Volume 12, Number 13 February  22, 2023



BREAKING NEWS

Last issue, we ran several articles critical of private, for-profit insurance companies running Medicare Advantage plans (see "Most-Read Articles" below). We learned this week that the reality may be worse than even the most severe accusations we heard and reported on at last month's Home Care 100 gathering. 

According to Kaiser Family News, CMS issued a final rule declaring it would treat MA plans differently than it treats Home Health Medicare episodes and claims from other care providers. When CMS investigates an MA plan's patient acuity assessments, which is how plans are paid, if it finds exaggerations in its samples, it will demand returns of overpayments only from the samples and will not extrapolate to a plan's entire population. 

We ran the Kaiser article by several attorneys and other experts and learned that there is more than one issue at play. CMS is 10 to 12 years behind in sampling MA acuity assessments, though it does not explain why. CMS is never more than three years behind examining Home Health and Hospice claims. When its contractors do find overpayments in our industry, they always extrapolate from samples, often resulting in crippling repayment demands. 

 

 

Is Fairness Off the Table?

Or do insurance companies simply have that much clout?

The largest in-home care providers report annual revenues in the $2 to $2.5 billion range. There are not many in that category, mostly national providers that have grown by acquisition. It has always been the case that more than two-thirds of Home Health providers gross $2 million per year or less.

In contrast, CMS reported that Medicare will pay $385 billion in 2023 to insurance companies such as United Health, Humana, Anthem, Aetna, and Cigna. You know them, the ones that advertise during every TV commercial break throughout the annual enrollment period, usually fronted by the likes of Joe Namath and Jimmy Walker and other aging celebrities.

It gets worse.

We reported nearly five years ago that MA plans pad their Medicare revenue by exaggerating patient acuity, resulting in a net cost to the Medicare trust fund 1.2 percent higher than per-patient costs for traditional Medicare. In addition, they deny care at a higher rate than traditional Medicare and apparently not for legitimate reasons. When appealed, 75 percent of MA denials are overturned, most in the first level of appeal without having to get to the ALJ level.

 

 

This was not the only time we reported on this scandal. Here is a report Darcey Trescone and I did in 2020. It compares $192 million of suspected Home Health fraud unearthed by the OIG to a $1.4 billion lawsuit by the Justice Department against a cheating MA plan.

First read the article by Kaiser's investigative reporter Fred Schulte, reprinted with the permission of Kaiser Health News, then switch to our commentary and reflections from our expert panel. Let us know whether you are as appalled as we are. Then take action in two ways. CMS needs to hear from you, otherwise it will think you are OK with its unequal treatment of MA plans. And get more aggressive when MA plans deny care. Yes, 75% of appeals are successful, but less than 2% of denials are appealed. It is your money. 

Have a great week. Keep making a difference!

Editor signature
Tim Rowan



Government Lets Health Plans That Ripped Off Medicare Keep the Money
CMS says it will not extrapolate overpayments for MA plans the way it does for Home Health episodes, but only charge for the samples.

Home Health Experts React to Special Treatment of MA Plans
Attorneys and consultants talked to us about a new CMS Final Rule's double standard.



During the 1st Quarter of 2023, web sites of the above advertisers were visited by home care and hospice executives and staff 4163 times.

To inquire about placing your message here, contact:

Kristin@rowanresources.com

As of this date, approximately 48,796,000 Baby Boomers have become Medicare eligible.

 

Last Week's Most-Read Stories:

Medicare Advantage Is Neither Medicare Nor an Advantage
Former insurance executive who used to sell Medicare Advantage explains why it is stealing from taxpayers and seniors.

Our Medicare Payment System is Broken
At Home Care 100, four top executives and one MedPAC commissioner agree. The formulae CMS use to calculate profit margins and determine rate cuts is "stupid."


Upcoming Events

 

Shine Your Light
Illinois HomeCare & Hospice Council Annual Meeting and Exposition

Dates: April 9-10
Venue: NIU Naperville

Information and Registration


FREE WEBINAR: CMS’ Proposed Hospice FY2024 Payment Rule: Implications for Agencies and the Hospice Community

Sponsored by NAHC
Featuring: Theresa Forster, Katie Wehri

Date: April 11
Time: 12:00 - 1:30 EDT

Details and Registration

 

Description: In addition to routine annual payment changes, CMS proposed FY2024 Hospice Payment Rule, issued on March 31, contains valuable updates on the Hospice Quality Reporting Program (HQRP). Perhaps most notable, the rule's deep dive into utilization trends signals an intensified interest in hospice care patterns, potentially inappropriate behavior in the hospice sector, and program integrity concerns.  Join two of NAHC's hospice experts as they detail proposed changes, including a new requirement that hospice certifying physicians be Medicare enrolled (or to have validly opted-out) and CMS' Requests for Information on hospice utilization and health equity, and examine their potential impact on hospice practice going forward.

Faculty: Theresa M. Forster, NAHC VP for Hospice Policy & Programs
Katie Wehri, NAHC Director of Home Health & Hospice Regulatory Affairs


WEBINAR: Audits: What to Do

A 90-minute Lunch & Learn Audio Conference by Elizabeth E. Hogue, Esq. Health Care Attorney

Date: Thursday, April 6
Time: 1:00 - 2:30 EDT

Encore date: April 13
On-demand recording available 24/7
Option to purchase recording and handouts

 

Information and Registration

 

Audio-Conference Description: Home care providers of all types; including home health agencies, private duty agencies, hospices and HME companies; remain targets of audits by various regulators, including but certainly not limited to United Program Integrity Contractors (UPICs). The results of these audits can be devastating because they may threaten the ability of providers to remain in business, especially when overpayments are extrapolated to millions of dollars. Audits of all types must be taken seriously and providers must take action to close audits as quickly as possible! The first thing providers must do is to review records requested by auditors.

The purpose of this teleconference is to give providers detailed steps to follow to avoid adverse consequences of audits. Examples of common issues targeted by auditors will be provided and there will be time for questions and answers.


 

First Joint Conference of the Carolinas

Association for Home & Hospice Care of North Carolina & South Carolina Home Care & Hospice Association

Dates: April 23-26

Venue: Westin

City: Charlotte

Information and Registration 



Rise Above!

Michigan Home Care & Hospice Association Annual Conference

Dates: May 3-5
Venue: Grand Traverse Resort & Spa

Registration and Information

The theme for the Conference is “RISE ABOVE” a fitting recognition of the challenges our industry and each of you overcame in your personal lives and professional careers to navigate the challenges of the past three years.

The MHHA conference presents an opportunity to meet new friends and reacquaint with peers. What better place to rise above, than at the spacious and beautiful Grand Traverse Resort & Spa? This conference has a little bit for every service line and discipline. Wednesday offers a track for Volunteer Managers and Thursday offers a track for Palliative Care as well as many other sessions for Certified Home Health, Hospice, DME and Private Duty Home Care.


2023 Annual Home Health & Hospice Conference
Homecare and Hospice Association of Utah

Date: May 10-11

City: Sandy

Attendee Registration

Exhibitor/Sponsor Registration


2023 Rocky Mountain Home Care, Home Health & Hospice Conference *Presented by: Home Care and Hospice Association of Colorado

Dates: May 18-19
Venue: Beaver Creek


Information and Registration for Attendees and Exhibitors


Home Care Innovation Forum*Presented by: The Influence Group

Dates: June 4-6
Venue: Park Hyatt Aviara 
City: 
Carlsbad, CA


Information and Registration

Featured Speakers:

Partial list of topics:


HI2: Home Care Innovation and Investment Conference *Presented by: Lincoln Healthcare Leadership

Dates: June 12-14
Venue: Swissotel 
City: 
Chicago


Information and Registration

Featured Speakers:


leading ONE vision

Homecare Homebase User Group Meeting

Dates: June 12-14
Venue: Sheraton Dallas Hotel

Information and Registration

Clinical Education Credits
Nationally recognized speakers, eight clinical sessions. Clinicians are encouraged to sign up for the clinical sessions, but are free to jump between clinical and non-clinical topics. Clinical topics include a homecare focus on Wound Care, Value Based Purchasing, Clinical Leadership, conflict resolution, Quality Report, Oasis and more.

Featured Speakers:



Your state or national association meeting or webinar not listed? Send the details to Conferences@RowanResources.com using this format:

Conference Title
Sponsoring Association
Date(s)
Hotel or Conference Center, City, State
URL



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