Lawmakers, Regulators Push CMS for Greater Hospice Program Oversight

McKnight’s Home Care / By Adam Healy
 
The Centers for Medicare & Medicaid Services is facing mounting pressure from lawmakers and regulators to improve hospice program integrity. 
 
In a letter sent last week to the Centers for Medicare & Medicaid Services, 38 House representatives pointed out “instances of pervasive fraud and abuse” plaguing the Medicare hospice program. Though CMS has taken action against bad actors — notably through a period of enhanced oversight in four states — the lawmakers said more could be done.
 
“CMS has taken positive steps to increase its oversight of hospice programs,” they wrote. “However, we are deeply concerned by new reports indicating many potentially fraudulent hospices are continuing to bill Medicare and CMS is still enrolling suspicious new providers into the program.”
 
They asked CMS to explain the ways in which its oversight measures have addressed hospice fraud and abuse, and gave the agency a May 31 deadline to respond. 
 
Providers agree
 
The National Hospice and Palliative Care Organization described the letter as a “significant next step in holding CMS accountable for addressing the rising level of fraud and abuse by bad actors within the Medicare hospice benefit.”
 
“CMS must take decisive action against bad actors tarnishing the reputation of hospice care,” Logan Hoover, NHPCO’s vice president of policy and government relations, said in a statement. “This concerted effort, driven by our congressional allies, builds upon nearly two years of grassroots, policy and regulatory initiatives aimed at combating fraudulent practices within hospice care.”
 
GAO findings
 
Meanwhile, a recent report by the Government Accountability Office found that, as of May 2023, roughly 10% of hospices were overdue for a survey. These surveys are supposed to be conducted every three years. Of the overdue hospices, 10% had not been surveyed in more than six years.
 
The report also noted that CMS had only fully implemented five of the eight hospice oversight provisions mandated by the Consolidated Appropriations Act of 2021. GAO recommended CMS take action to fully implement the three outstanding oversight measures.
 
CMS said the COVID-19 public health emergency resulted in the need to reprioritize surveying activities. Still, the lawmakers pointed out that “longstanding hospice quality of care issues that need to be addressed,” according to their letter.

An Increasing Number of Hospices Will be Entitled to Cap Liability Refunds

The Health Group, LLC 

As more hospices become subject to claims denials and Medicare program repayments because of these denials, many hospices become eligible for refunds of CAP liabilities paid to the Medicare program.  Many of the claims denied are associated with patients who had longer lengths of stay during the terminal episode of care.  Accordingly, the denial of these claims generally decreases any historical CAP liability.

The Medicare Administrative Contractor (“MAC”) recalculates the hospice CAP liability based on their recalculation schedule but only for years they determine appropriate for recalculation.

The increase in claim reviews has resulted in more hospices being eligible for CAP liability refunds.  We have identified several hospices entitled to refunds for years which would not have been recalculated by the respective MAC.  In these situations, the hospice must request a recalculation.  We recommend that in these situations the hospice not only requests a recalculation but also provide the calculation supporting their refund request.

The MAC will not issue any refund of recovered CAP liabilities until the payment related to the claim denials has been recovered.

Hospitals’ New Message for Patients: Stay Home

Politico / By Daniel Payne
 
Health systems are trying to move more of the work they do to your house.
 
Sensors that enable staff to monitor patients remotely are less intrusive than they once were, meaning more patients comply with wearing them. That enables care providers to watch over someone from afar, Jiang Li, CEO of remote care company Vivalink, said.
 
“Almost everybody’s thinking about how to make adjustments to embrace new technology,” Li said. “This trend definitely will continue — it will continue on a global scale, not just the U.S.”
 
Most providers have increased their spending on technology in recent years, including an emphasis on telehealth and remote care, according to a 2023 report.
Health regulators are taking note — and engaging in the conversation.
 
Dr. Meena Seshamani, deputy administrator and director of the Centers for Medicare and Medicaid Services, said in a statement that the agency “continually assesses opportunities” to better the speed and reliability of care, including via technology. That assessment includes discussions “with the medical community and patient advocates on an ongoing basis.”
 
Some large hospitals are essentially opening tech consulting operations, selling the systems they’ve built in-house, or their staff’s expertise.
 
“You’re finding more health systems say: ‘What else could we do that is not necessarily wildly profitable but that just covers its own costs plus a little bit so that we can turn around and do other things?’” said Niyum Gandhi, chief financial officer and treasurer at Mass General Brigham.
 
Mass General, a major Boston hospital system, has done just that. It created an artificial intelligence business, relying on tech industry players, from GE HealthCare to Nvidia, to validate its tools. The health system, like other large health providers, is building its own AI products too, with some seeing opportunities to license them to peers.
 
That’s not a business plan just anyone can pursue.
 
In underserved areas, care options are shrinking. Rural hospitals have cut services that they see as unsustainable, even if they’re important to patients in the area.
 
Congress, in an effort to preserve care in rural areas, created a new Medicare payment designation for rural hospitals that would allow facilities to eliminate inpatient services to keep emergency rooms open.
 
And some doctors, in both small and large systems, are skeptical that technology is a panacea. Even where state-of-the-art tech is available, they worry they won’t be able to examine patients as thoroughly — or at all — when care is remote. Investigations into the use of remote monitoring sometimes suggested it led to substandard care.
 
But for patients looking for the convenience of the remote care they got during the pandemic — or hospitals who see remote care as a path to financial stability and better care — the future is coming.
 
“Things are going in the right direction,” Couris said.

The Wrong Way to Use AI in Healthcare

The Rowan Report / By Tim Rowan, Editor Emeritus

Lawsuits are beginning to pile up against insurance companies participating in the Medicare Advantage program. The complaint? The wrong way to use AI in healthcare is with faulty algorithms to approve or deny claims. While AI can be extremely helpful in streamlining administrative tasks — comparing physician notes with Home Health assessments and nursing notes or reading hospital discharge documents — it seems not to be any good at deciding whether to approve or deny care.

The Wrong Way to Use AI in Healthcare Example 1

The Minnesota case, November, 2023, UnitedHealth Group:

• An elderly couple’s doctor deemed extended care medically necessary
• UnitedHealth’s MA arm denied that care
• Following their deaths, the couple’s family sued UnitedHealth, alleging:
  • Straight Medicare would have approved the extended care
  • United uses an AI model developed by NaviHealth called nH Predict to make coverage decisions
  • UnitedHealth Group acquired NaviHealth in 2020 and assigned it to its Optum division
  • nH Predict is known to be so inaccurate, 90% of its denials are overturned when appealed to the ALJ level
  • UnitedHealth Group announced in October, 2023 that its division that deploys nH Predict will longer use the NaviHealth brand name but will refer to that Optum division as “Home & Community Care.”

The family’s complaint stated, “The elderly are prematurely kicked out of care facilities nationwide or forced to deplete family savings to continue receiving necessary medical care, all because [UnitedHealth’s] AI model ‘disagrees’ with their real live doctors’ determinations.”

The Wrong Way to Use AI in Healthcare Example 2

The Class-Action case, December 2023, Humana:

• A lawsuit was filed on December 12, 2023 in the U.S, District Court for the Western District of Kentucky
• It was filed by the same Los Angeles law firm that filed the Minnesota case the previous month, Clarkson
• The suit notes that Louisville-based Humana also uses nH Predict from NaviHealth
  • The plaintiffs claim, “Humana knows that the nH Predict AI Model predictions are highly inaccurate and are not based on patients’ medical needs but continues to use this system to deny patients’ coverage.”
  • The suit says Medicare Advantage patients who are hospitalized for three days usually are eligible to spend as many as 100 days getting follow-up care in a nursing home, but that Humana customers are rarely allowed to stay as long as 14 days.
  • A Humana representative said Humana their own employed physicians see AI recommendations but make final coverage decisions.

What Makes This Possible

According to experts we speak with, there are many ways to use data analytics. The insurance companies named in the lawsuits use predictive decision making. This way of analyzing data compares a patient to millions of others and deduces what treatment plan might be suitable for one patient, based on what was effective for most previous patients. Opponents of this method have called it “data supported guessing.”…

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