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The OIG is flagging hospice patients without prior acute care utilization as a high-risk eligibility red flag. At the same time, PEPPER is relaunching as a free self-audit tool and the DOJ just closed a $6.5 billion fraud takedown with a record Medicaid component. That is three enforcement levers tightening at once. The audit criteria are published, the comparison data is coming, and the prosecutors are warmed up. | ||
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1.
Regulatory / Payment Alert
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Proposed Federal Bills Aim to Combat Loneliness, Offering New Policy Framework & Grant Opportunities for Home-Based Care
All
· MOD
Two new federal bills, the National Strategy for Social Connection Act and the SILO Act, are aiming to build a framework around loneliness and social isolation in older adults. The SILO Act proposes $63 million a year in grants to area agencies on aging and community-based organizations. That is real money on the table for agencies willing to build interventions around social connection. If you serve an aging population that struggles with isolation, this is worth watching as a funding stream, not just a policy headline.
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2.
Compliance Watch
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Proposed 340B Reforms Could Significantly Reshape Hospital Finances and Referral Dynamics
All
· MOD
Senator Bill Cassidy introduced a draft to reform the 340B Drug Pricing Program, with upfront discounts and rebates, stricter definitions, and limits on contract pharmacies. Your agency does not touch 340B directly. But your hospital referral partners do, and their finances run on it. When the money model under a major referral source shifts, it changes how they discharge, who they partner with, and how much volume flows your way. Track this one because it moves your referral landscape, even though it never lands on your books.
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3.
Documentation Issue
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OIG Signals Heightened Scrutiny on Hospice Patient Eligibility, Warning of Fraud Risk
Hospice
· HIGH
The OIG has named specific hospice patient populations as high-risk for eligibility concerns, which means your admission and recertification documentation is about to get read a lot more closely. This is the documentation issue of the week. If your charts cannot show a clear decline trajectory and a defensible terminal prognosis, you are exposed. Review your admission and recert documentation now, especially for patients who came in without a recent hospitalization or emergency room visit. Those are the charts that get pulled first.
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4.
Payer Update
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DOJ Opinion Challenges Olmstead Decision, Threatening State Mandate for Home-Based Services
All
· HIGH
The DOJ issued a legal opinion arguing that federal disability law does not impose an integration mandate on states for home and community-based services. That position runs directly against the 1999 Olmstead Supreme Court decision. If states adopt this interpretation, they could shrink their HCBS obligations, which would hit availability, funding, and the kinds of patients you are able to serve. This is a slow-moving legal thread, not an immediate change. But if you are building long-term capacity around Medicaid HCBS growth, watch it closely before you commit.
Hospice Operators Navigate Fraud Scrutiny, HOPE Tool Challenges, and Market Evolution
Hospice
· MOD
Hospice operators are getting squeezed from three directions: fraud scrutiny, the HOPE tool rollout, and a market consolidating through joint ventures. None of these is going away. The agencies handling it well are treating compliance, quality reporting, and growth strategy as one connected problem instead of three separate fires. If you are managing them in silos, you are working harder than you need to and still leaving gaps between them. Revenue protection needs to take compliance and audit risks into consideration.
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5.
TrueTime Insight
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OIG Hospice Scrutiny Means Your Eligibility Docs Get Read Closely
All
· MOD
The OIG is flagging specific hospice populations as high fraud risk, which means your eligibility documentation is getting read by reviewers who are actively looking for gaps. TrueTime Chart Review runs a per chart QA pass against the documentation standards reviewers actually use. One agency caught missing recertification narrative on 11 charts before an audit cycle, avoiding what would have been straightforward denials. Not using Chart Review? Pull your last 20 recerts and read them the way a skeptical reviewer would. If the decline story is not on the page, it does not exist. Watch the CTI narrative and your LCD criteria. TrueTime provides an audit defence document for every chart, ready to present if you are audited.
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6.
Growth Tip
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Voice AI Funding Boom: $120M for Platforms Automating Patient Calls, Appointments, and Administrative Tasks
All
· MOD
Assort Health, a voice AI platform, just raised $120 million to automate patient calls, scheduling, intake, referrals, and payments. The money pouring into this space tells you where front-office work is heading. There is real efficiency here, especially for the routine calls that eat your intake team's day. But read the room this week. The same automation that saves you time can bill a claim you cannot defend if no human reviews it. Adopt the efficiency, but keep the human in the loop. Ask any vendor to show you exactly where a human reviews the work before it bills. If they cannot point to it, you are the one who answers for it when the audit comes.
Anticipating Future Referral Dynamics: Understanding Top Nonprofit Health Systems by 2025 Revenue
All
· MOD
A new forecast ranks the top nonprofit health systems by 2025 revenue, and these are the systems that will dominate referral flow in most markets. Knowing who they are is the first step to building a referral strategy around them. If one of these systems operates in your service area, understand their discharge patterns, their priorities, and where home-based care fits their plans. The agencies that build relationships with the biggest referral sources before their competitors do are the ones that grow without fighting for scraps.
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7.
Retention Tip
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New Report Outlines AI Opportunities and Risks for Home Care Agencies
All
· MOD
The National Council on Aging put out a report on AI in home care, and the line that matters most is this: AI should support human judgment, not replace it. That framing is exactly right, and it applies to retention more than people realize. Your staff do not fear tools that make their jobs easier. They fear being replaced by them. When you bring in AI, frame it as something that takes the administrative weight off their shoulders so they can do the work they actually trained for. Tools that respect your clinicians keep your clinicians. Your users are more important than your savings.
Hospice Leaders Explore AI for Workforce Support and Operational Efficiency
Hospice
· MOD
Hospice leaders are moving AI from conference-room theory to real operational use: easing administrative load, improving communication, supporting clinical decisions. The retention angle is the part worth holding onto. When AI takes the friction out of a clinician's day, you give them back the time they came into hospice to spend, sitting with patients and families. Used right, AI is not a threat to the human element of hospice. It is what protects it by taking everything that is not the human element off your clinician's plate.
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8.
Case Snapshot
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A $1.2 Million Reminder That Eligibility Is Not a Formality
Hospice
· MOD
Horizons Hospice, later renamed 365 Hospice, agreed to pay 1.24 million dollars to settle False Claims Act allegations that it billed Medicare and Medicaid for patients who did not qualify for end-of-life care. The government alleged the agency claimed billable care for patients who lacked a terminal prognosis of six months or less, and that clinical documentation was fabricated to support those claims. Several former medical staff and managers had already pleaded guilty to or been sentenced for healthcare fraud. This is exactly the profile the OIG just flagged: hospice patients whose eligibility cannot be defended by the clinical record.
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9.
Case Outcome
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What Defensible Eligibility Actually Looks Like
Hospice
· MOD
The contrast with a compliant agency is simple. A defensible admission has a documented decline trajectory, a physician narrative tying the clinical picture to a six-month prognosis, and supporting evidence that any reviewer can follow without knowing the patient. It does not rely on memory, assumption, or a referral source's word. The agencies that survive this enforcement wave are not the ones who admit fewer patients. They are the ones whose every admission and recertification is backed by a clinical story that stands on its own. When the OIG tells you which charts they are going to pull, the time to build that story is at intake, not under subpoena. There should be an additional audit defense copy in every chart to ensure readiness.
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10.
Lighter Side
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The Real Red Flag
Hospice
· LOW
The OIG flagged hospice patients with no prior acute care as high risk. Meanwhile, every hospice nurse knows the real high-risk patient is the one whose family says "oh, she's been doing this for years" thirty seconds before you realize exactly how long this admission visit is going to take.
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TrueTime Health
Eligibility. Compliance. Certainty.
Home Health · Hospice · Personal Care
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