In brief: Medicare spending, OIG savings, telehealth flexibility, cath reviews 

WASHINGTON – Medicare spent 27% more, on average, for people who were covered by traditional Medicare after disenrolling from Medicare Advantage than for people who were continuously covered by traditional Medicare, after adjusting for differences in health status and other characteristics, according to a new analysis by the Kaiser Family Foundation. 

This is a difference of $2,585 in Medicare spending per person, on average, between the two groups in 2022. 

Other highlights from the analysis: 

• Differences in Medicare spending between people who disenrolled from Medicare Advantage and beneficiaries continuously in traditional Medicare varied by health condition, ranging from 15% for people with pneumonia to 34% for people with diabetes. For example, among people with certain cancers, Medicare spending was 28% ($4,907) higher, on average, among those who disenrolled from Medicare Advantage than among people continuously covered by traditional Medicare. 
• Differences in Medicare spending between people who disenrolled from Medicare Advantage and those continuously in traditional Medicare increased with age for Medicare beneficiaries ages 65 and over. For example, among people ages 85 and over the difference was 46% ($7,113) compared to 25% among people ages 65 to 69 ($1,843). 
• Differences in Medicare spending between people who disenrolled from Medicare Advantage and beneficiaries continuously in traditional Medicare were larger among Black (55%, $5,203) and Hispanic (54%, $4,434) beneficiaries than White beneficiaries (25%, $2,464). 
• People dually-eligible for Medicare and full Medicaid benefits who disenrolled from Medicare Advantage had spending that was 61% ($9,435) higher than their counterparts who were continuously in traditional Medicare, while the difference in spending for Medicare beneficiaries who do not receive Medicaid was 20% ($1,684). 
• Skilled nursing facility spending accounted for the largest share of the difference in average Medicare spending per person between people who disenrolled from Medicare Advantage and those continuously in traditional Medicare (34%), followed by outpatient hospital spending (23%), and inpatient hospital spending (20%), with some variation by chronic conditions and other beneficiary characteristics. 

KFF says the analysis raises several questions, including why are some Medicare Advantage enrollees choosing to disenroll from Medicare Advantage rather than get the medical care they need from their plan, and why are they receiving more medical care in the year following disenrollment and similar people who have been continuously covered by traditional Medicare? 

• FMI: https://www.kff.org/medicare/issue-brief/medicare-spending-was-27-percent-more-for-people-who-disenrolled-from-medicare-advantage-than-for-similar-people-in-traditional-medicare/ 

HHS-OIG highlight $7B in savings in new report 

WASHINGTON – The Fall 2024 Semiannual Report to Congress (SAR) highlights more than $7 billion in expected recoveries and receivables resulting from HHS-OIG investigations and audits conducted during fiscal year 2024. HHS-OIG reported 1,548 criminal and civil enforcement actions in FY 2024 against individuals and entities suspected of engaging in crimes targeting HHS programs and the people they serve, including settlements resulting from using OIG's civil monetary penalty authorities and criminal convictions. HHS-OIG also excluded 3,234 individuals and entities from participation in federal health care programs. Among the DME-related activity highlighted in the report: 

• Charles Burruss and Ardalaan “Armani” Adams were charged with defrauding Medicare through the submission of claims for medically unnecessary durable medical equipment, mostly braces. Burruss and Adams paid millions in kickbacks and bribes to acquire the DME claims, which were generated using aggressive telemarketing strategies in concert with fraudulent telemedicine involving bribed doctors who rarely spoke to the beneficiaries for whom the DME was ordered. Burruss, Adams and their co-conspirators submitted the illegal DME claims to Medicare and other programs through a conglomerate of fraudulently established DME companies. The defendants pled guilty before the U.S. District Court and the Southern District of California to one count of conspiracy to commit wire fraud, conspiracy to commit healthcare fraud, and conspiracy to violate the anti-kickback statute. 
• OIG excluded Elizabeth Hernandez, an advanced registered nurse practitioner, for 97 years based on her conviction for her role in a scheme to defraud Medicare by submitting more than $192 million in claims for orthotic braces and other items patients did not need and telemedicine visits that did not occur. Hernandez was ordered to pay approximately $111 million in restitution and was sentenced to 20 years in prison. 

AAH joins efforts to extend telehealth flexibilities 

WASHINGTON – AAHomecare joined 62 other organizations and health care providers in asking congressional leadership to extend the telehealth flexibilities that are set to expire Dec. 31 for at least two additional years. “The flexible telehealth policies put in place following the public health emergency (PHE) have been nothing shy of a lifeline for millions of patients – they have increased virtual access to a wider array of clinicians and services, mitigated the clinician shortage, improved access to specialists, and shortened wait times to be seen,” the groups state in a Dec. 3 letter. “Importantly, as patients and clinicians navigate challenging economic conditions, the use of telehealth has provided affordable health care options.” Stakeholders seek to extend the following telehealth policies that were included in the Consolidated Appropriations Act (CAA) of 2023: 

• Waiving geographic and originating site restrictions so that urban, suburban and rural Medicare patients can continue to receive telehealth services at any location, including their home as the “originating site” rather than have to travel to a brick-and-mortar healthcare facility; 
• Expanding the list of telehealth practitioners to include qualified occupational therapists (OTs), physical therapists (PTs), speech-language pathologists (SLPs), and audiologists;  
• Continuing payment for telehealth services delivered in rural health clinics (RHCs) and federally qualified health centers (FQHCs); 
• Waiving the in-person requirement for telehealth treatment of certain mental health conditions; 
• Permitting use of audio only technology when broadband is insufficient or unavailable to support a video visit; 
• Allowing recertification of a patient’s need for hospice to occur via telehealth; and 
• Continuing the Acute Hospital Care at Home (AHCAH) initiative, which allows certain Medicare-certified hospitals to treat patients with inpatient-level care at home from participating hospitals. 

Noridian to review cath claims 

WASHINGTON – Noridian Healthcare Solutions, as the Supplemental Medicare Review Contractor (SMRC), is conducting post-payment review of intermittent urinary catheter claims billed with dates of service from Jan. 1, 2022, through Dec. 31, 2023. It’s reviewing HCPCS codes A4351, A4352 and A4353. Noridian noted that in February 2024, the Washington Post published an article alerting readers of an investigation into utilization for intermittent urinary catheters. As a result of the investigation, seven suppliers were identified in a scheme to bill claims for Medicare beneficiaries who either did not need the intermittent urinary catheters or did not receive them. In May 2024, Noridian completed research on HCPCS codes A4351, A4352 and A4353, and noted an increase in volume. In a recent bulletin, AAHomecare noted: “The SMRC is the third contractor now auditing intermittent catheters. Suppliers should carefully monitor the claims that are audited as the same claim cannot be audited by more than one auditor (excluding UPIC and CERT). If a supplier determines a claim has previously been audited, they should notify the contractor and it will be removed.” FMI: https://noridiansmrc.com/current-projects/01-130/. 

Rehab Medical taps UHC exec for new role 

INDIANAPOLIS – Rehab Medical has appointed Michael Farrell to the newly created position of vice president of regulatory and funding. With nearly two decades of health care experience, Farrell has worked as a compliance consultant for various providers and previously served as vice president of revenue cycle management for UnitedHealthcare (UHC) and Optum. “I’ve been in the health care industry 15 years, providing operational guidance so facilities could build solid teams and implement processes that improved their efficiencies,” Farrell said. “With my transition to Rehab Medical, I’m not only able to provide operational guidance, but I’m also part of the implementation process, and that excites me the most about my role.” Farrell’s primary responsibility will be to create processes and procedures that align with insurance carrier policies. He will collaborate with the compliance team to ensure adherence to Medicaid and Medicare regulations, while also partnering with the payer relations team to prevent excessive audits, reduce insurance denials and expedite claim submissions. 

Clinician Task Force names new leader 

YARMOUTH, Maine – The Clinician Task Force will have a new executive director, Tamara Kittelson, starting in January 2025. Kittelson is an occupational therapist, RESNA-certified ATP/SMS and ISWP-certified intermediate wheelchair provider who has worked in the complex rehab industry for 39 years. She founded Posture 24/7 and Eleanore’s Project, promoting 24-hour posture care management and appropriate seating and wheeled mobility provision in low resource settings, and has presented and written on these topics nationally and internationally. She is a 16-year member of the Clinician Task Force, a Friend of iNRRTS, founding chair of the RESNA 24-7 Posture Care Management special interest group, and a member of RESNA and AOTA. “I am confident the CTF will be in great hands with Tamara's guidance,” said Cara Masselink, outgoing executive director and an associate professor & fieldwork coordinator in occupational therapy at Western Michigan University. “I also would like to give my sincere thanks for the support, camaraderie and collaboration over the last four years. I'm so grateful to have been a part of a team that has made significant changes to access for people who need CRT.”   

New Marketplace enrollment nears 1M mark 

WASHINGTON – CMS reports nearly 988,000 consumers who do not currently have health care coverage through the individual Marketplace have signed up for coverage for 2025. Last year, a record-setting 21.4 million consumers signed up for coverage, driving the uninsured rate to a historic low, the agency says. Nearly 4.4 million existing consumers have already returned to the Marketplace to select a plan for 2025, it says. “ACA Marketplace open enrollment continues with more than 5.3 million people signing up for coverage since the beginning of the open enrollment period,” said CMS Administrator Chiquita Brooks-LaSure. “These numbers reflect the strong and ongoing demand that individuals and families have for affordable, high-quality health care coverage and we expect this year will set another plan selection record.” Marketplace open enrollment on HealthCare.gov continues through Jan. 15. To view the Marketplace enrollment snapshot report, please visit: https://www.cms.gov/newsroom/fact-sheets/marketplace-2025-open-enrollment-period-report-national-snapshot-0 

Podiatrist, recruiter sentenced for $8.5M compounding scheme 

WASHINGTON – A podiatrist and a patient recruiter were sentenced to 45 months and 60 months in prison, respectively, and ordered to pay more than $7 million in restitution for their roles in a scheme to fraudulently bill TRICARE for compounded pain and scar creams. According to court documents and evidence presented at trial, Brian Carpenter, 58, of Paradise, Texas, was a podiatrist who signed prescriptions for compounded pain and scar creams for TRICARE beneficiaries to whom he never spoke and whom he never examined or treated. Jerry Lee Hawrylak, 71, of Lake Worth, Texas, recruited Carpenter to sign the prescriptions and recruited TRICARE beneficiaries to accept the medically unnecessary creams. From November 2014 to January 2017, Carpenter, Hawrylak, and others caused a Fort Worth-based pharmacy involved in the conspiracy to fraudulently bill TRICARE approximately $8.5 million for these creams. Evidence at trial included so-called standing orders signed by Carpenter that were backdated so the pharmacy could change prescriptions after the fact to maximize TRICARE reimbursement. The prescriptions Carpenter signed and maintained in his office authorized unlimited refills and listed fake addresses for beneficiaries. In April 2023, a jury in the Northern District of Texas convicted both Carpenter and Hawrylak of one count of conspiracy to commit health care fraud and six counts of health care fraud. FMI: https://www.justice.gov/opa/pr/podiatrist-and-patient-recruiter-sentenced-85m-compounding-fraud-scheme.