Category: Regulation

CMS Releases Updated Information about PECOS

Are your ordering/referring  physicians enrolled in PECOS?

On June 20th CMS released a revised MLN Matters article with updated information regarding PECOS and Phase 2 of the Ordering/Referring Physician Requirements.

During Phase 2, Medicare will deny Part A HHA claims that fail the ordering/referring provider edits. CMS has not announced a date when the edits for Phase 2 will become active. CMS will give the provider community at least 60 days notice prior to turning on these edits. Physicians and others who are eligible to order and refer items or services need to establish their Medicare enrollment record (PECOS).

It is possible that it could take 45-60 days, sometimes longer, for Medicare enrollment contractors to process enrollment applications. All enrollment applications, including those submitted over the web, require verification of the information reported. Sometimes, Medicare enrollment contractors may request additional information in order to process the enrollment application.

Waiting too late to begin this process could mean that physicians’ enrollment applications will not be able to be processed prior to the implementation date of Phase 2 of the ordering/referring provider edits. In Phase 2, if the Ordering/Referring Provider does not pass the edits, the claim will be denied.This means that the billing provider will not be paid for the items or services that were furnished based on the order or referral. For more information Click Here

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New Code to Report Date of Death on Medicare Claims

October is months away but be prepared…Effective Oct.1, 2012 Medicare-certified agencies will use occurrence code 55 to indicate a date of death on claims.

The new occurrence code will be used in conjunction with all discharge status codes indicating the patient has expired – 20 (expired), 40 (expired at home), 41 (expired in a medical facility), or 42 (expired – place unknown)

Please note that hospices are not to use discharge status code 20 per Section 30.3 of Chapter 11 of the Medicare Claims Processing Manual. Additional information on the use of code 55 can be found in the MLN Matters and in the Change Request (CR) 7792

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Dual Eligible Services Demo RFR Now Available

The state’s Executive Office of Health and Human Services (EOHHS) has released the Request for Responses relative to the demonstration project to integrate care for dually eligible individuals.

The RFR is a solicitation for potential Integrated Care Organizations, or ICO’s, that will manage the integration of services and payment for dual eligibles aged 21-64. The Home Care Alliance is holding a special event for all agencies interested in this initiative. Please see the event in our Calendar section titled “Building Partnerships with Managed Care Plans for Dual Eligible Care” where special guest speakers will educate attendees on the demonstration and how agencies can play a key role. Potential ICO’s have also been invited for discussion and networking.

For those interested in viewing the  solicitation and corresponding materials, the instructions are below:

1)  In your browser, enter the URL for the Commonwealth’s procurement web page: www.comm-pass.com.

2)  Near the bottom of the page, click on the hyperlink that reads: “Search for Solicitations.”

3)  When the Search page comes up, scroll down to the section that says “Search by Specific Criteria” and in the document number box, enter the following: 12CBEHSDUALSICORFR.

4)  The Search result will appear as a hyperlink at the top of the new page. It should read: “There is 1 solicitation(s) found that match your search criteria.”  Click on this sentence and it will take you to the Comm-PASS listing for this solicitation.

5)  Click on “view” (the eyeglasses on the right) and you will get the summary page for the Request for Responses for Integrated Care Organizations.

6)   Click on the blue folder-type tab called “Specifications” and you will see the RFR documents and appendices that have been posted for this topic. In addition, the required forms that Respondents to the RFR will need to provide are available under the “Forms and Terms” tab.  To view the documents, click on the eyeglasses to the right of the title of each document,  .

The documents will also be posted shortly on our duals demonstration website, www.mass.gov/masshealth/duals, under “Information for Organizations Interested in Serving as ICOs.”

Responses to the RFR will be due to MassHealth by 4:00 PM (EDT), July 30, 2012.

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Hospice Quality Reporting Program Update

Hospices will be mandated-for the first time-to collect data on specific quality measures during the final calendar quarter of 2012 as part of the Hospice Quality Reporting Program. Failure by a hospice to submit the required data will result in a 2 percent reduction to that hospice’s payments during fiscal year 2014

In the June 4, 2012 Federal Register there is a notice regarding the data submission form to be used for reporting the required quality data. The Hospice Quality Reporting Program submission forms is now available, once you download the form click on “Hospice Mandatory Data Submission Form”.

For additional information about the Hospice Quality Reporting Program Click Here

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Senate Passes $32.4 Billion Budget with Telehealth Reimbursement

Building off the success of getting a telehealth amendment in the Senate’s Health Care Payment Reform bill, the Home Care Alliance earned a victory with the Senate also passing a telehealth amendment during their budget deliberations.

The amendment establishes MassHealth reimbursement for telehealth services provided by home health agencies through regulations that have yet to be determined. The next step for the initiative, though, is to get through a conference committee where the House and Senate meet to hammer out the differences in their separate budget proposals. That final product is then sent to the Governor for his approval.

The Alliance will have new advocacy messages available on the Legislative Action Center once the legislature’s budget conference committee is named.

The Alliance’s other priorities pertaining to Certificate of Need, home health nursing rates past 60 days of care, and relative to pediatric home care were not passed, although the certificate of need issue is seeing increased interest. This and the passage of telehealth owe credit to the hundreds of emails sent out by HCA members and advocates through the Legislative Action Center.

The other major item that the Senate approved was the Human Service Salary Reserve worth $20 million. This account to provide a slight increase in pay for 31,500 human service workers in the state was not approved by the House and will be a huge bargaining chip in conference committee negotiations. If passed, the increase in pay would amount to about $12 per week, per worker.

Other amendments of note that passed the Senate budget include a special commission to study causes, prevention and treatment strategies pertaining to Chronic Obstructive Pulmonary Disorder (COPD). This would present an opportunity for home care to promote their chronic disease management programs and telehealth services. Also passed was an amendment that would create an advisory committee on long-term services and supports. If passed in the state’s final budget, home care agencies would have a chance to be on the committee or at least to submit data and recommendations.

Finally, other rejected amendments from the Senate included items from the state’s Home Care Program from the Executive Office of Elder Affairs that funds the ASAP programs. Specifically, the amendments for Home Care Purchased Services, Enhanced Community Options, and Case Management were all denied.

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Guest Post: Fraud and Abuse Tied to MD Face-to-Face Encounters

The following is a guest blog post on fraud and abuse issues by Robert W. Markette, Jr., CHC, Of Counsel for
Benesch Friedlander Coplan & Aronoff LLP. Mr. Markette’s primary areas of practice are health law and litigation and his wide range of health care clients includes home health, hospice and private duty providers.

Mr. Markette is also responsible for assisting the Home Care Alliance with its “Keeping it Legal in Home Care” resources on patient choice.

To view the entire article, click the link after the introduction:

As home health and hospice care continue to become more and more competitive and reimbursement continues to decline, referral sources are discovering new ways to leverage this for their own benefit. Two new examples include physicians requesting “administrative fees” to complete face to face paperwork and referral sources seeking “donations” from providers to defray the cost of capital equipment and other improvements. Providers need to understand the risks in these arrangements in order to avoid entering into arrangements that place them in violation of the Anti-Kickback Statute and/or the Stark Law.

The entire article from Mr. Markette is available here.

 

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HCA Succeeds with Amendments to Senate Health Care Payment Reform Bill

The Massachusetts Senate spent the past week debating their landmark health care payment reform proposal, which included 265 amendments that were filed after Senate leadership released the bill to all Senators and the general public.

The Home Care Alliance worked to have several amendments filed and advocated for other amendments that were seen as beneficial.

The Alliance saw victories in the adoption of the following amendments:

  • Amendment #43, which instructs insurers to cover telemedicine.
  • Amendment #13, which allows employers to count a spouse or parent’s insurance coverage to qualify their employee under the state’s “fair share contribution” regulation.
  • Amendment # 223, which adds community-based behavioral providers to the e-Health Institute’s spectrum of care.
  • Amendment # 121, which requires hospitals, nursing homes, and assisted living facilities to provide appropriate patients with information regarding the availability of palliative care and end-of-life options.
  • An amendment installing a representative of a certified home care agency on an e-Health Commission.

The focus on health care payment reform will move to the House although the timing on that debate and process has not yet been formally announced. Stay tuned to our UPDATE newsletter and the HCA blog for the latest information. If members or advocates have any questions related to payment reform, please contact James Fuccione at the Alliance.

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Health Care Market Reform Is Advancing – What Does it Mean?

All three branches of government, the Governor’s office, the State Senate and the House of Representatives have all now weighed in with versions of health care marketplace reform.  Even with little time left on the legislative calendar and a state budget to craft, there seems no doubt that something will pass, perhaps quickly and with limited public input beyond what was provided to legislatures in the bill crafting stages.

All of the bills are about market and delivery system reform, with a strong emphasis on health care economics, payment reform at a very global letter and physician practice issues (medical homes, tort reform).  There is very little in either bill about specific sectors beyond hospitals and physicians.  In each bill there are limited mentions of “downstream” providers such as home health, hospice or adult day health.  Workforce training has some prominence in both legislative branch proposals, as does Health IT (with home care a named recipient of possible funds).  WBUR’s Commonhealth blog has a concise summary of the legislative proposals.

Where does this leave the debate and what does it mean for home health? At a very macro level, the Home Care Alliance has been working with a Coalition or providers and insurers on some principles to achieve sustainable reform without enormous disruption.   The Coalition position is that any law must balance the need to reduce costs with a recognition that the health care sector is a key part of the state’s economy and that any measure must not lead to excessive reduction of jobs.

The Coalition is looking to support a bill that:  1) includes a voluntary (rather than mandatory) transition to integrated, globally paid systems; 2) preserves some fee-for-service payment where it makes sense in the market; and 3) includes a reasonable and attainable spending growth target, which the Coalition put at getting total health spending to 1% above the states Potential Gross State Product (PGSP) within three years and to even with  PSGP within five years.  By contrast the House and Senate bills call for a more aggressive glide path for health care spending, with the House looking at limiting growth to one half percent below PSGP.   At a breakfast meeting with the Boston Chamber of Commerce this week,  the governor indicated some support for the Coalition’s spending targets and voluntary transition process.

In terms of home care and hospice, it is clear that all bills envision a more integrated and accountable approach to care delivery.  From what we have seen and heard relative to integration efforts that are already moving  forward (Pioneer ACOs, medical homes),  hospital utilization is targeted to go down and more care will be delivered in the home, both traditional home care/hospice and new chronic,  palliative, and care transitions services.  The goal is to be sure that these services are provided by the entities in this state that have the skills and experience to do it correctly.

However, the message from legislators is that much of what home care and hospice needs to do to ensure this may lie less in legislative language and more in market visibility:  in having confidence in what we do,  in being able to be more nimble pricing, and in demonstrating our effectiveness in reducing health care costs and delivering on quality.

The Alliance is supporting – beyond the Coalition principles above – reform language that would make more specific the language that exists in each bill about including home care services in integrated systems ACOs (Beacon ACOs, as the Senate bill calls them) and assuring our representation on certain governing task forces, such as that which will allocate state IT funds.

At the same time, we are also seeking to protect home cares services in the dual eligible demonstration and have invited Attorney General Martha Coakley’s office to our Annual Meeting to be sure that her efforts at looking the balance or imbalance in market power includes more than hospitals.  We have published and  made available to all provider groups and members a brochure on Home Care Role in a Global Payment Model.

Both our Board and our Legislative Committee are engaged in these efforts, but we need and welcome more member feedback about how we can continue to refine and advocate for a common industry position that assures home care a central role in the next chapter of healthcare reform.

Wage & Hour Legal Memorandum; Briefings Scheduled for Alliance Members

Over the past months, the Alliance’s Private Care Advisory Committee has held a series of discussions with employment law attorney Allyson Kurker regarding Massachusetts wage & hour laws as they relate to home care agencies and workers.  A labor law attorney with significant experience advising home care agencies, Ms Kurker has researched the broad range of questions raised during those discussions and has prepared a Legal Memorandum on Wage and Hour Issues especially for Alliance members.

The memorandum covers several topics of interest to certified and private care agencies alike, including record keeping and payroll, overtime, exempt vs. non-exempt employees, working time, and issues specific to live-in caregivers.  The Memorandum is posted to the MA Regulatory page of the Alliance’s website (link is at the bottom right).

The Alliance will host two free member forums this month during which Ms Kurker will present the substance of the memorandum and address additional questions from the Alliance membership.   Agency CEOs and HR specialists are especially encouraged to attend one of the sessions:  Tuesday, May 22, at Great To Be Home Care, 2024 Westover Road, Chicopee, or Thursday, May 24, at CareWell Health Group, 141 Longwater Drive, Norwell.

Both sessions will include a continental networking breakfast at 8:30 followed by an Alliance Update presented by Alliance Executive Director Patricia Kelleher at 9:15, and the Wage & Hour presentation at 9:30.

The sessions are open to Alliance members only.  Pre-registration is required by calling Stephanie Drakes at 617/482-8830.

House Releases Health Care Payment Reform Legislation

Nurses Hall in the State House was crowded with attendees eager to hear highlights of a long awaited bill on health care payment reform.

House Speaker Robert DeLeo and the Health Care Financing Committee’s House Chair Representative Steve Walsh announced their proposal that will be followed soon by a Senate version that will transition the state away from fee-for-service payments.

During his speech, Chairman Walsh said that the bill would save the state $160 billion over fifteen years and would bring full health IT interoperability to Massachusetts within five years. Accountable Care Organizations are not mandated, but are among options that providers can shift into from the current fee-for-service model. Chairman Walsh, in fact, mentioned four payment options that providers can choose: bundled, episodic, global and the patient centered medical home. He added that if there is an innovative model that does not include fee for service payments, a provider or provider group is welcome to bring that to the table as a proposal. Chairman Walsh also mentioned home health during his State House speech in reference to workforce development and although home care was not specifically mentioned in that section of the bill, it appears there would be an opportunity in the form of pilot projects and future policy recommendations.

At a quick glance, here are some other notable sections concerning home care:

  • Section 60: the Home Care Alliance is mentioned by name as having one representative on a special committee that will make recommendations on behavioral health services (page 67).
  • Section 105: Insurance coverage of physician assistant care is established “for purposes of health maintenance, diagnosis and treatment,” which includes “home care setting” as a covered benefit (page 128).
  • Section 109: The bill creates a new medical malpractice section that puts “home health agency” in the definition of a facility (page 133).

News outlets are beginning to release articles on the bill, including this story on Boston.com.

The Home Care Alliance will provide updates and more information as the bill continues to be examined.

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