Compliance Monitor (04/15/2025)

Overall respiratory illness activity in the United States 

https://www.cdc.gov/respiratory-viruses/data/index.html

As Dr. Mehmet Oz completes his first week as the 17th Administrator of the Centers for Medicare & Medicaid Services (CMS), he is sharing his agenda and vision for the agency.  We aim to mark our Make America Healthy Again efforts with curiosity, courage, competence, and compassion. Under his leadership, CMS will work to modernize Medicare, the Marketplaces and Medicaid, so Americans get the care that they want, need, and deserve. This includes: 

• Empowering the American People with personalized solutions they can better manage their health and navigate the complex health care system. As a first step, CMS will implement the President’s Executive Order on Transparency to give Americans the information they need about costs. 

• Equipping health care providers with better information about the patients they serve and holding them accountable for health outcomes, rather than unnecessary paperwork that distracts them from their mission. For example, CMS will work to streamline access to life saving treatments. 

• Identifying and eliminating fraud, waste, and abuse to stop unscrupulous people who are stealing from vulnerable patients and taxpayers. 

• Shifting the paradigm for health care from a system that focuses on sick care to one that fosters prevention, wellness, and chronic disease management.  For example, CMS operates many programs that can be used to focused on improving holistic health outcomes.  

The U.S. Department of Health and Human Services (HHS) announced a dramatic restructuring in accordance with President Trump’s Executive Order, “Implementing the President’s ‘Department of Government Efficiency’ Workforce Optimization Initiative.” 

It will streamline the functions of the Department. Currently, the 28 divisions of the HHS contain many redundant units. The restructuring plan will consolidate them into 15 new divisions, including a new Administration for a Healthy America, or AHA, and will centralize core functions such as Human Resources, Information Technology, Procurement, External Affairs, and Policy. Regional offices will be reduced from 10 to 5. 

For more detailed information, visit the fact sheet. 

CMS) is taking action to preserve the core mission of the Medicaid program by putting an end to spending that duplicates resources available through other federal and state programs or isn’t directly tied to healthcare services.  Mounting expenditures, such as covering housekeeping for individuals who are not eligible for Medicaid or high-speed internet for rural healthcare providers, distracts from the core mission of Medicaid, and in some instances, serves as an overly-creative financing mechanism to skirt state budget responsibilities.  

CMS sent a letter to states notifying them that it does not intend to approve new or extend existing requests for federal matching funds for state expenditures on these two types of programs — designated state health programs (DSHP) and designated state investment programs (DSIP).  DSHPs and DSIPs are state-funded health programs that, without “creative interpretations” of section 1115 demonstration authority, would not have qualified for federal Medicaid funding. 

As CMS continues to focus on the statutory objectives of the Medicaid program and improving health outcomes for the most vulnerable, the agency is refocusing its resources on Medicaid programmatic goals. To ensure this vital safety net continues to be available in the future, CMS is taking this action to safeguard the financial health of the Medicaid program. While CMS will continue to work with states on innovative state section 1115 demonstrations, those demonstrations should be focused on improving health outcomes of the most vulnerable dependent on Medicaid. 

To view the letter to states, visit https://www.medicaid.gov/resources-for-states/downloads/dshp-dsip.pdf  

The Fiscal Year 2026 Hospice Wage Index and Payment Rate Update and Hospice Quality Reporting Program Requirements [CMS-1835-P] was posted on the Federal Register Public Inspection desk on 4/11/2025.  

Read the CHAP summary of the proposed rule. 

Learn about updates for claims (PDF) received on or after April 1, 2025: 

• Updated guidance on non-reportable principal diagnosis codes 

• Clarified liability for claim denials during a hospice election 

• Added related conditions to the Medicare Claims Processing Manual, Chapter 11 (PDF), section 50 

• Review the Change Request 13882 – Page 7 of the change Request lists an updated list of unacceptable principal diagnosis codes under the hospice benefit 

• Review the MLN Matters article  

Rep. Erin Houchin (R-IN) introduced a bill, HR 2437, to amend title XVIII of the Social Security Act to require hospitals to provide information on available hospice programs to certain individuals upon discharge under the Medicare program.  This Act may be cited as the “End-of-life Access to Supportive and Essential care Act of 2025” or the “EASE Act of 2025”. 

(a) In general.—Section 1861(ee)(2)(D) of the Social Security Act (42 U.S.C. 1395x(ee)(2)(D)) is amended— 

(1) by inserting “, home health services,” after “including hospice care”; 

(2) by striking “including the availability of home health services through individuals and entities” and inserting the following: “including— 

“(i) in the case of individuals who are likely to need home health services, the availability of such services through home health agencies”; 

(3) by striking “listed by the hospital as available and, in the case of individuals who are likely to need post-hospital extended care services,” and inserting the following: “listed by the hospital as available; 

“(ii) in the case of individuals who are likely to need post-hospital extended care services,”; 

(4) by striking the period and inserting “; and”; and 

(5) by adding at the end the following new clause: 

“(iii) in the case of individuals who are likely eligible for hospice care, the availability of such care through hospice programs that participate in the program under this title and that serve the area in which the patient resides.”. 

(b) Effective date—The amendments made by paragraph (1) shall apply with respect to discharges occurring on or after January 1, 2026. 

This newsletter contains information for home health agencies (HHAs) related to the expanded Home Health Value-Based Purchasing (HHVBP) Model, including Model highlights, training updates, new insights, reminders, resources, and contact information. IN THIS ISSUE:  

• Interim Performance Reports (IPRs) – Final January 2025 IPRs Available on iQIES  

• Public Reporting – First Performance Year Results Now Available in the Provider Data Catalog  

• Getting Ready for the CY 2025 Measure Set – Available and Upcoming Resources  

• Help Desk Highlights  

• Contact Information 

The March 2025 Quarterly Confidential Feedback Reports for the fiscal year (FY) 2026 Skilled Nursing Facility Value-Based Purchasing (SNF VBP) Program are now available to download via the Internet Quality Improvement and Evaluation System (iQIES). 

These reports contain interim stay-level data for the SNF 30-Day All-Cause Readmission Measure (SNFRM) for 10/1/2023 – 6/30/2024 (Quarter 1 – Quarter 3 of FY 2024, the FY 2026 SNF VBP Program performance period). The interim data contained in these reports are not final and are subject to change; thus, they are not eligible for the SNF VBP Program’s Review and Correction process.  

These reports contain stay-level data for the SNFRM protected by the Health Insurance Portability and Accountability Act of 1996 (HIPAA). Any disclosure of protected health information (PHI) or personally identifiable information (PII) should only be in accordance with, and to the extent permitted by, the HIPAA Privacy and Security Rules and applicable law. When referring to the contents of the report, use the Line Number (located in the leftmost column of the ‘SNFRM Eligible Stays’ tab) of the stay in question. 

To locate your new report in iQIES, please follow the instructions listed below: 

1. Log into iQIES at https://iqies.cms.gov/ using your Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) user ID and password. (If you do not have a HARP account, you may register for a HARP ID.) 

2. In the Reports menu, select My Reports. 

3. From the My Reports page, locate the MDS 3.0 Provider Preview Reports folder. Select the MDS 3.0 Provider Preview Reports link to open the folder. 

4. Here you can see the list of reports available for download. Locate the desired SNF VBP Program Quarterly Confidential Feedback Report. 

5. Once located, select More next to your desired SNF VBP Program Quarterly Confidential Feedback Report and the report will be downloaded through your browser. Once downloaded, open the file to view your facility’s report. 

For additional questions about accessing your SNF’s report, which can only be accessed in iQIES, please contact the iQIES Service Center by phone at (800) 339-9313 or by email at iqies@cms.hhs.gov. 

For more information about the SNF VBP Program, please visit the CMS website: https://www.cms.gov/medicare/quality/nursing-home-improvement/value-based-purchasing  

For additional questions, please contact the SNF VBP Program Help Desk at SNFVBPquestions@cms.hhs.gov. 

The HHA Provider Preview Reports have been updated and are now available. These reports contain provider performance scores for quality measures, which will be published on the compare tool on Medicare.gov and the Provider Data Catalog (PDC) during the July 2025 refresh. 

Data contained within the Provider Preview Reports are based on quality assessment data submitted by HHAs from Quarter 4, 2023 through Quarter 3, 2024. The data for the claims-based measures will display data from Quarter 1, 2022 through Quarter 4, 2023 for the Discharge to Community and Medicare Spending Per Beneficiary measures, Quarter 1, 2021 through Quarter 4, 2023 for the Potentially Preventable 30-Day Post-Discharge Readmission measure, and Quarter 1, 2023 through Quarter 4, 2023 for the Home Health Within-Stay Potentially Preventable Hospitalization measure. Additionally, the data for the HHCAHPS measures will display data from Quarter 1, 2024 through Quarter 4, 2024. 

Providers have until May 2, 2025, to review their performance data. Only updates/corrections to the underlying assessment data before the final data submission deadline will be reflected in the publicly reported data on Medicare.gov. If a provider updates assessment data after the final data submission deadline, the updated data will only be reflected in the Facility-Level Quality Measure (QM) report and Patient-Level QM report. Updates submitted after the final data submission deadline will not be reflected in the Provider Preview Reports or on Medicare.gov. However, providers can request a CMS review of their data during the preview period if they believe the displayed quality measure scores within their Provider Preview Reports are inaccurate.                                                                                             

For those users experiencing issues locating their agency’s HHA Provider Preview Reports, follow the steps outlined below: 

1. Log into iQIES using your Health Care Quality Information Systems (HCQIS) Access Roles and Profile (HARP) user ID and password. (If you do not have a HARP account, you may register for a HARP ID.) 

2. From the Reports menu, select My Reports. 

3. From the My Reports page, locate the HHA Provider Preview Reports folder. Select View Folder to open the folder. 

4. Displayed for you is a list of reports available for download. The reports or files are listed in descending order and the newest files are displayed at the top of the list. 

5. Select the desired HHA Provider Preview Report name link and the report will display. 

In 2023, the improper payment rate for lower limb orthoses was 36.6%, with a projected improper payment amount of $92 million (see 2023 Medicare Fee-for-Service Supplemental Improper Payment Data (PDF), Appendix D). Learn how to bill correctly for these services. Review the Lower Limb Orthoses provider compliance tip for more information, including: 

• Billing codes 

• Denial reasons and how to prevent them 

• Billing and coding criteria 

• Example of improper payments due to insufficient documentation 

• Resources 

• Home infusion therapy (PDF): 
  • Utilization for service visits 
  • Characteristics of users and supplier organizations 

• Home intravenous immunoglobulin (IVIG) (PDF): 
  • Number of beneficiaries with claims that included a primary immunodeficiency disease diagnosis 
  • Utilization of home IVIG drugs and visits 
  • Characteristics of home visit recipients and supplier organizations 

CMS Finalizes 2026 Payment Policy Updates for Medicare Advantage and Part D Programs 

CMS released the Calendar Year (CY) 2026 Rate Announcement for the Medicare Advantage (MA) and Medicare Part D Prescription Drug Programs that finalizes the payment policies for these programs. This release — combined with the CY 2026 MA and Part D final rule that was released on April 4 — makes annual routine and technical updates to the MA and Part D programs.  

Payments from the government to MA plans are expected to increase on average by 5.06% from 2025 to 2026. This is an increase of 2.83 percentage points since the CY 2026 Advance Notice, which is largely attributable to an increase in the effective growth rate. 

CMS is also completing a three-year phase-in of improvements to the MA risk adjustment model that the agency finalized in the CY 2024 Rate Announcement, with the first year of the three-year phase-in starting with CY 2024.  

CMS is concurrently releasing the Final CY 2026 Part D Redesign Program Instructions that continue to implement the redesign of the Medicare Part D program. These instructions contain a detailed description of, and guidance related to, changes to the Part D drug benefit in place for CY 2026.  

Read the CMS Summary of the rule 

You must report all current managing employees on your Medicare enrollment application, or we may deactivate your enrollment.  

You can make updates by:  

• Submitting an 855 enrollment application in PECOS 

• Mailing a paper application to your Medicare Administrative Contractor (MAC) or DME National Provider Enrollment Contractor (NPE) (PDF) 

Managing employees are general managers, business managers, administrators, directors, or other individuals who exercise operational or managerial control or directly or indirectly conduct day-to-day operations. 

While not an exhaustive list, these roles qualify as managing employees: Chief Executive Officer, Chief Operating Officer, Chief Financial Officer, Compliance Officer 

• Regional Manager, Clinical Manager, Operations Manager, Care Coordination Manager, Location Manager, Administration Manager 

• Compliance Director, Clinical Director 

Contact your MAC or NPE if you’re unsure if an individual meets the definition. 

To learn more, see the Medicare Program Integrity Manual, Chapter 10 (PDF). 

The External User Services (EUS) Help Desk website has a new URL and contact information: 

• Website: https://eus.cms.gov 

• Email: EUS_Support@cms.hhs.gov 

• Phone: 866-484-8049