Category: Regulation

HCA, NAHC Offer Guidance on Physician Face-to-Face Requirement

In an effort to assist agencies in navigating their way through a major piece of a recent CMS Final Rule, the Home Care Alliance and the National Association for Home Care & Hospice have released a list of documents aimed at improving the understanding of patients and educating doctors while encouraging their coordination and cooperation.

The requirement is that a face-to-face visit between a patient and their physician is necessary in order to be certified for home health services.  Please see the sample documents below for guidance and for your agency’s use.

A link to the entire Final Rule as published in the Federal Register is available here. The section of note is Letter “F” for the face-to-face requirement, which is available here.

If there are any questions, or if you would like further information, please contact the Home Care Alliance. Please note that clarification has been asked of CMS regarding certain aspects of the rule, including documentation.

Return to www.thinkhomecare.org.

HCA Submits Comments to CMS on Moratorum, Screening Requirements Rule

The Home Care Alliance submitted comments on a proposed rule from CMS, specifically focusing on “Temporary Moratoria on Enrollment of Medicare Providers and Suppliers, Medicaid and CHIP Providers.”

The comments point out data that supports the need for a temporary moratorium on Medicare-certified home health providers. For instance:

…from 2001-2006, Medicare spending grew 2.5 times more in states where the number of home health agencies (HHA’s) increased as compared to states where the number of providers remained the same or decreased.

Highlighting the lack of licensure and Certificate of Need, along with the growth in the number of certified agencies, the Alliance saw an opportunity to protect the hard work of existing agencies that have established a tradition of quality and honesty in the business.

Click here to see more on the CMS proposed rule (CMS-2010-0239-0001: “Medicare, Medicaid and Childrens Health Insurance Programs: Additional Screening Requirements, etc, for Providers and Suppliers)

Return to www.thinkhomecare.org.

MEDPAC Commissioners Discuss Medicare Home Health Payment Overhaul

Even as home health agencies prepare to implement the deep payment cuts and regulatory changes called for in the health reform law and 2011 payment rule, MEDPAC’s Commissioners are considering recommending major PPS payment changes in their Spring 2011 report to Congress.   At their November meeting, the Commissioners considered a presentation by home health analyst Evan Christman  on Improving Incentives and Safeguards for the Home Health Benefit .

Christman focused much of his presentation on variations in profitability and how in particular financial performance tracks to cases with therapy use.  Christman also provided detailed data on what he charatcerized as a 48% growth in home health episodes with no prior hospitalization or other post acute services.   The rate of growth for these types of cases, he informed the Commissioners, is 14 times the rate of growth for home health as a post acute care services.  Supply, he said, is expanding to take care of less severely ill patients.   The Commissioners were clearly – by their comments – taken back at this.

Christman recommended the the Commissioner endorse a “redistributive payment recommendation” that would reduce percentage of overall dollars going to cases with therapy in favor of non-therapy and dual eligible patients.  He also  recommended a 3% adjustment for dual-eligibles   Finally, he recommended consideration of a co-payment, specifically on home health cases with no prior hospitalization.   A lengthy and instructive discussion of home health trends, payments and value ensued – all of which can be found on the meeting transcript –beginning on page 211.

While ether are some things in the MEDPAC discussion that this association has  supported (dual eligible adjustments), a review of the transcript reveals we still have both an image and a substance issue when it comes to (many) MEDPAC Commissioners and our services.

Return to www.thinkhomecare.org.

NY Times: Medicare Standards Too Strict

The New York Times reported on a federal court ruling that said Medicare beneficiaries do not have to show that their conditions will improve as a result of home health care.

According to the article:

“Medicare will pay for those services if they are needed to maintain a person’s ability to perform routine activities of daily living or to prevent deterioration of the person’s condition, the courts said. Medicare beneficiaries do not have to prove that their condition will improve, as the government sometimes contends, the courts said.”

The Home Care Alliance obtained a copy of a letter sent by 17 members of Congress to the Director of the Center for Medicare Management arguing against the improvement standard. US Representative Barney Frank was among the cosigners of the letter, which is available here.

Return to www.thinkhomecare.org.

PPS Final Rule Makes Some Changes; Not Enough

CMS has issued the final home health payment rule. While the rule includes some modest improvements over the proposed rule, the bottom line is difficult payment cuts to an industry saddled with greater regulatory responsibilities.   Among the major payment changes:

  • CMS withdrew its proposal to eliminate certain hypertension codes from the case-mix scoring model;
  • CMS dropped the application of the 3.79% case-mix weight change adjustment for non-routine supplies;
  • CMS maintained the 3.79% coding weight change adjustment in 2011;   but dropped proposal for an additional 3.79% in 2012. CMS promises to revisit its method of assessing case-mix weight changes prior to any further adjustments,  but the 2012 cut well may resurface as a proposal in the 2012 rate setting.
  • The final rates include a 2.1% market basket index increase — down from the proposed 2.4% — that is reduced under the health care reform legislation by 1 point to 1.1%. (As a result, the base 2011 episodic rate in non-rural areas is $2192.07; $2257.83 in rural areas.)

CMS made some significant changes in the requirements for face-to-face encounters between a patient and his/her physician or non-physician practitioner.  Most importantly, the following changes – suggested in industry comments  – were made:

  • Face-to-face physician encounter timeframe has been extended to 90 days before the start of care or 30 days after the start of care.; an extension on the 30-day/14 day timeline in the proposed rule.
  • Hospitalists will be allowed to perform and document face-to-face visits in certain cases.
  • The overall face-to-face requirement applies to certifications only. (this is a requested clarification)

Additional changes in home health face to face provisions:

CMS allows that hospitalists may perform the encounter, even where a different community-based physician continues care of the patient in home health services and certifies the patient’s care plan. The hospitalist would need to identify the community physician in the discharge plan of home health care.

CMS maintains the documentation requirements but will not hold the HHA responsible for the physician’s documentation. However, CMS does not permit standardized encounter documentation that the physicians or non-physician practitioners simply sign for the HHA.

CMS infers that the face-to-face encounter will not bring any additional physician payment for the services above existing certification payment (G0180) and claims for specific physician services beyond the encounter certification.

HHAs cannot use the Home Health Advance Beneficiary Notice (HHABN) to inform patients that care would not be covered in the event that here is no qualified encounter. CMS does not indicate what kind of notice is authorized, even though this requirement is a condition of payment to an HHA.

Unchanged from the proposed rule – and of great concern –  is the January 1, 2011 effective date. At this stage only Congressional intervention will change this.

In other rule changes:

Agencies will have more flexibility and time to comply with stricter therapy documentation requirements. Specifically:

  • CMS replaces the 13th and 19th visit in an episode proposal with a more flexible approach. A professional therapist assessment in rural areas and non-rural areas under extenuating circumstances (undefined by CMS) must take place any time after the 10th visit but no later than the 13th visit; and after the 16th visit but no later than the 19th visit specific to each discipline of therapy.
  • The assessments required relate only to each therapy discipline individually and not to the combination of therapist services. For example, if a patient has 12 physical therapy visits and 12 occupational therapy visits in an episode, the additional assessments would not be required.
  • CMS does not intend to change longstanding requirements on coverage of maintenance therapy or the development of a maintenance plan of care.
  • CMS maintains its spontaneous improvement limitation on coverage but expresses that a professional therapist should judge whether such is possible with an individual patient.
  • The effective date on assessments is delayed until April 1, 2011.

HH-CAHPS deadlines stay in place. Despite agency concerns about the burden of patient-satisfaction survey requirements in addition to continued OASIS-C implementation, CMS will move forward with plans to withhold agencies’ 2% annual payment update for 2012 if they fail to report data and don’t apply for an exemption.

CMS retains the so-called 36- month rule regarding ownership changes, but with significant exceptions. If there is a change in majority ownership of an HHA by sale (including asset sale or sale of stock, mergers, and consolidations) within 36 months after the effective date of the HHA’s initial enrollment in Medicare or within 36 months of the HHA’s most recent change in majority ownership, the HHA’s provider agreement does not convey to the new owner. The new owner must enroll in Medicare as a new (initial) agency and obtain state survey or accreditation.

The final rule can be accessed electronically at www.ofr.gov/OFRUpload/OFRData/2010-27778_PI.pdf.

ACO Committee Finds Consensus and Takes Other Issues Under Consideration

At today’s meeting of the state’s Payment Reform Commission consensus began to emerge about some ACO Framework issues while diverse opinions were voiced on others.   Consensus is emerging around ACO core capacities and the arrangements with primary care and specialty physicians; the former should (with only certain exceptions) be a member a single ACO, specialists can be in multiple ACOs.  There is consensus that consumers need to be able to seek care outside the ACO (a position the Alliance has supported), with the ACO responsible for these costs – except in circumstances of out of state care or catastrophic need.

Obligations of ACOs to include and be accountable for a broader range of services beyond primary acute inpatient care are still being debated.    The Home Care Alliance has submitted and made comments at meetings that in order for ACOs to avoid creating (or recreating) a hospital-centric, ‘siloed’ system of care, the qualifying criteria must include a capacity for coordinating care across primary, acute and post acute services.       This capacity could be in an integrated model, or in a more virtual manner, but the later (virtual model) should be required to be constructed with strong performance based contracts or other explicit arrangements for care across the continuum.   The position for not mandating a broad continuum of services is espoused by  members of the Committee who advocate  giving ACOs broad flexibility in terms of scope of services for which they are responsible.  A limited scope of responsibility, they argue, might encourage more early interested parties.   Secretary Bigby expressed a position that the ACO must be responsible for an assigned patient’s total health, which would argue for having a full continuum of services.

The meeting ended with some discussion of ACOs having an unintended consequence of changing the market in ways that certain essential community services (ER’s, public health programs) are lost.  This was acknowledged but with little resolution.

How is An ACO Like a Unicorn? – and Other Questions Raised at October Payment Reform Meeting

At the October 6th meeting,  the Committee charged with dissecting and debating formation of new payment reform strategies in Massachusetts raised as many questions as it answered. One of the bigger areas for today’s debate: the degree of prescriptiveness or flexibility of authorizing statutory language.  While there was general agreement among business leaders and trade associations for large provider groups (hospitals and doctors, in particular) that flexibility be the goal, there was some concern that too much flexibility might dilute the reform’s key provision: Accountability.   (“If we don’t spell out who is accountable for what and too whom,   we risk having none,” was how one participant put it.)   Home health and behavioral health providers were united in expressing concern that too much “flexibility” could undermine access to  essential “downstream” services in the interest of cost savings.

Other questions debated without little resolution: what is the relationship to be between ACOs and insurers?   Can models exists with very different levels of  integration (full vs virtual, of payment (fully bundled, partially for only certain services)?  How prescriptive should oversight be on collecting and reporting of quality data?   The idea of allowing – at least initially – many models had significant (although not universal support), including the Alliance’s. There was at least one expressed opinion that virtually  integrated ACOs could simply mimic the fee for service system that the state is committed to moving away from.  This was somewhat countered by the support for transparency and shared “performance risk” across collaborating entities that has been shown in some demonstrations, such as STAAR,  can begin to improve outcomes.   HHS Secretary Judy Ann Bigby indicated support for tiers of  integration that could be seen as “stages of payment reform development” with an oversight Board assessing how various models are working and then changing incentives to move system towards the most effective.

As to the apropos unicorn analogy, it came from Mass Hospital Association VP Jim  Fitzpatrick.  Fitzpatrick quipped that ACOs were like unicorns in that no one has ever really seen one locally, but we all seem to know what they look like.   Indeed!

Mass Moving on Comprehensive Payment Reform

The Massachusetts Committee on the Status of Payment Reform Legislation has begun meeting regularly with an aggressive schedule to  draft an outline of legislation to implement comprehensive payment reform.  Secretary Judy Ann Bigby, who chairs the Committee,  has committed to a process that is open to input from all interested stakeholders and experts.

The Committee will next convene on October 6th;  on the agenda:  the structure and regulatory construct for creating and monitoring Accountable Care Organizations.   Among the questions to be considered: what will be legislated in terms of operating structure and what will be left  to a proposed “Oversight Board” to monitor?   How tightly integrated should operating ACOs be – and can many different models for “integration” exist?   How will members be assigned to or chose an ACO?   And, the very central questions involving  provider relations with ACOs: can primary care MDs be in only one or multiple, and what of specialists and other providers?

The later – the role and relationships of providers who are neither hospitals or doctors – has been and will be the focus of the Alliance’s participation on the Task Force.   Based of positions drafted by our Legislative and Policy Committee, the Alliance has submitted initial comments that:

– express strong support for ACOs  with different configurations that vary  from tightly to virtually integrated and models that allow a variety of provider payment configurations .  

– support making explicit in the ACO enabling  legislation that each ACO model must  receive global payment to reflect – and be able to manage  – the full continuum of care settings and services for its assigned patients.

– require that attention and financial resources must be made available to allow providers in an ACO’s post acute care network to connect to integrated IT infrastructure for clinical care management.

Future discussion will focus on modeling global payments and the role and composition of the Oversight Board.

The Alliance welcomes and encourages member feedback – to us or to the Committee directly – on these critical discussions.  Comment or send to pkelleher@hcalliancema.org.

Return to www.thinkhomecare.org.

Reminder of PECOS deadline

As of October 4, Medicare home health agencies will be receiving warning messages from the Centers for Medicare and Medicaid Services (CMS) in response to claims where the ordering physician is not enrolled in PECOS (Provider Enrollment, Chain, and Ownership System).

Agencies will still be paid for claims, but the warning message will indicate that such payments will be denied as of January 3, 2011.

For more background on this issue, visit previous newsfeed posts here.

Return to www.thinkhomecare.org.

New CMS Proposed Rule Issued on Provider Screening, etc.

The Centers for Medicare and Medicaid Services issued a new proposed rule on September 20 that lays out changes in provider screening, suspension of payments, fraud control, temporary moratorium criteria, and cross program terminations.

A summary of the rule will be made available in this week’s issue of UPDATE for Alliance members.

Those interested in submitting comments, which are due by November 16, can be made electronically by clicking here, or by mail at the address below:

  • Centers for Medicare & Medicaid Services, Department of Health and
    Human Services, Attention: CMS-6028-P, P.O. Box 8020, Baltimore, MD
    21244-8020.

Return to www.thinkhomecare.org.