Category: Regulation

The Centers for Medicare and Medicaid Services released an announcement of a new proposed rule that would include home health and hospice agencies in the expanded list of providers required to give Medicare beneficiaries written notice of their right to file a quality of care complaint.

The written notice would consist of information on the beneficiary’s right to contact a Medicare Quality Improvement Organization (QIO) as well as how to contact their local QIO with quality of care concerns.

CMS will be accepting comments on this proposed rule until April 3 and links are available with more information on the rule itself and how to comment below.

 

Medicare proposes new rules for notifying beneficiaries of their right to lodge quality of care complaints

Providers Would Have to Give All Beneficiaries Written Notice of Their Rights

The Centers for Medicare & Medicaid Services (CMS) issued a proposed rule today that would require most Medicare-participating providers and suppliers to give Medicare beneficiaries written notice about their right to contact a Medicare Quality Improvement Organization (QIO) with concerns about the quality of care they receive under the Medicare program.

Under current rules, only beneficiaries admitted to hospitals as inpatients are required to receive information about contacting their state QIO regarding quality of care issues. Today’s proposed rule would require that in order to participate in the Medicare program, providers and suppliers would need to inform beneficiaries of their right to complain to a QIO about quality of care, as well as how to contact their local QIO. In all, the following care settings are impacted by this proposal:

• Clinics, rehabilitation agencies, and public health agencies that provide outpatient physical therapy and speech-language-pathology services
• Comprehensive outpatient rehabilitation facilities
• Critical access hospitals
• Home health agencies
• Hospices
• Hospitals
• Long-term care facilities
• Ambulatory Surgical Centers
• Portable x-ray services
• Rural health clinics and Federally Qualified Health Centers

“Today’s proposed rule would ensure that beneficiaries know they have a voice in the care they receive under the Medicare program,” said CMS Administrator Donald Berwick, M.D. “By requiring providers and suppliers to furnish QIO contact information to all beneficiaries, we are protecting beneficiaries’ rights to bring their worries about quality of care to a third party for review, which can lead to better care not only for the beneficiary, but for all patients in a given care setting.”

Since the 1970s, Medicare has contracted with private, mostly not-for-profit organizations such as QIOs to preserve beneficiaries’ access to high-quality, high-value healthcare.  QIOs are located in every state as well as the District of Columbia, Puerto Rico, and the U.S. Virgin Islands. Each QIO is staffed by professionals, mostly doctors and other healthcare professionals, who are trained to review medical care and help beneficiaries with complaints about the quality of care they receive. These professionals also work directly with providers and facilities to make improvements in quality across all care settings.

One of the key tools QIOs use to improve quality of care is responding to complaints from Medicare beneficiaries regarding the care they receive from Medicare-participating providers and suppliers.  QIOs investigate these complaints, gather facts from all parties involved, and recommend action to help providers and suppliers improve quality of care.

“Medicare beneficiary complaints are an important source of information that QIOs use to improve the quality of care for all patients,” said Dr. Berwick. “Sometimes providers themselves are unaware of problems or the reasons for these problems until a beneficiary shows the courage to ‘speak up’ and report the issue to a QIO. By speaking up, beneficiaries can help other patients escape the same poor outcomes they have experienced.”

CMS will accept comments on the proposed rule until April 3, 2011 and will respond to comments in a final rule to be issued in the coming months. . To submit comments click here: http://www.regulations.gov/#!documentDetail;D=CMS_FRDOC_0001-0641

The proposed rule has been published today (2/2/11) at the Federal Register and can be found online at http://www.gpo.gov/fdsys/pkg/FR-2011-02-02/pdf/2011-2275.pdf

For more detailed information check out the CMS Overview webpage at http://www.cms.gov/qualityimprovementorgs It has more information about the QIO Program and how it works to improve care for Medicare beneficiaries and all Americans, including contact information for each of the 53 QIOs across the country.

Beneficiaries with questions or concerns about the quality of care they receive under Medicare can learn more about their rights by calling 1-800-MEDICARE or by reading Medicare’s fact sheet, “Quality of Care Concerns,” online at http://www.medicare.gov/Publications/Pubs/pdf/11362.pdf.

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The Massachusetts Hospital Association has released a helpful guide they are recommending providers use in constructing documentation for the face-to-face encounter rule, which is being implemented currently and will be enforced by the Centers for Medicare and Medicaid Services beginning in April.

The guide was formed by  New Jersey’s Hospital  and Home Care Associations and the Home Care Alliance recommends this to those providers looking for extra direction.

Previous newsfeed posts related to the physician face-to-face encounter rule are available here.

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Enforcement of the face-to-face encounter requirement from a recent CMS Final Rule will be delayed for three months thanks to a coordinated and effective advocacy effort.

Home Care Alliance has been informed that the Centers for Medicare and Medicaid Services (CMS) has sent instructions to its contractors advising them that home health agencies and hospices are to be allowed to use the first quarter of 2011 to implement procedures to meet face-to-face encounters requirements.

It is vitally important to note that providers should continue to implement face-to-face encounters as soon as possible. Doing so will enable the collection of information about provider and beneficiary problems and pitfalls related to this regulation that need to be addressed with CMS. According to NAHC, CMS has plans to begin meetings with home health and hospice representatives, and other stakeholders, early in January to answer remaining questions and resolve problems as they come to light.

According to VNAA, the 3-month transition period will not be extended and CMS called on national organizations to take action and to work with CMS during the transition period.

This delay represents a victory for home health and hospice and is a prime example of how advocacy is effective in making a difference. The member agencies of HCA joined others nationwide in a great effort and, together with other associations, were able to convince CMS that a delay was necessary. Massachusetts was also fortunate to have great support from the federal legislative delegation.

For the purpose of continuing with implementation, NAHC has outlined the requirements for physician signature and the regulatory basis as to why after January 1, 2011, date stamps will no longer be accepted if the physician does not sign AND date.

Details are available in the Medicare General Information, Eligibility and Entitlement Manual under section 30.1. That requirement is also addressed in this summary.

HCA will provide more information as it becomes available.

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CMS Provides Details for Face to Face Encounter by Hospitalist, Other Clarifications

Effective January 1, 2011, home health agencies will be required to meet current certification and plan of care requirements and new face to face encounter requirements.

During a lengthy conference call, a representative from the Centers for Medicare & Medicaid Services (CMS) provided detailed information to the National Association for Home Care & Hospice (NAHC) as to how home health agencies will be able to meet face-to-face encounter requirements for patients referred to home health from institutional settings. CMS explained that this policy will apply not only to patients referred by hospitalist, but to patients referred by physicians from all inpatient settings, such as rehab facilities and skilled nursing facilities.

Generally patients are referred to home health agencies as follows:

1. By a community physician who is caring for the patients in an institutional setting or in the community, or
2. By an inpatient facility physician who is willing to continue to be responsible for patients after their discharge from institutions until they see a community physician, or
3. By an inpatient facility physicians who is unwilling to be responsible for patients after their discharge from institutions.

When referred by community physician, whether the patient is in an institutional setting or the community, that physician will document face to face encounters and continue to meet all certification and home health plan of care requirements as they do today. When inpatient facility physicians refer patients and are willing to continue to be responsible for those patients after discharge from institutions until they see a community physician, those physicians will document face to face encounters and continue to meet all certification and home health plan of care requirements, as they do today.

It is in those cases where an inpatient facility physician is unwilling to be responsible for patients after discharge from the facility that will present problems for home health agencies in meeting face to face encounter requirements. In order to remove roadblocks for these patients, CMS announced that it will amend the longstanding policy in Pub 100-02 Chapter 4, Section 30 that “since the certification is closely associated with the plan of care (POC), the same physician who establishes the plan of care must also certify to the necessity for home health services.”

According to CMS, since the certification and plan of care regulations do not specify that these functions be performed by the same physician, CMS will amend the policy and allow different physicians to perform each of these functions. As a result, facility physicians will end their responsibility for patients upon discharge from the inpatient setting will be permitted to complete the required face to face encounter documentation based on the patients clinical condition while under their care, and to certify that the patient is homebound and requires intermittent skilled nursing or therapy services. The community physicians will establish the home health plan of care, as they do at the present time.

Unresolved Issue

According to 42 CFR 424.22, as a condition for payment, the content of a home health certification includes a signed statement that:

• The patient needs intermittent skilled nursing or therapy
• Home health services are required because the patient is confined to home
• A plan for furnishing the services has been established
• Services were furnished while the patient was under the care of a physician

The first two bullets under certification requirements are not at issue. However, NAHC has asked CMS to respond as to how it intends for inpatient facility physicians who end their responsibility patients will be able to meet the plan and attestation about services furnished requirements in the third and fourth bullet.  This information will be shared with home health agencies once a response if received from CMS.

Travel Together Requirement

In regard to the CMS Open Door Forum statement that the face to face encounter documentation and certification (versus plan of care) must “travel together” CMS explained that certification and plan of care are two separate requirements: CMS wrote in to an email inquiry:

The “traveling together” discussion may be the source of the confusion. Our intent was to describe that the face to face encounter documentation is a part of the certification.  It isn’t a separate thing.  Although we allow the documentation to be on an addendum, that addendum is still part of the certification.  The entire certification is also part of the patient’s entire medical record documentation, and of course the physician who assumes POC responsibility would need to have access to the documentation associated with the encounter, as would the HHA.

Face to Face Encounter Guide

In regard to agencies concerns as to whether a guide or template is acceptable, similar to that found on the NAHC web site, CMS was asked by a home health agency whether “it would be acceptable to label the section of the plan of care or addendum where the physician’s documentation should be placed, titling it and include subheadings such as: Date of Encounter, Medical Condition for Encounter, Services Needed, Clinical Findings, Homebound Status, Physician Signature, Date.”  CMS responded:

“Yes, this is fine.  As long as the info/clinical findings and how the findings support eligibility are documented by the physician,  in his/her own words.”

Certification Statement on Home Health Plans of Care

NAHC advised home health agencies to retain the certification statements for intermittent skilled nursing and therapy services and homebound statement on plans of care when another physician does the face to face encounter and initial certification. Also, although face to face encounters are not required at recertification, the homebound and medical necessity statements are required for recertification plans of care.

Face to Face Encounters After Start of Care

In response to inquiries from home health agencies as to what steps to follow when face to face encounters are to occur after the start of care and before day 30, NAHC suggests that the following steps:

1. HHA obtains verbal orders
2. HHA documents the orders on the plan of care, which includes a “box” or “addendum” with directions to the physician to document the face to face when it occurs and identify what information that must be included in the narrative.
3. HHA drops the RAP once the plan of care, “certification,” form has been sent to the physician.
4. Physician has an encounter with the patient
5. Physician completes the encounter documentation, signs and DATES the plan of care and certification of the encounter/homebound status/medical necessity and returns it to the agency
6. HHA agency files final claim.

Enforcement Effective Date

NAHC has been urging members of Congress and CMS via letters to Dr. Donald Berwick, the CMS Administrator, to delay enforcement of face-to-face encounter requirements for six months after the January 1st effective date. This endeavor is similar to that undertaken by NAHC regarding PECOS, whereby the effective date of the regulation will remain unchanged but CMS will not impose penalties for failure to comply until a time when physician education has taken place and home health agency questions have been adequately addressed.

NAHC and the Home Care Alliance will provide updates on progress toward achieving this end.

Materials for educating physicians, patients and home health agencies are available here in a previous newsfeed post.

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