number issued to another individual, thus making this individual a victim of identity theft.  She then presented a copy of the victim’s license to potential employers.  Amponsah altered her name on applications to include the victim’s last name. She falsely claimed that she had been a supervisor and that she had a nursing degree from Florida State University.

Imposter Clinicians

Adding Injury to Insult

Amponsah also used a second stolen identify to obtain employment.  In July 2021 she submitted an online job application to a staffing agency.  She used a Florida nursing license that belonged to another victim. Amponsah provided a copy of this victim’s license to the staffing agency along with a fictitious resume. She then worked for at least twenty-one different skilled nursing facilities on behalf of the staffing agency.

Imposter Identity Uncovered

Although several employers learned her true identity and terminated her employment, Amponsah continued to gain employment as a nurse in other facilities. She faces a maximum sentence of five years in federal prison for false statements related to health care matters and a mandatory two-year sentence served consecutively to any other sentence for aggravated identify theft.

A Common Occurrence

Then there is the recent case of a Pennsylvania woman, Shannon Nicole Womack, who posed as a nurse in four different states.  She used various false names and paperwork while employed at twenty nursing homes and rehab facilities as a licensed practical nurse, registered nurse, and even nurse supervisor.  Womack was charged with endangering the welfare of care, unlawful use of a computer, identity theft, forgery, theft by unlawful taking, and several other crimes.

Inherent Risks of Imposter Clinicians

There are many implications for services provided by imposters. One is, of course, the possibility of injuries to patients.  Another is that providers may wonder if they are liable under the False Claims Act for services provided by unlicensed individuals. 

Southern Maryland Home Health Services, for example, hired Diane Cannon as a physical therapist (PT) who was unlicensed, even though she claimed to be a fully qualified PT. In order to gain employment, Cannon used the name of an actual licensed PT and provided false references from supposed former employers. In addition, the provider’s hiring agent who interviewed her said that Cannon was familiar with PT terminology and procedures. While Cannon was employed, the provider did not receive any complaints about her that would have put the provider on notice that she was an imposter.

Agency Liability

Consequently, the U.S. District Court for the District of Maryland concluded that providers are only liable for false claims for services provided by imposters if some degree of culpability is attributable to employers other than simply employing an imposter. In other words, providers will probably not have any liability for filing false claims for imposters’ services so long as providers comply with their internal policies and procedures and state and federal requirements, and nothing occurs that puts employers on notice that staff members are imposters.

Final Thoughts

It is quite scary to think about the provision of healthcare services by unlicensed personnel. The consequences could certainly be dire for both patients and providers. However, vigilance by providers usually, but not always, pays off.

# # #

Elizabeth E. Hogue, Esq.
Elizabeth E. Hogue, Esq.

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.

©2025 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.

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. 

Imposter Clinicians
 

Although it is relatively rare, there are individuals who impersonate clinicians! Imposters will inevitably slip through the cracks despite concerted efforts by providers.

 

For example, Thomasina Amponsah recently admitted to posing as a licensed registered nurse at more than forty facilities in Maryland. Beginning in about September 2019 through approximately August 2023 Amponsah used stolen nursing credentials and false educational and professional histories to secure employment at multiple facilities. She was employed primarily at rehab facilities and nursing homes. She earned at least $100,000 in wages with her false credentials.

 

Amponsah used a Maryland nursing license number issued to another individual, thus making this individual a victim of identity theft.  She then presented a copy of the victim’s license to potential employers.  Amponsah altered her name on applications to include the victim’s last name. She falsely claimed that she had been a supervisor and that she had a nursing degree from Florida State University.

 

Amponsah also used a second stolen identify to obtain employment.  In July 2021 she submitted an online job application to a staffing agency.  She used a Florida nursing license that belonged to another victim. Amponsah provided a copy of this victim’s license to the staffing agency along with a fictitious resume. She then worked for at least twenty-one different skilled nursing facilities on behalf of the staffing agency.

 

Although several employers learned her true identity and terminated her employment, Amponsah continued to gain employment as a nurse in other facilities. She faces a maximum sentence of five years in federal prison for false statements related to health care matters and a mandatory two-year sentence served consecutively to any other sentence for aggravated identify theft.

 

Then there is the recent case of a Pennsylvania woman, Shannon Nicole Womack, who posed as a nurse in four different states.  She used various false names and paperwork while employed at twenty nursing homes and rehab facilities as a licensed practical nurse, registered nurse, and even nurse supervisor.  Womack was charged with endangering the welfare of care, unlawful use of a computer, identity theft, forgery, theft by unlawful taking, and several other crimes.

 

There are many implications for services provided by imposters. One is, of course, the possibility of injuries to patients.  Another is that providers may wonder if they are liable under the False Claims Act for services provided by unlicensed individuals.

 

Southern Maryland Home Health Services, for example, hired Diane Cannon as a physical therapist (PT) who was unlicensed, even though she claimed to be a fully qualified PT. In order to gain employment, Cannon used the name of an actual licensed PT and provided false references from supposed former employers. In addition, the provider’s hiring agent who interviewed her said that Cannon was familiar with PT terminology and procedures. While Cannon was employed, the provider did not receive any complaints about her that would have put the provider on notice that she was an imposter.

 

Consequently, the U.S. District Court for the District of Maryland concluded that providers are only liable for false claims for services provided by imposters if some degree of culpability is attributable to employers other than simply employing an imposter. In other words, providers will probably not have any liability for filing false claims for imposters’ services so long as providers comply with their internal policies and procedures and state and federal requirements, and nothing occurs that puts employers on notice that staff members are imposters.

 

It is quite scary to think about the provision of healthcare services by unlicensed personnel. The consequences could certainly be dire for both patients and providers. However, vigilance by providers usually, but not always, pays off.

©2025 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.

OASIS-E2

by | Aug 28, 2025 | CMS, OASIS, Regulatory

OASIS-E2

by Kristin Rowan, Editor

OASIS-E2 Instruments and Change Table draft are available from The Centers for Medicare & Medicaid Services (CMS). They are available for download here. The draft proposes an off-cycle implementation date of April 1, 2026

Change Table

Changes include:
  • Transportation listing changed from A1250 to A1255
  • Hearing (B0200) and Vision (B1000) added to ROC
  • Sex (A0810) replaces Gender (M0069)
  • COVID vaccination up to date removed
  • Language (A1110) added to ROC
  • Minor changes to replace outdated item numbers with updated ones (ex: all instances of A1250 changed to A1255)
OASIS E2 Change Table

Change Timeline

The Changes are effective April 1, 2026. However, the changes are not final pending approval from the Office of Management and Budget (OMB). Agencies are able to use the draft form for training purposes, but should look for the final form that includes the OMB control number and expiration date.

Implications

OASIS accuracy is linked to PDGM payments and quality outcomes. Prepare early for the off-cycle April 1, 2026 changes to ensure a smooth transition to E2 requirements and continued reporting accuracy. 

Resources

Draft versions of the instruments are on the CMS website in a ZIP file. You can download the file here.

The PRA package, which includes four separate documents, is available for download here.

Submit comments to CMS about OASIS-E2 or any other item in the Home Health Prospective Payment System Rate Update for CY 2026 here and here.

Quality Improvement Project

by | Aug 28, 2025 | Admin, Clinical, Home Health, Hospice

by Kristin Rowan, Editor

Quality Improvement Project

Joint two-year effort publishes results

The Quality improvement project, a joint two-year research initiative between BerryDunn, Strategic Healthcare Partners, and National Alliance for Care at Home, aimed to improve the care experience for patients and improve CAHPS scores. The study implemented best practices targeted toward the CHAPS survey to see what really was working in improving patient and family satisfaction.

“Very little research has been done in the area of home health and hospice CAHPS, and this project is helping to close that gap. By identifying and validating true best practices, we’re giving agencies actionable tools to improve patient and family experience. At the heart of care is the relationship between providers, patients, and families—and improving that experience is essential to achieving meaningful outcomes.”

Lindsay Doak

Director of Healthcare Research and Education, BerryDunn

The Quality Improvement Project

The study included 27 hospice and 36 home health agencies. It ran from October of 2023 through June of 2024. Participating agencies underwent supervisory training and support, customer service and PCC training and support, and patient-centered mentorship certification. They also participated in bimonthly review calls for performance metrics and best practices.

Data comparisons

CAHPS data collected between June 1 and December 31, 2023 served as a baseline to compare with data collected using best practices. New CAHPS data collected between June 1 and December 31, 2024 showed outcomes of the project.

Quality Improvement Project Hospice Domains
Quality Improvement Project Home Health Domains

Best Practice Findings

  • Before funding new or additional initiatives, ensure internal readiness and operational stability to ensure successful implementation
    • Customer service training improved CAHPS outcomes in communication and willingness to recommend
    • Supervisory training improved roll-up scores for hospice and both specific care issues and willingness to recommend for home health
    • Mentorship boosted overall scores in hospice, but had little impact in home health
  • Home Health agencies may benefit from mandated interdisciplinary team meetings for mentorship, peer connection, and ongoing staff education
  • Turnover rates had mixed results
    • Intentional staff changes due to performance issues increased scores
    • General high turnover disrupted continuity and long-term success

Key Takeaways/Conclusions

Implementing patient-centered care (PCC) yielded strong improvement in some areas for some organizations, but overall the project produced varied results. The project was more successful among hospices than home health agencies. PCC training will need changes to achieve measurable impact. The best results came from agencies with the highest participation rates. Further improvement efforts need to be tailored to agency types, cultures, dynamics, and internal barriers.

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This report and the information contained therein is the property of BerryDunn. For more information, contact BerryDunn directly. Download the full report here.

Bayada CEO Succession Plan

by | Aug 21, 2025 | Partner News

Bayada CEO Succession Plan

FOR IMMEDIATE RELEASE

Contact:               Kristen Kirkpatrick
419-350-4963
394064@email4pr.com

David Baiada to transition out of the CEO role, join BAYADA Home Health Care Board of Directors

Board Succession Committee launches a thorough CEO search

Moorestown, N.J., August 19, 2025 – BAYADA Home Health Care (“BAYADA”), a nonprofit organization and one of the nation’s largest providers of home health, personal home care, private duty nursing, and hospice services, today announced the start of a leadership transition that will conclude with current Chief Executive Officer (CEO) David Baiada moving into a new role on the BAYADA Board of Directors (“Board”) upon the appointment of the company’s next CEO.

First CEO Outside the Family

The Board’s Succession Committee has initiated a comprehensive search for BAYADA’s next CEO—the first non-family member to lead the organization. As the search progresses, David will continue in his role as CEO and will serve as an advisor during the transition.  

David Baiada CEO Succession Plan Bayada

“Since joining the business more than 20 years ago, David has helped us grow in size and strength, while always putting The BAYADA Way® at the center of every decision. As we celebrate our 50th anniversary, this transition is about the next chapter—the thoughtful continuation of a promise to protect our mission, preserve our values, and pass on our legacy with care.” 

Mark Baiada

Founder and Chairman, Bayada

The announcement comes on the eight-year anniversary week of David’s appointment to CEO in 2017, which is also when BAYADA announced its transition to nonprofit status. 

In His Own Words

“Serving as CEO has been an incredible honor. Together, we’ve grown stronger, strengthened our values, and deepened our commitment to helping people live safely at home with comfort, independence, and dignity.”  

David Baiada

CEO , Bayada

Accomplishments

Under David’s leadership, BAYADA has more than doubled in size; restructured into specialized practices of care and invested in technology and clinical innovation. David also helped guide the organization through the global pandemic; expand its community-based services, and strengthen its nonprofit identity. Most importantly, David and his leadership teams have nurtured a culture deeply rooted in The BAYADA Way—the organization’s guiding values of compassion, excellence, and reliability. 

From the Board

“The Board is deeply grateful to David for his leadership and devotion to BAYADA’s mission,” said Teresa Carroll, Chair of the Board Succession Committee. “With David’s continued leadership during this transition, then as a Board member, and with our strong executive team in place, we are well positioned for continued success.” 

# # #

About Bayada Home Health Care

Celebrating 50 years of care that comes from the heart, BAYADA Home Health Care is the nation’s largest independent, nonprofit home health care provider with over 370 locations across the United States and in Germany, India, Ireland, New Zealand, and South Korea.

Since 1975, BAYADA has been earning the public trust by helping people stay safe at home and by caring for them with compassion, excellence, and reliability, the core values expressed in its statement of purpose,The BAYADA Way®.

BAYADA is proud to support clients of all ages and abilities with a full range of personalized nursing, rehabilitative, therapeutic, hospice, and personal care services. Always anticipating future trends, BAYADA is building a movement of stakeholders to transform home health care so millions can receive the essential services they need.

DOJ Settles with UnitedHealth and Amedisys

by | Aug 21, 2025 | Legal, M&A, Medicare, Medicare Advantage

by Kristin Rowan, Editor

DOJ Settles with UnitedHealth and Amedisys

Judge to Weigh In

DOJ settles with UnitedHealth and Amedisys after almost nine months of negotiations. The Department of Justice (DOJ) initially blocked the proposed merger between UnitedHealth and Amedisys, citing concerns over eliminating competition in home health and hospice services in some areas of the U.S. After the most recent settlement hearing, the merger seems to be back on track.

Public Comment Period and Judicial Review

Now that the DOJ hurdle has been passed, there is a public comment period. Following the public comment period, the U.S. District Court for the District of Maryland will enter final judgement. From the Justice Department website:

As required by the Tunney Act, the proposed settlement, along with a competitive impact statement, will be published in the Federal Register. Any interested person should submit written comments concerning the proposed settlement within 60 days following the publication to Jill Maguire, Acting Chief, Healthcare and Consumer Products Section, Antitrust Division, U.S. Department of Justice, 450 Fifth Street NW, Suite 4100, Washington, DC 20530. 

Antitrust Division Statement

“In no sector of our economy is competition more important to Americans’ well-being than healthcare. This settlement protects quality and price competition for hundreds of thousands of vulnerable patients and wage competition for thousands of nurses. I commend the Antitrust Division’s Staff for doggedly investigating and prosecuting this case on behalf of seniors, hospice patients, nurses, and their families.”

Abigail Slater

Assistant Attorney General, Justice Department Antitrust Division

Divestiture Agreement

According to the new agreement, UnitedHealth will sell 164 home health and hospice locations across 19 states. In addition to the sale, the agreement provides the buyers of these locations with assets, personnel, and relationships to help them compete with remaining UnitedHealth locations. Also included are protections to deter UnitedHealth from interfering with the new owners’ ability to compete.

BrightSpring Health Services and Pennant Group will acquire the 164 locations. Slater said the settlement, which includes the largest ever divestiture of outpatient healthcare, protects quality and price competition patients as well as wage competition for nurses. However, antitrust specialist Robin Crauthers, a partner with McCarter & English, says it doesn’t go far enough. According to Crauthers, the settlement agreement does not address all of the markets that would have less competition and that the DOJ accepted less than they wanted in the agreement.

Additionally, critics argue the divestiture moves 164 home health and hospice agencies from one large player to two other large players in the space. Arguably, rather than preserve competition, this divestiture agreement will only serve to strengthen the largest players in the market, giving them a substantial advantage over smaller agencies in these areas.

UnitedHealth Amedisys divestiture locations

Not the Only Concern

Vertical Integration

Joe Widmar, Director of M&A at West Monroe consulting firm, says that the number of home health and hospice agencies is not the tipping factor in competition. Rather, it is UnitedHealth’s vertical integration. A health insurance company that also owns nearly 2,700 subsidiaries, including pharmacies, home health and hospice, behavioral health, consulting for healthcare organizations, surgery centers, hospitals, mental health, managed care for Medicaid and Medicare, and specialty care. Virtually any referral from a PCP to any other health professional puts more money into the health care giant’s pockets. The lack of competition is across all forms of healthcare, leaving patients no choice buy to support UnitedHealth Group in areas where all local healthcare providers are subsidiaries. I 2024, UnitedHealth insurance paid $150.9 million to its subsidiaries for care. These provider companies are not counted in the profit caps placed on insurance companies.

Upcoding

In addition to side-stepping profit caps, vertical integration aids in upcoding. Upcoding is the practice of digging into a patient’s life to find (or create) additional patient needs. Insurers add as many codes as possible for the greatest reimbursement rates. According to a recent study, UnitedHealthcare overbilled Medicare Advantage by $14 billion through upcoding. 

In-home health risk assessments and patient reviews, often offered to beneficiaries as a free service, result in an average risk score 7% higher than in patients seen in medical practices and hospitals. UnitedHealth generates more income from patient review diagnoses than any other MA insurer. The Department of Justice is currently investigating UnitedHealth’s Medicare billing practices.

Final Thoughts

If you own a home health, hospice, or palliative care agency in any of the states shown in the graphic above, write to Jill Maguire with comments and concerns. Our primary objective is providing quality care to patients in their homes. We know that home care is less expensive for the patient and government-funded insurance. But not when all the home care agencies in an area are owned by only a few of the largest home health agencies in the country. And not when the insurer is adding diagnostic codes to pad their bill. 

# # #

Kristin Rowan, Editor
Kristin Rowan, Editor

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

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

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

 

HIS to HOPE Help

by | Aug 21, 2025 | Admin, Clinical, CMS, Hospice

by Curantis Solutions

HIS to HOPE Help

HOPE visit types

The HOPE (Hospice Outcomes & Patient Evaluation) model introduces a new rhythm to hospice documentation, one that centers on the patient’s evolving experience of care. To meet HOPE’s standards with confidence, it’s critical to understand the different visit types and their timing.

Let’s break down the three visit types defined by HOPE: INV, HUV, and Symptom Follow-Ups, so your team knows exactly what’s required, when, and why it matters.

HIS to HOPE Help Curantis Solutions

INV

Initial Nursing Visit

What it is: The first clinical touchpoint in the HOPE timeline. The INV marks the beginning of structured data collection and sets the baseline for all subsequent updates.

When it’s due: As soon as possible after admission, ideally within the first day.

What it captures:

  • Key demographic and clinical data
  • Initial symptom impact ratings
  • Observations that may trigger a future follow-up

HUV

HOPE Update Visits

HOPE requires two follow-up check-ins to capture how the patient’s condition is changing over time. These are called HOPE Update Visits—HUV1 and HUV2.

HUV1

When it’s due: Days 6–15 after admission
Purpose: Reassess symptoms and update the patient’s status.

HUV2

When it’s due: Days 16–30 after admission
Purpose: Continue tracking trends and changes, especially as patients stabilize or begin to decline.

Pro tip: Even if the visit wasn’t originally intended as a HOPE Update Visit, clinicians can update their response at visit close ensuring the right file is created.

Symptom Follow-Up Visits

What they are:
Special visits required when certain symptoms (e.g., pain, shortness of breath, anxiety) are rated as having a moderate or severe impact on the patient’s well-being.

When they’re due:
Time-sensitive, must occur within days of the symptom being flagged.

Why they matter:
These follow-ups are the heart of HOPE’s patient-centered approach. They ensure that care plans are adapted quickly and that patients don’t suffer in silence.

Symptom follow-ups should be:

  • Automatically evaluated after each visit
  • Clearly flagged with alerts across the system
  • Auto-documented into the HOPE record upon completion and QA

HOPE Hub

To support you every step of the way, Curantis Solutions has created the HOPE Hub—a dedicated resource center designed to guide your team through a seamless transition to HOPE-based documentation. For more HOPE Resources, visit here.

# # #

About Curantis Solutions

Curantis Solutions

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Medicaid Enrollees Sent to ICE

by | Aug 21, 2025 | Legal, Medicaid, Regulatory

by Kristin Rowan, Editor

UPDATE

The Rowan Report originally published this article on August 7, 2025. This update is as of August 15, 2025.

After HHS began providing access to personal data on Mediciad enrollees to the Department of Homeland Security (DHS), 20 states filed to sue the department for violating privacy laws. Shortly thereafter, CMS entered into a new agreement to give DHS daily access to view the same data.

Federal Judge Vince Chhabria of California ordered HHS to stop giving DHS access to personal information. The ruling grants a preliminary injunction, stopping HHS from sharing Medicaid data with ICE in the 20 states that participated in the lawsuit. The injunction will last until 14 days after the two agencies complete and submit a reason for the decision to share information. The reasoning must comply with the Administrative Procedure Act. The injunction can also end if litigation is concluded (a formal hearing and decision).

Chhabria noted that there is no formal law preventing government agencies from sharing information, he cited agency policy as his reasoning for the injunction. ICE has a well-publicized policy against using Medicaid data for immigration enforcement. Judge Chhabria wrote in his ruling:

“Given these policies, and given that the various players in the Medicaid system have relied on them, it was incumbent upon the agencies to carry out a reasoned decisionmaking process before changing them. The record in this case strongly suggests that no such process occurred.”

August 7, 2025

Associated Press Confirms

Enrollee Information Given to ICE

In a surprise announcement on July 17, 2025, investigative reporter Kimberly Kindy and reporter Amanda Seitz filed a report. They uncovered information confirming Medicaid enrollee information given to ICE from CMS. ICE will use this to find “aliens” across the country. The health and personal information disclosed includes home addresses, birth dates, Social Security numbers, and ethnicities.

Department of Homeland Security Responds

DHS Assistant Secretary Tricia McLauglin said, “…CMS and DHS are exploring an intitiative to ensure that illegal aliens are not receiving Medicaid benefits….”

DHS Spokesperson Andrew Nixon said, “With respect to the recent data sharing between CMS and DHS, HHS acted entirely within its legal authority—and in full compliance with all applicable laws….”

Opposing Viewpoints

Senator Adam Schiff (D-CA) said, “The massive transfer of the personal data of millions of Medicaid recipients should alarm every American. This massive violation of our privacy laws must be halted immediately. It will harm families across the nation and only cause more citizens to forego lifesaving access to health care.”

Similarly, CA Governor Gavin Newsom said, “This potential data transfer brought to our attention by the AP is extremely concerning, and if true, potentially unlawful….”

HHS and DHS Sued

State Attorneys General from 20 states, led by California Attorney General Rob Bonta have filed suit. They are suing the Department of Health and Human Services (HHS), the Department of Homeland Security (DHS), HHS Secretary Robert F. Kennedy Jr., and DHS Secretary Kristi Noem.

The Associated Press found a Medicaid internal memo and emails. Subsequently, the AP reported that Medicaid officials tried to stop the data transfer due to legal and ethical concerns. The objection was unsuccessful. CMS had 54 minutes to comply with an order coming from two advisors within Secretary Kennedy Jr’s camp.

Disclosure Focuses on Violation of Laws

Current laws provide that states can create their own health plans, eligibility standards, and coverage, as long as the plan follows federal criteria. Medicaid laws also provide for emergency coverage for non-citizens. Seven states and D.C. started programs that offer full Medicaid coverage to non-citizens.

Four of the seven states, New York, Oregon, Minnesota, and Colorado, never submitted identifiable information about Medicaid recipients to CMS. The data shared with ICE came from the remaining three states; California, Illinois, & Washington State; and Washington D.C.

Map of U.S. States Compromised by CMS and DHS

The Allegation

The lawsuit was filed in the U.S. District Court for the Northern District of California. It alleges that the federal government is allowing the personal data of Medicaid recipients to be used for purposes unrelated to the Medicaid program.

Further, the coalition of states alleges that the disclosures violate several federal data privacy laws. These  include Health Insurance Portability and Accountability Act (HIPAA), Federal Information Security Modernization Act (FISMA), and the Privacy Act. 

Additionally, the Attorneys General state that the disclosures are contrary to the Social Security Act and a violation of the Spending Clause.

The lawsuit calls upon the court to bar CMS from sending additional PII to DHS and to bar DHS from using any of the information it has already received.

“In the seven decades since Congress enacted the Medicaid Act to provide medical assistance to vulnerable populations, federal law, policy, and practice has been clear: the personal healthcare data collected about beneficiaries of the program is confidential, to be shared only in certain narrow circumstances that benefit public health and the integrity of the Medicaid program itself.”

Attorneys General

Coalition of States

Final Thoughts

This lawsuit is the latest of many against the current administration. The Rowan Report will continue to update this and other stories impacting care at home as the lawsuits continue.

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Kristin Rowan, Editor
Kristin Rowan, Editor

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

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

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

 

Research Institute Joins Alliance

by | Aug 21, 2025 | Advocacy, Home Health, Hospice, M&A, Partner News

FOR IMMEDIATE RELEASE
August 20, 2025

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

Research Institute for Home Care and National Alliance for Care at Home Ink Affiliation Agreement

Alexandria, VA and Washington, DC, August 20, 2025 – The Research Institute for Home Care (the Institute) and the National Alliance for Care at Home (the Alliance) have entered into an affiliation agreement to strengthen and expand research efforts while further unifying the care at home movement. The agreement is effective immediately. 

Research Institute for Home Care

Since its founding in 2008, originally as the Alliance for Home Health Quality & Innovation, the Institute has invested in research and education about home care and hospice and its ability to deliver quality, cost-effective, patient-centered care, demonstrating the value proposition for patients and the entire U.S. healthcare system. With this affiliation, the Institute will remain an independent research organization, continuing to pursue its mission of funding and promoting research to inform policy and identify best practices and care models that expand access to healthcare in the home. Its vision remains clear: promoting healthy patients and communities through home care research, education, quality, and innovation. 

Research Institute for Home Care

The Institute’s Board of Directors will continue to independently oversee its research agenda and initiatives. The Alliance will provide comprehensive management support for the Institute’s operations. At the launch of the affiliation, Dr. Steve Landers, CEO of the Alliance, will also serve as the President of the Institute. Jennifer Schiller, the former Executive Director of the Institute, has joined the Alliance leadership team and will continue to support Institute initiatives along with other Alliance leaders. Jennifer Sheets, Founder and CEO of Carezzi, will remain the Board Chairman of the Institute.   

The enhanced collaboration and amplification opportunities provided by this affiliation elevate and unify the care at home movement. Together, the strengthened Alliance and Institute leadership will continue to invest in and focus on critical home care and hospice industry research and data to inform effective policy, clinical practice, and underscore the value of home-based care. 

In Their Own Words

“We are thrilled to announce our affiliation with the Research Institute for Home Care. The Institute’s more than decade-long commitment to rigorous research perfectly complements our mission. This affiliation strengthens our ability to further demonstrate that care at home is the preferred choice for patients and families and the highest-value option for our healthcare system.” 

Dr. Steve Landers

CEO, National Alliance for Care at Home

“This is an important milestone for the Institute that will amplify our research impact while preserving our integrity and academic rigor. By joining forces with the Alliance, we ensure that evidence-based findings continue to inform policy and best practices that benefit patients, families, and the entire healthcare system.”

Jennifer Sheets

Chairman of the Board, Research Institute for Home Care

Director Agreement

The decision, reached by both organizations’ independent Boards of Directors, reflects the shared recognition that care at home is at a pivotal juncture. By combining the Alliance’s resources with the Institute’s research expertise, the partnership positions both organizations to influence policy, strengthen clinical practice, and advance innovation in care at home.  

“The timing of this affiliation reflects a shared recognition that care at home stands at a critical juncture. By bringing together the Alliance’s resources with the Institute’s research expertise, we are better positioned to navigate today’s complex healthcare landscape and drive meaningful policy change. This partnership represents a strategic investment in the future of home-based care that will benefit providers, patients, and policymakers alike,” said Ken Albert, Board Chair for the Alliance. 

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About the National Alliance for Care at Home

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

About the Research Institute for Home Care

The Research Institute for Home Care (the Institute) is a non-profit, national consortium of home care providers and organizations. The Institute invests in research and education about home care and its ability to deliver quality, cost-effect, patient-centered care across the care continuum. The Institute is committed to conducting and sponsoring research and initiatives that demonstrate and enhance the value proposition that home care has to offer patients and the entire U.S. healthcare system.