The Regulator

Georgia gets nearly $219 million in Rural Health Transformation money, with Florida at $193.7 million the same day. The Centers for Medicare & Medicaid Services (CMS) announced both awards October 23 under the $50 billion Rural Health Transformation Program, which is funded by the law the administration calls the Working Families Tax Cuts Act. Georgia’s money backs five initiatives: clinician recruitment, training and residencies, mobile clinics and telehealth pods, rural hospital technology such as electronic records and cybersecurity, modernized rural hospitals and clinics, and services across 126 rural and partially rural counties. Florida’s award funds telehealth, remote patient monitoring, pharmacy-based services, diagnostic kiosks and community paramedicine, with $81 million going to Northwest Florida per Rep. Jimmy Patronis. Who it hits: rural hospitals, clinics and vendors in both states, which will compete for sub-awards. So what: neither release breaks the money out by initiative, names individual recipients, or sets application or spending deadlines, so the dollars cannot yet be traced to specific providers. Confidence: High on the totals; Low on who is funded. Sources: CMS Georgia press release, CMS Florida press release.

California: 103 home care providers face felony charges over more than $4.5 million, days after CMS deferred another $1.2 billion in federal Medicaid payments. California Attorney General Rob Bonta announced October 22 that a year-long statewide effort produced 103 felony cases against providers in In-Home Supportive Services, the state program that pays caregivers to help low-income elderly and disabled residents at home, alleging they defrauded Medi-Cal, California’s Medicaid program. Separately, trade press reports that CMS Administrator Mehmet Oz announced the $1.2 billion deferral October 20, citing personal care spending growth of about 24% over three years, roughly double the national rate. A deferral delays federal payment until the state documents that claims meet federal rules. It does not cancel the money. California’s Medicaid director has argued the growth reflects a deliberate shift to cheaper home-based care, per the same reporting. Who it hits: California’s counties and caregivers, and the state budget if the funds are not released. So what: the $4.5 million alleged in the criminal cases is under 0.4% of the amount deferred, so the two actions measure very different things. Confidence: High on the 103 cases; Med on the deferral, because we could not find CMS’s own release and rely on reporting by Becker’s and Home Health Care News. Sources: HHS Office of Inspector General listing of the California Attorney General announcement. Supplemental: Becker’s Payer Issues, Home Health Care News.

74%: two dialysis chains now hold about that share of the U.S. dialysis market, up from roughly 59% in 2006, according to a Department of Health and Human Services (HHS) plan released October 20. The Kidney Care National Plan blames consolidation and entry barriers, including capital-heavy facility requirements for new dialysis suppliers, and says private insurance pays up to 500% of Original Medicare rates for dialysis. It also reports that end-stage kidney disease cost Original Medicare about $24.4 billion and Medicare Advantage $27.7 billion in 2023, an all-time high, and that about 16% of dialysis patients dialyzed at home in 2023. The plan’s other pillars are prevention (about 87% of adults with chronic kidney disease do not know they have it) and transplant reform, including accountability for organ procurement organizations. Who it hits: the two largest dialysis operators, commercial insurers paying their rates, and transplant organizations. So what: this is a policy direction, and the National Kidney Foundation says it sets no new payment rates, coverage requirements or deadlines. We did not find a proposed rule. Confidence: High on the figures as stated by HHS; Low on any near-term payment effect. This plan was released five days ago and we had not covered it. Sources: HHS Kidney Care National Plan. Supplemental: National Kidney Foundation statement.

Maryland: a federal jury convicted a laboratory owner in an $18.7 million Medicare respiratory testing scheme aimed at nursing homes. The Justice Department and the U.S. Attorney’s Office for the District of Maryland announced the verdict October 20. Prosecutors said he billed Medicare for expensive respiratory tests that nursing home residents did not need, that physicians did not order, and that in many cases were never performed, exploiting facilities that needed COVID-19 testing during the pandemic. Who it hits: Medicare, which paid the claims, and nursing homes whose residents were billed for tests. So what: the announcement does not give a sentencing date or maximum penalty, and billed amounts are what prosecutors alleged, not necessarily what Medicare paid. Confidence: High on the conviction; Low on the final loss figure. Sources: HHS Office of Inspector General listing of the Justice Department announcement.

Missouri surgeon sentenced for taking $379,000 in sham consulting fees from a spinal implant maker. Jason Montone, a surgeon from Lawson, Missouri, received one year of supervised release and must forfeit $379,000, the amount of consulting fees he received from SpineFrontier, Inc., according to an announcement posted October 22 from the U.S. Attorney’s Office for the District of Massachusetts. He had pleaded guilty in October 2020 to conspiracy to violate the Anti-Kickback Statute and to obstructing the federal investigation. Judge Indira Talwani presided. A Kansas medical device distributor was sentenced in the same case; the announcement as posted does not give that sentence. Who it hits: surgeons and device makers who pay or accept consulting fees tied to product use. So what: the forfeiture equals the fees, which shows prosecutors treating the payments themselves as the proceeds of the scheme. Confidence: High on the sentence; Low on the distributor’s outcome. Sources: HHS Office of Inspector General listing of the Justice Department announcement.