Category: Regulation

Alliance Comments on Proposed PPS Rule

The Home Care Alliance of Massachusetts today submitted comments to CMS on the proposed rule for Medicare home health PPS.  In our comments, we recommend that CMS rescind the across-the-board 5.06% case mix reduction and instead use its enforcement authority to identify and prosecute those few agencies that inflate their billings.  The Alliance urges CMS to conduct a comprehensive review of the case mix system, with involvement of home health industry experts.

Regarding the proposed wage index changes and in light of the new rural floor wage index for hospitals in Massachusetts, we urge CMS to establish a policy to set the wage index for home health agencies to be equal to the wage index of the largest hospital within each CBSA if that hospital has been re-classified to another CBSA or qualifies for the rural floor wage index.

The Alliance also urges CMS to waive the Face-to-Face documentation requirement for patients discharged from an acute or post-acute care setting within 14 days of the home health admission, and recommends that CMS provide additional clarification to the “confined to the home” definition (and provides clarification and guidance to Medicaid programs to reduce wasteful TPL initiatives that hinge on the definition.

Alliance member agencies are urged to use the Alliance’s comments as a model to submit their own comments on the www.regulations.gov website.

Advocacy Needed During August Recess to Avoid Cuts and Co-Pays

A so-called Debt Reduction Super Committee evolved out of the federal debt ceiling debate and will be charged with reducing the federal deficit over the next ten years.

Although cuts to entitlement programs and home health co-payments are on the table as options, a potential bright spot was reported this week in that US Senator John Kerry (D-MA) is among the members appointed to the Super Committee. Kerry was instrumental in getting cuts to home health reduced as part of health care reform.

Even with the work of Senator Kerry, Medicare home health payments are still taking a $39.7 billion hit over the next ten years. Additionally, CMS is proposing a 5.06% reduction in payments for calendar year 2012. Both of those points need to be raised when this committee considers even deeper cuts that could drastically impact agencies and patients.

Home health co-pays are another option that must be broadly opposed. Seniors could be forced to pay as much as $150 per 60-day episode of home health care, which would only push those who cannot afford it or unwilling to pay into costlier care.

Below are issues and materials that advocates can use to contact the Massachusetts Congressional Delegation, not just during August recess, but as the discussion of the Super Committee progresses. There are also materials and advocacy messages that can be used to urge Congressional support of other home care initiatives.

Advocates should be contacting their Congressperson, as well as Senator Kerry, to ask that they in turn urge the Super Committee to oppose home care cuts and copays.

Home Care Co-Pays & Medicare Cuts:

Support Home Health Access Protection Act:

Support Home Health Planning Improvement Act:

See a list of other issues, talking points, and messages available on the HCA Legislative Action Center. You can also compose your own message here.

Return to www.thinkhomecare.org.

 

Public Hearing on Temporary Nursing Agency Regulation

The state’s Division of Health Care Finance & Policy (DHCFP) is holding a public hearing and accepting written comments on amendments to regulations regarding temporary nursing services.

According to an official hearing notice, DHCFP is required to review and establish maximum rates that temporary nursing agencies may charge facilities annually. The proposed regulation is estimated to result in an increase of 4.13%, or $2.56 million, in aggregate provider expenditures for temporary nursing services.

It should be noted that eighteen of the 108 nursing facility rates decrease, all in Health Service Area 3 – Merrimack Valley, due to a decrease in the median reimbursement paid to permanent staff at nursing facilities in that region, according to the notice.

The hearing will take place at 10:00am on Wednesday, September 7th at DHCFP Headquarters, located at 2 Boylston St in Boston. For more info on the regulation, visit the regulation page on DHCFP’s website (See or search 114.3 CMR 45.00)

Return to www.thinkhomecare.org.

CMS Responds to Congressional Letter on MD Face-to-Face

Congressman Jim McGovern, along with the rest of the state’s Congressional Delegation, received a response to a letter sent to the Centers for Medicare and Medicaid Services (CMS) that reflected the struggles of home health providers in Massachusetts relative to the physician face-to-face encounter requirement.

Unfortunately, the response from CMS is mostly a reiteration of the reasoning behind the rule and a commitment to monitor the implementation of the policy “to ensure that there are no unintended disruptions in access to medically necessary home health care for our beneficiaries.”

For more on the Physician Face-to-Face Encounter Requirement, see previous posts on the subject.

Return to www.thinkhomecare.org.

ADRs Increasing

Home Care Alliance members are reporting an increase in” additional documentation requests” or ADRs from the fiscal intermediary, NHIC.  Although there does not seem to be a pattern to the diagnoses requested, the majority are LUPAs. Additionally, many are being denied after the initial review and the first appeal.  Members are encouraged to continue the appeal process if you feel your decision has merit.

The fiscal intermediaries are required to do a certain percentage of review and it is usually around 10%.  This is in addition to the TPL process which created a backlog until recently and is why they may be “catching up” to their regular workload.

Members are encouraged to contact Helen Siegel at hsiegel@thinkhomecare.org with appeal results and/or if the number of ADRs seems unusually large.

OIG Examines Hospice Services for Nursing Facility Residents

A new report from the Office of Inspector General has found that Medicare spending on hospice care for nursing facility residents has grown nearly 70 percent since 2005.  Many hospices had a high percentage of their beneficiaries residing in nursing facilities, and most of these hospices were for-profit. Compared to hospices nationwide, these high-percentage hospices:

  • received more Medicare payments
  • had a longer average length of stay
  • served Medic are patients whose diagnoses required less complex care
  • served more patients who already lived in nursing facilities before they elected hospice care.

A previous OIG study published in September, 2009, concluded that Eighty-two percent of hospice claims for beneficiaries residing in nursing facilities did not meet Medicare coverage requirements.

The OIG report notes that Medicare currently pays hospices the same rate for care provided in nursing facilities as it does for care provided in the home, but nursing facilities are staffed with professional caregivers and are often paid by third party payers, such as Medicaid. These facilities are required to provide personal care services, which are similar to hospice aide services that are paid for under the hospice benefit.

The OIG concluded that some hospices may be seeking beneficiaries with particular characteristics, including those with conditions associated with longer but less complex care. Such beneficiaries are often found in nursing facilities. By serving these beneficiaries for longer periods, the hospices receive more Medicare payments, which can contribute to larger profits.

The OIG report recommends that CMS (1) monitor hospices that depend heavily on nursing facility residents and (2) modify the payment system for hospice care in nursing facilities. CMS concurred with both of our recommendations. It also agreed that the current payment structure may provide incentives for hospices to seek out beneficiaries in nursing facilities, who often receive longer but less complex care

The OIG website has a special page devoted to Medicare hospice issues.  The page includes links to the new report, a podcast interview with Jodi Nudelman, the Region II Inspector General for Evaluation and Inspections, and several other OIG studies of hospice issues.  This is the first in a series of three studies by the OIG of hospice services to nursing facility residents.  Additional studies will examine the marketing practices of hospices that focus on nursing home residents and the business relationships of such hospices with nursing facilities.

Return to www.thinkhomecare.org.

CMS Community-Based Care Transitions Program Update

The Centers for Medicare and Medicaid Services (CMS) has provided new guidance and updates on their Community-Based Care Transitions Program.https://i0.wp.com/www.gmcf.org/transitions/images/transitions_image.jpg

New panel review dates for submitting applications beyond August 18th have been posted and are as follows:

  • October 6 & 7, 2011 – Applications must be received by September 6th to be considered for this review.
  • November 15 & 16, 2011 – Applications must be received by October 14th to be considered for this review.
  • November 30 & December 1, 2011 – Applications must be received by October 28th to be considered for this review.

Secondly, more than a full page of new guidance has been added to the program’s Question & Answer section. Below are a few examples:

  • Q: How shall we anticipate to cover up front costs? I heard that CBOs would be paid a per eligible discharge rate that is determined by target population, interventions proposed, anticipated volume and expected reduction in readmissions (cost savings) Can you give a concrete example of how this payment methodology would work?

A: Because this program seeks to build off of earlier care transitions initiatives and requires applicants to have a track record in the delivery of care transition services we are not paying “start up” costs. CBOs will be paid on a monthly basis for services delivered in the previous month. This payment will be whatever the agreed upon per eligible discharge rate is multiplied by the number of eligible beneficiaries served in the previous month. Please refer to the budget worksheet available on our program webpage for additional guidance on developing the per eligible discharge rate.

A: These are the patient experience measures that CBOs will be required to collect and report during the program. We will provide the instruments to awardees at the time of award.

The Home Care Alliance has also made a webinar available on the experiences from a previous CMS care transitions demonstration program that worked through 14 QIO’s across the US. The webinar focuses on, among other things, drawing from the Home Health Quality Improvement campaign’s Best Practices Intervention Package.

More info from this newsfeed on care transitions is available here.

Return to www.thinkhomecare.org.

Therapy Changes Clarified in PPS Rule

As part of the Home Health PPS Update for Calendar year 2012, CMS also made some minor technical changes to the therapy assessment language found in the prior PPS update for 2011.

Currently the regulation reads that the qualified therapist from each discipline must provide the therapy service and functionally reassess the patient…during the visit which would occur close to but before the 19th visit per the plan of care.  The regulation will now read “…during the visit which would occur close to but no later than the 19th visit per the plan of care.

Additionally, CMS clarified when occupational therapy is considered a “dependent” service and when it is considered a “qualifying” service.

It is a dependent service when the beneficiary initially qualifies for the home health benefit beginning the first episode of care.  That is, the beneficiary’s eligibility for the home health benefit is established by virtue of a need for intermittent skilled nursing, speech language pathology or physical therapy. Then they are entitled to SN, PT, ST, HHA, MSW and OT.

When occupational therapy is the sole skilled service being provided in subsequent episodes after the benefit has been established it is considered a “qualifying service.”

Advocacy Alert: Oppose Co-Pays for Home Health

The debt ceiling negotiations are accelerating in Washington and a deficit reduction deal could be imminent.  Clearly, from news reports, we know that  Medicare cuts are under serious consideration, including the imposition of a home health co-payment.

The Medicare Payment Advisory Commission (MedPAC), the National Commission on Fiscal Responsibility and Reform, and the Congressional Budget Office have all supported a copayment as a deficit reduction measures.   Also on the table, as reported in today’s Boston Globe, a substantial cut to medical education funding for Massachusetts teaching hospitals.   Given the clear evidence that imposing copayments can lead to delaying accesses to needed services (adding costs longer term), home health must send a message to their Senators and Representative urging them to oppose a home health co-pays in deficit reduction negotiations.

Given that these decisions may be made as early as next week, we are asking that you contact our federal officials, especially Senators Kerry and Brown today.

You may send a message using the NAHC Legislative Action Network (NAHC LAN). To oppose home health co-pays and payment cuts, click here. The sample messages found on the NAHC LAN should be personalized to provide members of Congress with your background and the potential impact payment cuts and co-pays would have on senior and disabled Medicare beneficiaries and their families in your state and district.

We suggest also weighing in by phone.  When calling, ask to speak to the staffer who handles Medicare issues.  You may obtain contact information for your Senators and Representative here:  Contact Your Elected Officials.  For a sample phone message, click here.

Return to www.thinkhomecare.org.

 

CMS Proposes Medicare Home Health Payment Changes for 2012

The Centers for Medicare and Medicaid Services (CMS) have issued a proposed rule regarding payment changes as well as revisions to the physician face-to-face and therapy assessment rules.

Below is a summary of the most noteworthy aspects of the proposed rule provided by the National Association for Home Care & Hospice (NAHC):

1.       Proposed 2012 payment base episode rates are reduced to $2112.37 from the current $2192.07. This is a reduction of approximately 3.56%.

2.       The rate changes are due to a proposed 2.5% market basket index inflation update, a 1 point reduction in the MBI under the health care reform law, and a 5.06% case mix creep adjustment.

3.       The increase in the case mix creep adjustment is due to the evaluation of 2009 coding weight changes. CMS found that ¾ of the coding increases was a result of increases in therapy visits above the 14 and 20 visit thresholds.

4.       The 3.56% rate reduction will impact individual providers unevenly. CMS proposes to make significant changes in coding weights by eliminating hypertension as a factor in the calculation, reducing the weights on therapy episodes, and increasing weights on non-therapy episodes. Providers with high volumes of therapy cases could see greater net rate reductions. A provider-specific analysis using the provider’s particular case mix is the only reliable way to assess impact.

5.       CMS proposes to change the face-to-face rule and allow one physician to do the encounter and report the information to another physician who completes the certification and plan of treatment documentation. This should help in circumstances where a patient is under the care of a hospitalist who transfers the patient to a community physician.

6.       CMS proposes to clarify the therapy assessment standard where more than one discipline is involved.

The proposed rule on rates is in line with what had been expected. Nevertheless, that does not turn a lemon into lemonade. The change on the face-to-face rule is appreciated, but will only make a slight improvement as the documentation requirements remain a problem.

CMS also posted the proposed rule on the Medicaid face-to-face encounter requirements. The proposal aligns the Medicaid time frames with the Medicare time frames while providing some flexibility to states to determine other aspects such as the content and form of documentation. The proposal also reaffirms CMS’s position that a homebound requirement in Medicaid home health is not permitted and that services can be provided outside the home. Finally, the proposal offers clarifications on the coverage of medical supplies and equipment.

Another summary is available in a press release issued by CMS with a few more specifics on payment. The Home Care Alliance is working on a specific analysis regarding the payment changes based on the northeast’s wage index and will have that available soon.

See links to the specific proposed rules in the Federal Register below:

 

Return to www.thinkhomecare.org.