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CMS’ fraud crackdown was a recurring topic at the National Alliance for Care at Home’s Annual Meeting & Expo this week in Washington, from the main stage to breakout sessions to hallway conversations.
I left the event thinking the home health enrollment moratorium’s next chapter might not be a simple choice between extending the nationwide freeze and letting it expire. CMS has options, including a potential gold card approach that would give established providers with strong compliance records a path to expand. Geographic limits are on the table, too. My bet is that CMS finds a middle path — though whether that offers meaningful relief will depend on the details.
Meanwhile, providers were awaiting the home health final rule, with payment rates and broader enrollment proposals still hanging in the balance. Even if CMS opens a door for expansion, it could tighten scrutiny elsewhere.
In this week’s exclusive, members-only HHCN+ Update, I’m writing from the airport to share key takeaways from the Alliance’s annual event, including:
- Why a “gold card” option could become the moratorium’s middle path
- The potential for a smaller freeze, but a wider compliance net
- The relationship between the moratorium and the payment rule
Creative moratorium solutions
In the opening mainstage panel, Brandt said that the home health industry has shared a slew of creative solutions to limiting the number of compliant providers caught in the program integrity net. One that she mentioned was a gold card approach.
Denis Fleming Jr., the Alliance’s chief government affairs officer, described the gold card system as a potential program in which CMS would provide exceptions to the moratorium for existing providers with strong compliance track records.
Costco’s gold star-level membership seems to be popular, and a potential CMS gold card model would likely be popular too, based on my conversations at the event.
The benefit here wouldn’t be access to bulk groceries, but a path for established, compliant providers to open new locations. Brandt acknowledged that CMS has heard concerns from existing operators that want to expand, particularly into rural areas, but are running into the enrollment restrictions.
That’s what makes the gold card idea worth watching. CMS could keep a barrier in place for new entrants while giving providers with demonstrated compliance records a way to keep growing. For communities where access is already strained, that could be more than a perk for the provider.
Of course, the details would make or break it. Neither Brandt nor Fleming laid out potential criteria for such a program, and CMS has not announced a gold card program. Brandt said the agency was working with its counsel’s office on potential solutions. Still, hearing a CMS leader openly consider the idea struck me as a meaningful opening.
A gold card also wouldn’t solve every problem. An exception for established operators would not necessarily help a legitimate new provider trying to enter the market. And the roughly 250 home health agencies blocked from enrollment during the moratorium should not be confused with 250 proven fraudsters. That number tells us how many agencies were not approved, not how many were doing something wrong.
Gold cards aren’t the only option on the table. Brandt also raised geographic limitations, which could allow CMS to focus its enrollment restrictions on certain markets rather than keeping a nationwide freeze in place.
CMS could also allow the moratorium to expire and instead apply other tools, including those used for hospice. That would not necessarily mean easing up on fraud. As Hillary Loeffler, BrightSpring Health Services’ (Nasdaq: BTSG) new vice president of federal government relations, pointed out during a separate panel, a moratorium stops new entrants; it does not, by itself, remove fraudulent providers already in the program.
On the flip side, a narrower moratorium would not necessarily mean a lighter compliance load. In that same session, Katie Wehri, the Alliance’s vice president for regulatory affairs, quality and compliance, warned about broader proposed enrollment requirements and the staffing and financial resources providers need to respond to mounting scrutiny. Relief on expansion could coexist with more oversight elsewhere.
After hearing the options discussed at the event, my bet is that CMS moves toward a modified moratorium rather than a blanket extension or expiration. I’ll be watching whether that middle path gives compliant providers a usable route forward.
Final home health rule loading
The Alliance’s event took place as providers awaited the Medicare home health final rule, which typically drops around Halloween. Panelists and attendees discussed possible timing and contents of the final rule. CMS’ July proposal included an aggregate payment increase of 2.4% and a temporary 3% reduction to the 2027 national, standardized payment rate.
It also included other measures, such as fraud-fighting tools, an RFI to develop a home health-specific wage index and a discussion of expanding access to palliative care.
Kim Brandt, CMS’ deputy administrator and chief operating officer, linked CMS’ anti-fraud efforts to more favorable payment rates, arguing that money going to bad actors was money taken away from compliant providers. But with a proposed 3% temporary adjustment still in the mix, I’m watching for how that anti-fraud progress translates into meaningful payment relief for legitimate operators.
I avoided going too in depth into the conversations surrounding the rulemaking process in this Update because, well, anything I write now could be moot in a matter of minutes. But the Alliance staff assured attendees they were closely watching for the final rule’s publication and would share their thoughts on what it means for the home health industry.
HHCN is watching too and will ensure readers know the details as soon as possible.
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