AI Adoption Risk in Home Health and Hospice

by Rowan Report | Dec 18, 2025 | Artificial Intelligence, Legal

by Bill Dombi and Jason Bring, Arnall Golden Gregory LLP

AI Adoption in Home Health and Hospice

Accelerating Regulatory Risk

Law firm Arnall Golden Gregory LLP, Bill A. Dombi, Senior Counsel and Jason E. Bring, Partner, recently published an article on navigating the AI frontier. The article proposes legal guardrails for Home Health and Hospice providers. As AI adoption becomes more prevalent, so too does the risk of regulatory errors in nondiscrimination, HIPAA, and CMS reimbursement, among others.

by Bill Dombi and Jason Bring – Arnall Golden Gregory, LLP

Key Takeaways

AI adoption in home health and hospice...

Is accelerating regulatory risk with Section 1557 nondiscrimination rules, HIPAA obligations, and CMS reimbursement scrutiny creating new exposure around bias, PHI handling, ambient listening, AI-generated documentation, and improper reliance on predictive models

Common AI failure points

Unauthorized tools, biased algorithms, ambient-recording missteps, hallucinated documentation, and eligibility-prediction “coding bias,” now trigger audits, denials, False Claims Act exposure, breach allegations, and malpractice risk, especially where human oversight is weak or documentation is inconsistent.

Providers must strengthen AI governance and transparency

Including enterprise-grade vendor controls, business associate agreements, patient disclosure and consent protocols, model-bias testing, workforce training, documentation review, and a comprehensive AI Acceptable Use Policy backed by ongoing monitoring and interdisciplinary oversight.

Read the full article here

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AGG Healthcare and Post-Acute & Long-Term Care attorneys, Jason Bring and Bill Dombi, advise home health agencies, hospices, and technology vendors nationwide on AI governance, compliance, and reimbursement strategy. For questions about these issues or in general, please contact Jason and Bill.

Fraud and Abuse Compliance

by Elizabeth E. Hogue, Esq. | Dec 18, 2025 | Admin, Home Health, Hospice, Legal, Waste Fraud and Abuse

by Elizabeth E. Hogue, Esq.

Fraud and Abuse Compliance

Why All Providers Should Have One

Providers may have heard or read about the importance of Fraud and Abuse Compliance Programs in their organizations. Despite the wealth of available information about Compliance Programs, many providers continue to express uncertainty about their value.

Coincidentally, as we are preparing to publish this article, HHS publishes this report on the compliance audit of Guardian Home Care, LLC.

Here are some of the questions providers often ask about Compliance Programs:

Why should we have a Fraud and Abuse Compliance Program?

First

The Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) has clearly stated that all providers are now required to have current Compliance Programs that are fully implemented.

As a practical matter, when providers establish and maintain Compliance Programs, it clearly discourages regulators from pursuing allegations of fraud and abuse violations. Jody Hunt, formerly of the DOJ, says providers should create robust fraud and abuse compliance programs. Then providers can argue that they shouldn’t be liable for violations because their compliance programs demonstrate that they had no intent to commit fraud.

Technically speaking, the Federal Sentencing Guidelines make it clear that establishment and implementation of Compliance Programs is considered to be a mitigating factor. That is, if accusations of criminal conduct are made, the consequences may be substantially less severe as a result of a fully implemented Compliance Program.

Additionally

Providers with Compliance Programs are more likely to avoid fraud and abuse. This is because Programs routinely establish an obligation on the part of every employee to report possible instances of fraud and abuse and include training for all employees.

Compliance Programs may also help to prevent qui tam or so-called “whistleblower” lawsuits by private individuals, rather than by government enforcers, who believe that they have identified instances of fraud and abuse. There are significant incentives to bring these legal actions since “whistleblowers” receive a share of monies recovered as a result of their efforts. Some “whistleblowers” have received millions of dollars. Compliance Programs make it clear that employees have an obligation to bring any potential fraud and abuse issues to the attention of their employers first.

Also…

The federal Affordable Care Act (ACA) requires providers to have Compliance Programs. In short, it’s the law!

Finally

The Deficit Reduction Act (DRA) requires providers who receive more than $5 million in monies from state Medicaid Programs per year to implement policies and procedures, provide education to employees and put information in their employee handbooks about fraud and abuse compliance. These requirements can be met through implementation of Fraud and Abuse Compliance Programs.

We don't receive reimbursement from the Medicare or Medicaid Programs.

Do we still need a Compliance Program?

Statutes and regulations governing fraud and abuse also apply to providers who receive payments from any federal and state healthcare programs, including Medicaid, Medicaid waiver and other federal and state health care programs, such as Tri-Care. Many private insurers have followed the federal government’s “lead” in terms of fraud and abuse enforcement. So private duty providers must have compliance programs, too.

Should we just use the model guidance that is applicable to us?

We hear that the OIG has provided guidance for various segments of the healthcare industry regarding Compliance Programs. Specifically, the OIG has already published guidance for clinical laboratories, hospitals, home health agencies, skilled nursing facilities (SMFs), hospices, physicians’ practices, third-party billing companies and home medical equipment companies. The OIG will publish updated guidance for all providers, It has already done so for SNFs.

The answer is “No!” Guidance from the OIG is not a model Compliance Program. Guidance from the OIG consists of general guidelines and does not constitute a valid Compliance Program. In addition, the OIG has made it clear that Programs must be customized for each organization.

Do we have to conduct internal audits first?

We have read that, before implementing Compliance Programs, providers must conduct expensive internal audits that can take many months to complete. Is this true?

While beginning the compliance process with an extensive internal audit is certainly one way to proceed, it is not the only viable way to work toward compliance. It is equally valid to begin with Compliance Programs that are customized for the organization that includes training for all employees about fraud and abuse and Compliance Programs. Then all staff members can subsequently participate in internal compliance activities, including audits, with a process in place to handle any issues that arise as a result of the audits.

We already have policies. Why do we need a Compliance Program too?

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 under the Federal Sentencing Guidelines described in the first question above if there is no formal document called a Compliance Program.

We're accredited. Doesn't that mean we are in compliance?

On the contrary, 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. In other words, organizations may be accredited but fail to meet applicable compliance standards for fraud and abuse.

Will it help with investigations?

Will the fact that our organization has a Compliance Program make any difference with regard to the outcome of fraud and abuse investigations and the imposition of Corporate Integrity Agreements (CIA’s)?

Yes, it may make a considerable difference based on statements from the OIG. If providers have Compliance Programs in place that are current and fully implemented, the OIG may be less aggressive in pursuing potential violations. When the OIG actually discovers problems with fraud and abuse in organizations, providers are usually asked to develop and implement a Corporate Integrity Agreement (CIA). The OIG often requires CIA’s to include a process for stringent monitoring by the OIG 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 to recognize and act upon the need to establish and maintain Compliance Programs. “Working on it” is no longer good enough.

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

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

What can Providers Give to Patients, Part 7

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

by Elizabeth E. Hogue, Esq.

What Providers can Give to Patients

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

Read Parts 1-6

OIG Advisory Opinion

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

A Case Example

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

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

OIG Analysis

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

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

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

Is It Promotional?

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

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

Crafted with Care

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

Final Thoughts

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

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

Subsidies Undecided

by Kristin Rowan | Dec 12, 2025 | Medicaid, Medicare, Regulatory

by Kristin Rowan, Editor

Subsidies Undecided

Senate cannot agree

The record-breaking government shutdown centered around one issue: extending the COVID-era Affordable Care Act supplemental subsidies. The subsidies were an additional discount for Americans within a certain income bracket. They helped make healthcare insurance through the ACA marketplace more affordable during and after COVID. The subsidies have been extended multiple times and expire at the end of the year. Senate Republicans are not willing to extend them again. Senate Democrats won’t vote in favor of any health care proposal that doesn’t include them.

Time is Running Out

Not only do the subsidies expire at the end of the year, but anyone enrolling in a marketplace plan has to apply by December 15th, leaving precious few days to find a way forward. Senate Democrats proposed a straight three-year extension of the subsidies, which failed. Senate Republicans proposed using the subsidy money to contribute to HSAs for bronze or “catastrophic” plans. That proposal also failed.

A hybrid compromise is in the works. Details have not been released but it will likely include income caps and eligibility restrictions on the subsidies as well as some HSA flexibility. Without an extension on the subsidies, premiums are expected to increase an average of 26% in 2026, although some analyses suggest premiums could go up by 73-90%.

Another Shutdown?

The 43-day shutdown that ended in November did not finalize the 2026 budget. It merely passed enough appropriations to temporarily fund some departments through January 30, 2026 and a few essential departments for longer. If the Senate and House cannot agree on the subsidy issue, we face another shutdown in February. Every shutdown impacts Medicare & Medicaid payments, approvals, and renewals.

Experts indicate nearly 50% of people buying marketplace plans are ages 50-64. Most, if not all of them, are looking at lower cost (and lower benefit) plans or dropping insurance altogether in 2026. If insurance costs remain high, this group of

people will enter Medicare with poorer health, which will cost the Medicare program and tax payers more in the long run. It will cause a vicious circle of higher Medicare costs, leading to higher taxes, lower subsidies, higher premiums, fewer people being covered, and finally higher Medicare costs again.

This is an ongoing story and The Rowan Report will continue to bring you the latest news on the subsidies and the impending expiration of the temporary government funding as we head into 2026.

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

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

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

CMS Proposed Changes

by Kristin Rowan | Dec 12, 2025 | Advocacy, CMS, Medicaid, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

CMS is Making Changes

Good or Bad?

CMS is making changes across Medicare and Medicare Advantage. From Star Ratings to Prescription Drug Prices to the Hospice benefit, CMS is embracing Make America Healthy Again. Will these initiatives benefit Medicare and Medicare Advantage recipients or the insurance companies who provide the plans?

Drug Payment Model

In early November, CMS announced a plan to lower prescription drug costs for Medicaid recipients. State Medicaid programs can opt in to the GENErating cost Reductions fOr U.S. Medicaid Model (GENEROUS). The pilot program is using the most-favored-nation pricing that was recently negotiated and announced by President Trump. Most-favored-nation pricing requires prescription drug manufacturers to charge the same low rate paid in other countries.

Limited Pilot

Beginning in 2026, CMS will negotiate with manufacturers of select drugs for lower pricing. Participating states will start using uniform, transparent coverage criteria. This is not criteria for inital coverage in Medicaid, but for standardizing access to high-cost medications.

Manufacturers are not required to participate in the GENEROUS Model, but can voluntarily apply. Participating manufacturers agree NOT to seek additional supplemental rebates or discounts outside the model price.

New Medicare Advantage Policies

CMS has proposed updates to the Medicare Advantage and Medicare Part D programs. The new plan would begin in CY 2027 and includes major changes to the Star Ratings system. CMS is also seeking feedback on new ways to modernize MA.

Star Rating Changes

The proposed changes are supposed to incentivize plans to improve care. CMS suggests removing 12 unique measures that look at administrative processes and those that don’t highlight differences between plans. Star Rating measurements of care, outcomes, and patient experience will remain.

Request for Feedback

CMS is seeking feedback on Medicare Advantage changes, including improving competition, refining risk adjustment, and aligning quality incentives to deliver greater value. CMS is open to either a limited model test or program-wide changes. Interested parties can submit feedback through January 26, 2026. Read the Proposed Rule here. Submit your comments.

Expanding Technology-Enabled Care

CMS may finally be recognizing what we’ve been promoting for 25 years: Care improves with technology support.

CMS Proposed Changes<br />
Technology-based Care

The ACCESS model tests a new payment approach in original Medicare to expand access to technology-supported care options. CMS aims to increase technology-supported care options to improve health and prevent and manage chronic diseases. More than two-thirds of Medicare beneficiaries are dealing with high blood pressure, diabetes, chronic musculoskeletal pain, and depression.

An interest form is now available for the 10-year Advancing Chronic Care with Effective, Scalable Solutions (ACCESS) Model test. The model test begins July 1, 2026. The application to participate must be received by April 1, 2026.

Impact

As these programs roll out between now and 2029, the impact on insurance plans, payors, beneficiaries, and taxpayers will unfold. Will lower cost prescriptions and technology-based care lower insurance rates? Payor reform may be necessary to change out-of-pocket costs. Regulations may have to further incentivize payors to increase care when costs go down, particularly with value-based care models.

Please take a few minutes to read the details on each of these proposals, add your comments, and sign up to participate. The industry needs reform and our aging family members deserve better.

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MedPAC Proposes Drastic Cut

by Kristin Rowan | Dec 12, 2025 | Clinical

by Kristin Rowan, Editor

MedPAC Proposes Drastic Cuts

Five Year Decrease Not Enough

The onset of PDGM and the recalculations of payments in 2020 have led to an overall decrease in Medicare reimbursement rates for home health by approximately 12%. CMS continues to calculate budget neutrality with flawed formulas. The Alliance, along with several other advocacy groups as well as agencies and individuals, continues to fight against the formula and the pay cuts, estimating that nearly half of all home health agencies will be losing money in order to stay open.

Industry Report

Despite the continual decrease in payment rates, MedPAC recommends additional steep cuts. Highlights from the MedPAC report include:

97% of beneficiaries have access to 2 or more HHAs
The total number of HHAs declined 1% in 2024 (excluding CA)
Only 7.9% of beneficiaries used HH in 2024
Number of 30-day periods per beneficiary increased 2.6%
The overall profit margin for Traditional Medicare is 21.2%
The overall profit margin for all payers is 5%
Anticipated profit margin for 2026 is 19% for Traditional Medicare (3% overall)

Less than 0

The Traditional Medicare profit margin in 2026 is projected at 19%. This is offset by the negative profit margin from Medicare Advantage and private insurance plans. It may not be realistic or fair for the taxpayer to offset poor policies in Medicare Advantage and private insurance plans, but that has been the reality for years. Medicare Advantage plans yield high profits for insurance payors, and negative margins for HHAs. With an overall profit margin of 3%, lowering the Medicare reimbursement rate by more than 3% will put all HHAs in the red.

The Math Isn't Mathing

The numbers are there. HHAs earn 5% now, 3% next year. MedPAC recommends that CMS reduce the 2026 rate by an additional 7%.

NET PROFIT MARGIN -4%

Conclusion from MedPAC: This will not impact care; providers will still be willing to treat Traditional Medicare beneficiaries.

That statement may be true. However, in order for HHAs to survive, they will have to drop all MA plans. More than 50% of Medicare beneficiaries are on MA plans. 40% of MA patients use HH care after hospitalization. Medicare Advantage will survive through hospitals and physicians, but the Home Health benefit won’t have any providers.

Hospice Tie-In

CMS is currently weighing the option of the hospice carve-in to Medicare Advantage plans. The pilot plan failed miserably and yet rolling this out across all plans is an option, somehow. CMS and MedPAC must not be able to see what has happened to Home Health under MA plans. Hospice will suffer the same fate through the carve-in. It is irresponsible and destructive to add Hospice to MA. For that matter, it is irresponsible and destructive NOT to remove Home Health from MA. Move it all back to Traditional Medicare where at least the profit margin is above 0.

May Cooler Heads Prevail

From the proposed rule in July to the final rule in November, CMS lessened the permanent rate cut by about 5%, finally hearing the concerns of advocates who told them HHAs would go out of business. We certainly hope CMS will keep that in mind when considering the MedPAC recommendation.

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What can Providers Give to Patients, Part 6

by Elizabeth E. Hogue, Esq. | Dec 4, 2025 | Legal

by Elizabeth E. Hogue, Esq.

What Providers Can Give, Part 6

Provider Kickback Exclusions

Background

Part 1

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

Part 2

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

Part 3

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

Part 4

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

Part 5

Part 5 describes an exception for preventive items or services.

Part 6: An exception

This article addresses an exception for free items or services to promote access to care.

The CMPL excludes items or services that improve beneficiaries’ ability to obtain items and services payable by the Medicare or Medicaid Programs and that pose a low risk of harm to both beneficiaries and the Programs because they are unlikely to:

Increase costs to federal health programs or beneficiaries through overutilization or inappropriate utilization
Interfere with or skew clinical decision-making
Raise issues of patient safety or concerns about quality of care

Exclusions

This exception does not apply to waivers of copayments, or to the provision of cash or cash equivalents.

In addition, the exception applies only to items or services that promote access to care covered by the Medicare or Medicaid Programs, i.e., items or services that improve particular beneficiaries’ ability to obtain items or services payable by the Medicare or Medicaid Programs. The exception does not apply to items or services that reward receipt of care or incentives for complying with treatment regimens.

Inclusions

The OIG says, for example, that this exception includes giving patients the tools they need to remove socioeconomic, educational, geographic, mobility, or other barriers to getting necessary care. Such barriers may include free childcare, so that patients may attend educational programs or appointments for treatment; free local transportation or parking reimbursement for appointments; smartphone apps or low-cost fitness trackers; gift cards that promote access to care; educational materials and informational programs about disease states or treatments; and self-monitoring equipment, such as scales or blood pressure cuffs. The exception does not include movie tickets, for example, given to patients to reward them for attending educational sessions.

Final Thoughts

Providers should certainly utilize the exceptions described in this series of articles to provide the maximum permissible assistance to patients.

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

Feedback Adjusts Final Rule

by Rowan Report | Dec 4, 2025 | CMS, Medicare, Regulatory

FOR IMMEDIATE RELEASE
November 28, 2025

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

National Alliance for Care at Home: CMS Modifies Final Payment Rule Based on Stakeholder Feedback, but 1.3% Cut Still Undermines Access

Despite positive changes in final rule, home health leaders remain deeply concerned payment cuts will continue to impact patient access to care at home

ALEXANDRIA, VA and WASHINGTON, D.C. The National Alliance for Care at Home (the Alliance) today acknowledged that the Centers for Medicare & Medicaid Services (CMS) made significant adjustments in the Home Health Perspective Payment System (HH PPS) Final Rule for CY 2026 in response to community concerns regarding patient access and data integrity.

However, the Alliance remains concerned that any payment cut for home health providers will continue to compromise access for the millions of Medicare beneficiaries who rely on these services to age and recover from illness or injury safely at home.

Since 2019, Medicare home health providers have experienced severe cuts that have already led to a cascade of home health agency closures and reduced patient access to care, especially in rural and underserved communities. The cuts finalized by CMS today – 1.023% permanent and 3% temporary – will likely continue to exacerbate these trends.

“While the Alliance acknowledges that CMS took into account some of the home health community’s recommended changes in its final rule, resulting in a lower payment cut for next year, a 1.3% overall reduction in payments compared to 2025 will likely result in continued reductions in patient access, the closure of more home health agencies, and more patients waiting in costly hospital settings instead of recovering safely at home.”

– Dr. Steve Landers, CEO for the Alliance

The Alliance commends CMS for revisiting aspects of its flawed payment approach, including the conclusion of permanent payment adjustments with CY 2026 (using data from CY 2020 through 2022) based on issues that CMS acknowledged with isolating PDGM behavior changes from non-PDGM behavior changes in CYs 2023 and beyond. In total, CMS’s changes from proposed to final rule amount to approximately $915 million more in payments to home health agencies for 2026. However, any cut will be detrimental in the face of years of compounding decreases, and more action is needed to help preserve integrity, stability, and predictability in Medicare’s home health benefit. While CMS reduced the amount of overpayments that inform the temporary payment adjustments down to 4.7 billion for CYs 2020 through 2024, home health agencies will continue to face several more years of temporary adjustments without additional action.

“Home health care is among the most trusted, cost-effective, and patient-centered services in the Medicare program. The Alliance thanks its members, the broader home health community, and allied organizations and leaders for their advocacy to help achieve this substantial improvement for home health providers and patients nationwide. Congress must take further action to enact lasting reforms to the system that protect patient access to these services and ensure the sustainability of the Medicare home health benefit.”

Steve Landers

CEO, National Alliance for Care at Home

Expanding access to home health care is essential to improving health outcomes, enhancing patient independence, and reducing healthcare costs. Research shows that when patients are unable to access clinically appropriate home health services, hospital readmissions are 35% higher, mortality rates are 43% greater, emergency department utilization grows by 16%, and total spending is 5.4% more than if patients were able to access the services they need. Protecting this vital benefit is also popular as 70% of U.S. voters are opposed to Medicare home health cuts.

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About the National Alliance for Care at Home

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

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

Appeals Court Filing

by Kristin Rowan | Dec 4, 2025 | Advocacy, Clinical, CMS, Hospice, Legal

by Kristin Rowan, Editor

Appeals Court Filing

Hospice ALJ

A hospice claim may fall under review either before or after the claim has been paid. A hospice agency with a denied claim must file appeals until the claim is approved or the appeals are exhausted. First, they file a written request to reconsider. Then, they file an appeal to a Qualified Independent Contractor (QIC) who employs medical professionals to assess the case. Next, they file an appeal to an Administrative Law Judge (ALJ).

The ALJ is meant to review the documentation to determine whether it satisfies Medicare requirements. That’s all. There are two sets of criteria: the Medicare requirements and the patient record. If they match, the claim is paid. However, a recent ALJ decision and subsequent challenge suggests that the ALJ ignored expert testimony and decided independently that the patient did not qualify for hospice care.

Request to File

The hospice agency in this case filed suit against the ALJ, arguing that physician expertise should be shown deference in these cases. The National Alliance for Care at Home (the Alliance), joined by the American Academy of Hospice and Palliative Medicine (AAHPM), represented by William A. Dombi of Arnall Golden Gregory (AGG), has requested the right to file an amicus brief. An amicus brief provides extra information in a court case from an individual or group that is not part of the lawsuit, but has a vested interest in the outcome.

The Dispute

The Alliance puts at the heart of the case several issues, including:

Predicting death is inherently difficult
Physicians are the experts and their opinion should carry more weight
Oversight from non-qualified third parties add confusion, increase costs, and limit care

The Argument

The wording in multiple parts of the hospice benefit recognizes the expertise and importance of the physician. It is the physician who determines terminal illness. Physicians must have a face-to-face for continued eligibility. And it is the physician’s clinical judgment makes these determinations based on a patient’s individual circumstances, not an arbitrary set of standards.

If an ALJ, or any non-medical person, can overrule the treating physician’s assessment of a patient, they are effectively usurping the role of the doctor in providing a treatment plan. Medical care is subjective, which is why CMS has repeatedly considered and rejected defined criteria that would overrule a physician.

Broader Implications

The brief argues that medical professionals are better able to make care determinations. Further, the brief includes the complexity of health care prognosis, particularly in terminal illnesses. Previous court decisions have noted that “clinical judgments must be tethered to a patient’s valid medical records….” which already eliminates the need for this oversight. The Alliance stated a high probability that the decision in this case will carry substantial weight and influence both in the Sixth Circuit and in courts nationwide.

In fact, the implications may be farther reaching than that. Payors in and out of hospice deny claims deemed “unnecessary” regularly. Claims denials range from about 19% in the ACA Marketplace to as much as 49% from private payers. Even though about 80% of appeals are later accepted, only about 1% of denied claims are appealed.

Not only could this case help more patients get the hospice care they need, it could also lay the groundwork to require insurance companies to rely more heavily on the treating physician’s recommendation. We could see lower denials from prior authorization requests, unconventional treatment plans, VA benefits, and more.

Final Thoughts

The Rowan Report supports the Alliance’s efforts in this case and wholeheartedly agrees that a physician knows better the care his patient needs than a judge ever could. We are hopeful that Bill Dombi and his team at AGG will be successful in this case and that hospice providers can get back to the business of patient care. Read the statement from the Alliance here.

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BREAKING NEWS: Home Health Final Rule

by Kristin Rowan | Nov 29, 2025 | Breaking News, CMS, Home Health, Medicare, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

BREAKING NEWS

Home Health Final Rule

While most of us were still recovering from our Thanksgiving feast overload, CMS quietly released the CY 2026 Home Health Prospective Payment System Final Rule (HH Final Rule). In past years, CMS published the HH Final Rule on or about November 1. The HH Final Rule was delayed this year due to the government shutdown.

Payment & Policy Updates

The payment rate for 2026 will change based on multiple factors:

HH payment update of +2.4%
The final permanent rate adjustment of -0.9%
The final temporary adjustment of -2.7%
Fixed-dollar loss ratio for outlier payments update of -0.1%

The aggregated payment update for 2026 is a net decrease of 1.3%

Read the CMS Fact Sheet

Face-to-Face

The CARES Act allows Nurse Practitioners, Certified Nurse Specialists, and Physicians Assistants to order and certify eligibility for Medicare HH and establish a plan of care. CMS has updated face-to-face encounters to now allow NPs, CNSs, PAs and physicians to perform face-to-face encounters whether or not they were the certifying practitioner or one who cared for the patient prior to home health care.

Home Health VBPM

Effective in April 2026, the HHCAHPS survey will undergo changes. CMS is removing these three survey-based measures:

Care of Patients
Communications between Providers and Patients
Specific Care Issues

CMS is adding four measures to them measure set. These include three measures related to bathing and dressing and the Medicare Spending per Beneficiary setting measure. These changes also prompted alterations to the weights of each measure and measure category.

The expanded model has built-in criteria for the removal of any quality measure. CMS is adding an additional criteria to the list of factors. Factor 9 reads that CMS may remove a quality measure if it is not feasible to implement the measure specificiations.

Medicare Provider Enrollment Revocation

Currently, any provider must enroll and be approved to become a Medicare provider. CMS has the authority to both approve and revoke provider Medicare enrollment. When CMS revokes a provider’s Medicare enrollment, the revocation is effective 30 days after CMS mails notification to the provider. In certain circumstances, CMS can revoke enrollment retroactively to the first date of non-compliance and consequently collect any money paid to that provider back to the retroactive date. CMS is adding to the allowable grounds for retroactive revocation.

If an enrolled physician or practitioner has not ordered or certified services for 12 consective months
If a beneficiary attests that a provider did not actually perform the services they billed

Additional Changes

CMS is recalibrating case-mix weights under PDGM and LUPA thresholds.

DMEPOS accreditation regulations will now require suppliers to be resurveyed and reaccredited annually. Additionally, CMS is increasing the amount and frequency of data accrediting organizations (AOs) submit, expanding their ability to monitor AOs, and strengthening their ability to address poorly performing AOs.

The DMEPOS Competitive Bidding Program will change, but we are still waiting for the finalized improvements. CMS will begin paying for all continuous glucose monitors and insulin infusion pumps.

Read the Final Rule and additional Documents

Final Thoughts

A decrease in pay of any amount is unfortunate. However, we applaud CMS for listening to the feedback. CMS stated, “…commenters raised concers that behavior change after CY 2022 might [attribute] to factors unrelated to…PDGM.” Changes since 2020 include the introduction of OASIS-E, the expansion of value-based purchasing, and the large increase in the percentage of Medicare Advantage enrollees.

Whatever the reason, The Rowan Report joins the National Alliance for Care at Home in commending CMS for adjusting its payment calculations. The permanent pay adjustment for 2026 is listed as the final adjustment, a positive for HH moving forward. The proposed rule issued mid-year had a net -6.4% decrease in payments for a net decrease of more than $1 billion dollars. The final rule payment adjustment has a net decrease of $220 million. Still a decrease, but much more palatable.

CMS will continue to assess the need for temporary payment adjustments for several more years. Additional adjustments (read decreases) to the payment rate will impact patient access to care. The Alliance will continue to advocate and educate members of Congress and HHS to lower or eliminate they reductions. Your advocacy and support is needed to ensure the future of Care at Home. The Rowan Report will continue to support the Alliance and other advocacy groups and share with you opportunities for advovacy.

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