Haunted by TPE? Don’t Let It Frighten You!

Many home health care agencies have contacted me over the past few weeks with questions about the Targeted Probe and Educate (TPE). Here are answers to many common questions.

Many home health care agencies (HHAs) have contacted me over the past few weeks with questions about the Targeted Probe and Educate (TPE), so I thought I would review the rules because I am sure others have the same questions. NGS has contacted HCA to let us know that there are new TPE audits in Massachusetts: high therapy utilization, long lengths of stay, documentation supporting homebound for Heart Failure, COPD, Diabetes and Dementia, and medical necessity.

How Will the HHA Be Notified:  Agencies will receive a letter from NGS stating the focus of the targeted probe. Expect to receive between 20–40 ADRs, although every agency targeted so far has received a request for the 40 records. If you are currently in a TPE audit you will not be chosen for another. If for some reason you receive another TPE please contact Colleen Bayard because agencies should only be under one targeted probe and educate for home health at a time.

Additional Documentation Request: The Medicare system will generate ADRs and you have a total of 45 days to respond with the requested medical records. Note: It is best to send in at least 30 -35 days, as NGS considers their time to acknowledge receipt of the documentation into their system as part of the 45-day timeframe. If your ADR is one day late it is considered “no response” and counts as an error.

Calculation: NGS calculates the Percent Error Rate (PER) by taking the dollars Medicare would have paid the HHA versus the dollars denied obtaining a percentage. The PER must be 15 percent or below for the HHA to be released from the next round of TPE.

Results Letter: At the conclusion of a round of review, you will receive a letter outlining the TPE process, the reason for denials including the Medicare regulations, denial rates (PER), release or retention from medical review and offer for one-on-one education information.

Education: Agencies will be notified of one-on-one education between NGS medical reviewers and the provider. It is very important to accept the education from NGS at the end of the audit; accepting the education demonstrates that you are trying to improve documentation and will help with the second round of TPE.

HHAs are Experiencing New Round of Targeted Probe and Educate

National Government Service (NGS) announces two new rounds of Targeted Probe and Educate (TPE) for home health agencies

Last month, the National Government Service (NGS) notified the Home Care Alliance of Massachusetts about two new rounds of Targeted Probe and Educate (TPE):

High therapy utilization. NGS will be reviewing documentation to ensure all CMS requirements have been met on therapy assessments and 30-day reassessments, as well as, medical necessity.

Documentation supporting homebound criteria. The second edit is specific to four diagnoses: Heart Failure, COPD, Dementia, and Diabetes and if the documentation confirms homebound status.

Many HHAs have contacted me over the past few weeks with questions about the TPE, so I thought I would review the rules because I am sure others have the same questions.

How Will the HHA be Notified: You will receive a letter from NGS stating the focus of the targeted probe: high therapy or homebound for one of the four diagnoses listed above. Expect to receive between 20–40 ADRs, although every agency targeted so far has received a request for the 40 records.

Additional Documentation Request: The Medicare system will generate ADRs and you have a total of 45 days to respond with the requested medical records. Note: It is best to send in at least 30 -35 days, as NGS considers their time to acknowledge receipt of the documentation into their system as part of the 45-day timeframe. If your ADR is one day late it is considered “no response” and counts as an error.

Calculation: NGS calculates the Percent Error Rate (PER) by taking the dollars Medicare would have paid the HHA versus the dollars denied obtaining a percentage. The PER must be 15 percent or below for the HHA to be released from the next round of TPE.

Results Letter: At the conclusion of a round of review, you will receive a letter outlining the TPE process, the reason for denials including the Medicare regulations, denial rates (PER), release or retention from medical review and offer for one-on-one education information.

Education: One-on-one education between NGS medical reviewers and the provider. It is very important to accept the education from NGS at the end of the audit; accepting the education demonstrates that you are trying to improve documentation and will help with the second round of TPE.

If you have any questions or concerns about TPE, it would be great to hear from you. Good Luck!

CMS Proposes Changes to HH Quality Reporting Program

Proposed Changes Could Result in Another Revision to OASIS in 2021! How will this impact you? HCA is looking for your input.

CMS is proposing several changes to the Home Health Quality Reporting Program (HHQRP) in the CY 2020 Home Health Proposed Rule.

The Rule proposes to eliminate one measure (OASIS Item M1242, Frequency of Pain Interfering with Patient’s Activity of Movement), add two new measures, and add several new Standardized Patient Assessment Data Elements (SPADEs) to the Outcome and Assessment Information Set (OASIS) in CY 2021. The revised OASIS for 2021 will be very different from the current OASIS data items collected by your clinical staff.

As required by the IMPACT Act, the proposed two new measures are:

    1. Transfer of Health Information to the Provider-Post-Acute Care (PAC)
    2. Transfer of Health Information to the Patient-Post-Acute Care (PAC)

These measures are designed to improve patient safety by ensuring that the patient’s medication list is accurate and complete at the time of transfer or discharge. These proposed measures also supposed to fulfill CMS’s strategic initiatives to promote effective communication and coordination of care, specifically in the Meaningful Use Initiative area of transfer of health information and operability.

In addition, CMS is proposing to adopt several standardized patient assessments (SPADEs) to the OASIS data set. CMS plans to implement three assessment screens for mental status, confusion/delirium, and mood. The special service, treatments, and intervention assessment require the agency to identify the services and treatment the patient is receiving and if they are taking any high-risk drugs. The assessment item for medical conditions and comorbidities checks for pain during specific activities and checks for hearing and vision impairments. Click click here to see the proposed Item Mockup for the “Transfer of Health” and the “SPADE”

According to the National Association of Home Care & Hospice (NAHC), the organization sees two possible approaches in addressing the proposed changes to the HH QRP.

    1. Recommend that CMS stagger the implementation of the assessment items over several HHQRP years. However, this would result in more iterations of the OASIS assessment tool, and any changes to the assessment tool carry its own burdens and costs; or
    2. Support the new assessment items with the condition that CMS issues a draft version of the revised OASIS data set no less than six months before the implementation date.

Please let the Alliance know how these changes will impact you.

Return to www.thinkhomecare.org.

Members Flock to HCA’s Quality Improvement Meeting

Lots of member interest in HCA’s July QI meeting to discuss medical record audits and upcoming proposed rule changes.

With the sundry of regulation changes in the home health industry over the past few months, the July 24th Quality Improvement (QI) meeting had over 45 members participating in-person and by phone. The numerous medical record audits plaguing the industry dominated the meeting’s discussion.

Multiple agencies have received letters from C2C Innovation Solutions informing them that some claims under appeal have been selected for potential reopening as part of the Medicare Appeals Demonstration. The C2C auditors are conducting the analysis of claims previously adjudicated unfavorably by the Qualified Independent Contractor (QIC), that are currently pending at the Office of Medicare Hearings and Appeals (OMHA) and may be resolved favorably by the QIC.

Other audits that agencies are experiencing are new Targeted Probe and Educate (TPE) audits. These medical record requests are for 5-7 visits and lengths of stay greater than 90 days. No agency is in the third round of the Face-to Face TPE.

One agency reported at the meeting that they are facing three audits simultaneously; a hospice General Inpatient care (GIP) Targeted Probe from NGS, a home health PERM request for Face-to-Face (awaiting ALJ) and eight GIP Post Payment Review by Noridian.

During the meeting there was a lot of member engagement related the 2020 Proposed Rule; the proposal to require OASIS for all payors and the 8% behavioral adjustment. Agencies also discussed strategies for management with PDGM and the process for completing OASIS B-1 for January 1st episodes. PDGM will be a standing QI agenda item.

The HCA is planning to host a PDGM Networking Meeting to help our members with the transition to this new payment model. We are hoping to begin the meetings in September and have a guest speakers and consultants to assist with planning for this historic payment change. Stay tune for further details.

Don’t forget to check out our PDGM Bootcamp on September 24th!

PDGM Fix Introduced, Advocacy Needed

Last week, a bipartisan group of senators, led by Sen Susan Collins (R-ME)  introduced what will be a most important legislative priority for HCA of MA this year.  Senate bill (S.433) will curtail the so-called $1 billion “behavioral adjustment” cut under the Patient Driven Groupings Model (PDGM) to which all of home health is transitioning in 2020.  Among, many other changes, PDGM will move home health from a 60 to a 30 day payment unit. This is the most significant change to home health payment since the Prospective Payment System was introduced in 2000.

The Congressional action that called for a home health payment overhaul required that the new payment model be budget neutral against current spending levels. However,  the legislation also allowed that CMS to consider “behavioral  adjustments” defined as industry actions that would be taken to increase payment under the new model, unrelated to patient case mix changes. CMS has used this authority very broadly to institute a payment adjustment in the first year of PDGM based on “assumptions” of behavioral changes, and that adjustment calls for a 6.42% base rate reduction, or a possible $1b reduction in payments.

S 433 would prohibit CMS from making any pre-rate change reductions based on assumptions and instead to phase in any adjustments (either up or down) based on observed evidence (i.e., data supported) changes in provider behavior. The objective would be to achieve budget neutrality by 2029. This later piece addresses concerns the Congressional Budget Office (CBO) expressed regarding whether a similar bill introduced last session was truly budget neutral. S.433 also would allow Medicare advantage plans and Center for Medicare and Medicaid Innovations (CMMI) to waive the “confined to home”  provision when in the best interest of a Medicare beneficiary.

Regardless of the “behavioral adjustments,” the PDGM model is expected to have a tremendously varied impact state by state and agency by agency.  A significant amount of this impact is related to a Congressional  requirement that the payment model no longer use the volume of therapy as a payment level determinant.  (Something MEDPAC has been calling on CMS to do for years.)   The state of Florida, where therapy visits average 10.45 per episode of care is set to “lose” the most – projected at $141 million.  California on the other hand, where the average therapy utilization per episode was 5.76,  will be the largest gainer.  MA (need numbers from Tim)  Note: S 433 does not seek to make changes to the structure of the payment model that produces these changes.

It is important to reflect on CMS’ proposal in 2017, Home Health Groupings Model (HHGM) and how we arrived to where we are today. At the time, HHGM represented similar changes to the payment model, without soliciting industry feedback and some estimates predicting a 15% reduction in payments. As a result, the industry unified itself behind one message: that CMS withdraw its proposal and engage stakeholders to come up with an alternative. Upwards of 13,000 emails were sent to Congress from the industry, 49 members of the U.S. Senate and almost 160 members of the U.S. House of Representatives signed onto letters to CMS echoing the request to withdraw HHGM. This was a remarkable show of mobilization by the industry and we’ll need it again to make modifications to PDGM.

At present there is no bill in the House, but it is expected that one will be forthcoming.  Strong early sign on support is critical to keeping this bill moving and HCA of MA will be urging members to contact the MA delegation to support S.433 and the companion house legislation to be introduced. Stay tuned for these advocacy alerts in our weekly newsletter and advocacy messages in the coming weeks.

HCA will also be hosting a number of member events to prepare for the payment transition.  While the full day PDGM programs in March in Northampton are sold out, there will be a high concentration of sessions on PDGM at the New England Home Care Conference and Trade Show in on June 5 -7 inn Falmouth. Watch here for more details.

In the meantime, send a message here to Senators Warren and Markey about the need for their support on this issue. 

Let’s do this home care – we cannot sustain $1 billion in cuts based on assumptions, not facts!

How CMS Stole Home Care Christmas!

Every person in Home Care liked caring a lot.
But the Grinches south of Baltimore, they surely did not!
The Grinches hated home care, delivered in any which way.
Now, please don’t ask why. No one knows what to say.

It could be CMS didn’t have a mom or a dad.
It could be their jobs were incredibly sad.
But, the most likely reason was this just this my dear,
Their hearts were hijacked by nasty old fear.

They feared the support, the need and the caring.
“It has to stop now,” they said, nostrils flaring!
“I hate all their teamwork! I despise all they do!
I’ll pick them all off, one-by-one, two-by-two!”

With a laugh and snort, they sneered, “I know just what to do!”
And put pen to paper to plot their evil, awful coup.
They threw it all at us, with the usual glee,
COPs, OASIS changes, and even VBP!
“I’ve ruined them now and forever, I swear,
Let’s see how you cope, how you can possibly still care!”

But across the Land of Home Care, they got down to work.
HCA had their back, a membership perk!
Every worker in home care, the small and the tall,
Still kept making visits, swearing once and for all:
“The families, they need us, and we will be there!
No Grinches in DC can stop us with fear.”

And what happened then? Well… in home they say,
Those Grinches’ hearts grew three sizes that day!
The true meaning of home care shined right on through.
They ripped up their papers, stopped pre-claim review.
“Maybe home care,” they said, “isn’t about regs, or rules.
Maybe home care is bigger, a national jewel!”

“Thank you, home care,” they said, now with a smile.
“For once, in your shoes, maybe I’ll walk a mile.
I’ll make a home visit, I’ll assist with a med.
I’ll listen to stories from clients in bed.”

“I’ve a new understanding why you do what you do.
Let’s make a new year that’s bright with a start that’s brand new!”

Return to www.thinkhomecare.org.

HCA Submits Comment on Medicare Changes; Submit Your Comments Now!

On July 1st, 2018, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule which includes several changes to the home health benefit for 2019 and beyond. The public comment period closes this Friday August 31, 2018, at 11:59 p.m. As of this blog posting, 760 comments have been submitted to CMS which is encouraging, but far from the more than 1,300 comments submitted last year in response to the HHGM proposal which was ultimately withdrawn.

You can view the HCA’s written comments here and can download the word document here.

You may submit your own comments to CMS here.

Here are some of the key changes proposed, and an overview of HCA’s response:

Home Health Wage Index Changes

  • The 2019 proposed payment rates increase by 2.1% which represents a $400 million increase.
  • HCA of MA has long expressed concerns to CMS over inequities in how the wage index is calculated for home health agencies compared to hospitals. HCA urges CMS to adjust the 2019 home health agency wage index to reflect a policy to limit the wage index disparity between provider types within a given CBSA.

Proposed Patient Driven Groupings Model (PDGM) for CY 2020

  • Implementation: As the proposed PDGM would mark a major change in the way home health agencies will be reimbursed, the HCA urges CMS to delay implementation by one year to ensure that there is no disruption in access to services for beneficiaries and evaluate the accuracy of the model and its effect.

  • LUPA Thresholds: CMS proposes to set the LUPA visit threshold at the 10th percentile for each payment group. HCA believes this is complex and will complicate the care planning process for home health agencies. HCA urges CMS to retain the current LUPA thresholds and revisit them in future years.

  • Behavioral Assumptions: CMS proposed three ‘behavioral assumptions’ in the PDGM totaling -6.42%. However, these assumptions are not based in data or evidence. HCA believes that two of the three assumptions already exist in the current PPS methodology including; that agencies are already incentivized to both report the highest playing diagnosis codes and to develop and deliver plans of care that exceed the LUPA threshold. This could result in an over estimated impact of behavioral assumptions and the HCA urges CMS to eliminate the Clinical Group Coding and LUPA threshold assumptions.

  • Split percentage payment approach: HCA believes that changing from a 60 to 30 day billing period will be very disruptive to agencies’ operations and increase back-office costs. Therefore, HCA urges CMS to continue the split payment approach at the current 60/40 and 50/50 splits for early and late periods, respectively, to give agencies cash flow breathing room.

  • Certification and Re-certification of Patient Eligibility: HCA has long advocated for regulatory language to align with sub-regulatory guidance as it relates to documentation of the patient’s eligibility. HCA is encouraged by CMS’ proposal to eliminate the requirement that the physician provide an estimate of how much longer skilled services are required and we request that CMS consider revisions to the physician’s burden of the F2F encounter as a condition of payment. 
  • Remote Patient Monitoring: HCA strongly supports the proposal to recognize remote patient monitoring costs as an administrative cost on the HHA cost report. HCA does recommend however that CMS remove the regulation that does not allow remote patient monitoring to be used as a substitute for in-person home health services. 
  • Home Health Value Based Purchasing Model: HCA has long supported the HHVBP model aiming to improve quality by giving HHAs incentives to provide better quality care. However, HCA urges CMS to modify the HHVBP to recognize stabilization in the scoring because in many cases, stabilization (instead of improvement) is an appropriate goal for some patients.