Compliance Monitor (09/29/2025)

The Federal Register posted a 30-day notice that authorizes the HHS Secretary to “develop or demonstrate improved methods for the investigation and prosecution of fraud in the provision of care or services under the health programs established by the Social Security Act (the Act).” Pursuant to this authority, the CMS seeks to develop and implement a Medicare demonstration project, which CMS believes will help assist in developing improved procedures for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHA) providing services to Medicare beneficiaries.   

This revised demonstration helps assist in developing improved procedures for the identification, investigation, and prosecution of potential Medicare fraud. The demonstration helps make sure that payments for home health services are appropriate through either pre-claim or post payment review, thereby working towards the prevention and identification of potential fraud, waste, and abuse; the protection of Medicare Trust Funds from improper payments; and the reduction of Medicare appeals. CMS has implemented the demonstration in Illinois, Ohio, North Carolina, Florida, and Texas with the option to expand to other states in the Palmetto/JM jurisdiction. 

Providers in the demonstration states may participate in either 100 percent pre-claim review or 100 percent post payment review. These providers will continue to be subject to a review method until the HHA reaches the target affirmation or claim approval rate. Once an HHA reaches the target pre-claim review affirmation or post-payment review claim approval rate, it may choose to be relieved from claim reviews, except for a spot check of their claims to ensure continued compliance.  

Comments on the collection(s) of information must be received by the OMB desk officer by October 25, 2025. 

CMS) is hosting two in-person events to combat fraud involving health plan identifiers (ID) and enhance the security of those IDs. These collaborative events will bring together experts from diverse backgrounds to develop innovative ways to protect patient information. 

Attendees will spend a full day working in small teams of diverse, professional backgrounds to develop ideas to improve member ID security. At the end of the day, each group will pitch their solutions to CMS and vote on a winning concept. 

CMS is seeking participants who can offer varied perspectives to better protect patient information. No advance preparation is required, and you do not need technical skills to participate. 

Event Dates:  

• November 5, 2025, 9:00 AM – 5:00 PM PST, San Francisco, California   

• November 13, 2025, 9:00 AM – 5:00 PM EST, New York, New York  

To learn more, view the event webpage. To participate, submit an interest form by September 26, 2025.  

On October 1, 2025, the Hospice Outcomes and Patient Evaluation (HOPE) tool will replace the current Hospice Item Set (HIS). HOPE includes a combination of existing HIS items, revised, and new items. Once implemented, all HOPE records will be submitted to CMS via the Internet Quality Improvement and Evaluation System (iQIES).  

Final materials, resources, and trainings are available to assist providers and staff with  a successful implementation of HOPE. These are posted on CMS’HQRP website and include: 

1. The HOPE Guidance Manual v1.01, corresponding items sets, and the change table on the HOPE 
2. HOPE Data Specs and Vendor training on the HOPE Technical Information  
3. HOPE Training materials on the HQRP Training and Education Library page:  

• Course 1: Didactic Recorded Training Series  
• Course 2: Coding Workshop  
• HOPE Implementation Frequently Asked Questions (FAQs)  
• HOPE Tool Web-Based Training  

All of these resources can be accessed either from direct links or in the Downloads section on the webpages listed above. 

For additional questions about HOPE implementation or the HOPE tool, email:  HospiceQualityQuestions@cms.hhs.gov. 

HQRP: Achieving a Full Annual Payment Update (APU) Training 

The Centers for Medicare & Medicaid Services (CMS) is offering a recorded presentation that provides an overview to the Annual Payment Update (APU) for HQRP. 

• To access the training, click on the following link: https://youtu.be/x49Xtn5GpSc 

• A copy of the slides and a transcript of this presentation can be found in the downloads section at the bottom of the HQRP Training and Education Library 

In 2023, the improper payment rate for manual wheelchairs was 42.6%, with a projected improper payment amount of $42.8 million (see 2023 Medicare Fee-for-Service Supplemental Improper Payment Data (PDF)). Learn how to bill correctly for these services. Review the Manual Wheelchairs provider compliance tip for more information, including: 

• Billing codes 
• Denial reasons and how to prevent them 
• Documentation requirements 

Learn about updates (PDF) effective October 1, 2025: 

• Added and deleted HCPCS codes 
• Corrected 2024 deflation factors 

The Trump Administration announced its Unified Agenda of Regulatory and Deregulatory Actions, which provides the American people with a transparent look at regulations being considered by the Administration and ensures the public is engaged throughout the process. 

Including nearly 150 proposals under the U.S. Department of Labor’s jurisdiction, the agenda reflects President Trump’s ongoing commitment to protect workers, support business growth, and ultimately put American workers and businesses first. 

CMS released new Fast Facts (PDF) about the ways we’re making sure people aren’t enrolled in more than one state Medicaid program or enrolled in both Medicaid and a Marketplace plan. Duplicate enrollment wastes taxpayer dollars and puts added strain on an already burdened health care system. Individuals identified with potential duplicate enrollment may need to take action to ensure they’re enrolled only in the program they’re eligible for. 

We’re taking action to safeguard taxpayer funds and enhance the public’s confidence in these vital programs. Visit CMS.gov/fraud for more fast facts and resources.  

Your patients may tell you they’re having trouble remembering things, concentrating, or making everyday decisions. Their Medicare Summary Notice highlights that Medicare Part B covers a visit with their doctor or a specialist to talk about it and do an exam. 

Recommend appropriate Medicare services, including:  

• Cognitive Assessment & Care Plan Services  
• Preventive Services  

 Information for patients:  

• Cognitive assessment & care plan services  
• Preventive & screening services  

Register for this free, one-hour webcast introducing AHRQ’s new Consumer Assessment of Healthcare Providers and Systems (CAHPS^®) End-of-Life Care Survey. Join leading experts as they discuss why the survey was developed, how it was tested, and best practices for successful implementation. Kaiser Permanente will share lessons learned from field testing the survey in their end-of-life care programs.