CMS Finally Releases Updated ABN Form!

Providers will need to use the renewed ABN form starting this August.

CMS just released the long-awaited Advance Beneficiary Notice of Noncoverage (ABN). The current ABN form expired in March 2020, so CMS instructed providers to continue using the expired form, since the form’s renewal was on hold at the Office of Management and Budget during the Public Health Emergency. Yesterday, CMS posted the updated ABN Form CMS-R-131 and form instructions (see the Downloads section at the bottom of the linked page).

The renewed form (with the expiration date of June 30, 2023) will be mandatory beginning August 31, 2020.  The ABN is issued by home health and hospice providers to Medicare beneficiaries in situations where Medicare payment is expected to be denied. The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances. Guidelines for issuing the ABN can be found beginning in Section 50 in the Medicare Claims Processing Manual, 100-4, Chapter 30 (PDF).

CMS to Delay Expansion of Pre-Claim Review Demo

CMS announced yesterday afternoon that they are delaying the expansion of the Pre-Claim Review Demonstration for Home Health Services which began in Illinois on August 3, 2016.

According a notice on CMS’s website, based on early information from the problems encountered in Illinois, CMS believes additional education efforts will be helpful before expansion of the demonstration to other states; therefore, they will not move forward with initiating the demonstration in Florida in October.  This education effort will focus on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation.

According to the notice, CMS views these efforts as crucial to the long-term success of the demonstration for beneficiaries, providers, and the Medicare program. CMS will therefore take additional time prior to expanding to other states.   The start dates for Florida, Texas, Michigan, and Massachusetts have not been announced; however, CMS will provide at least 30 days’ notice on this website prior to beginning in any state.  CMS continues to expect a staggered start, beginning with Florida.

The Alliance has been working closely with the state associations in the other demonstration states and national home health groups to advocate for major changes to the project.  Building off of this short-term victory, HCA will continue those efforts and is also briefing our Congressional delegation on the issue. HCA will, of course, keep members informed of any changes in the demonstration.

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Home Care’s Part in the CMS Bundled Payment Program for Cardiac Care

Though no final announcements on participants have been made, several areas of Massachusetts were declared “eligible” by CMS for random selection of nearly 100 metropolitan statistical areas (MSA) across the country for a new innovation initiative that offers bundled payment for cardiac care.

CMS released the proposed rule on July 25th where the hospital in which a patient is admitted for care for a heart attack, bypass surgery, or surgical hip/femur fracture treatment would be accountable for the cost and quality of care provided to Medicare fee-for-service beneficiaries during the inpatient stay and for 90 days after discharge.

As with many similar alternative payment programs, established quality metrics would help determine whether the hospital would be required to pay Medicare for poor performance or receive reward payments for higher-quality care. CMS chose July 2017 to March 2018 as the “performance year” and then a gradual increase in the gains and downside risk for hospitals beginning at 5 percent in 2018 and capped at 20 percent in 2020-2021.

CMS is encouraging collaboration with other providers, including home health care and other post-acute providers. Equally important are a list of waivers this program will grant relative to the provision of post-acute care. Some notable highlights are listed below, with explanatory excerpts from the proposed rule, but the full list of waivers can be found in the proposed rule under “Subpart G” on page 885.

  • Waiver of direct supervision requirement for certain post-discharge home visits:
    • “CMS waives the requirement in  § 410.26(b)(5) of this chapter that services and supplies furnished incident to a physician’s service must be furnished under the direct supervision of the physician (or other practitioner) to permit home visits as specified in this section.  The services furnished under this waiver are not considered to be “hospital services,” even when furnished by the clinical staff of the hospital.”
  • Waiver of certain telehealth requirements:
    • “Except for the geographic site requirements for a face – to – face encounter for home health certification, CMS waives the  geographic site requirements of sec tion 1834(m)(4)(C)(i)(I) through (III) of the Act for episodes  being tested in an EPM, but only for services that  (1)  May be furnished via telehealth under existing requirements; and (2)  Are included in the episode in accordance with  § 512.210”
    • The Alliance is researching whether this is restricted to physicians performing telehealth or whether home health agencies would be allowed to engage in remote patient monitoring.
  • Waiver of the SNF 3-day rule
    • Only applies to the AMI (Acute Myocardial Infarction) model.

There is a 60-day public comment period and it is unlikely that the participating MSAs will be revealed before the final rule, but the “eligible” areas in Massachusetts are included below:

  • Barnstable Town, MA
  • Boston-Cambridge-Newton, MA-NH
  • Providence-Warwick, RI-MA

Based on CMS’ selection criteria, the Pittsfield and Springfield Metropolitan Statistical Areas are “excluded” from selection eligibility.

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National Fraud “Hot Spots” Revealed in Largest-Ever Operation Announced by US DOJ

The US Department of Justice announced that 301 individuals have been charged with falsely billing Medicare a total of approximately $900 million in what is being called the largest coordinated Medicare fraud take down in history.

Home health services were among a list of services involved in the fraud schemes that also included physical and occupational therapy, durable medical equipment (DME) and prescription drugs. In the process, the HHS Inspector General released a data brief titled “Nationwide Analysis of Common Characteristics in OIG Home Health Fraud Cases.”

That data brief reveal some trends in outlier patterns among home health agencies and affiliated physicians, but also identifies 27 “hot spots” in 12 states where home health care fraud is prevalent. Massachusetts is not among the states shown in the map below where much of the home health fraud activity is occurring.

Recently, Massachusetts has been included in a planned “pre-claim review” demonstration starting “no earlier” than January 2017 that will, according to CMS, test whether such a process improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies. Among the five states involved in the demonstration, Massachusetts is the only one not on any target list for the Medicare Fraud Task force known as HEAT (Health Care Fraud Prevention & Enforcement Action Team). For many years, the Home Care Alliance has repeatedly advocated for a temporary moratorium on new Medicare home health providers in response to recent growth in the number of new agencies, but such efforts have been denied by Medicare.

2016 HHA Fraud Hotspots

According the to HHS Inspector General, these are areas where characteristics commonly found in OIG-investigated cases of home health fraud were prevalent. The report states that “many of these hotspots are areas already recognized as having high rates of Medicare fraud, which suggests that home health fraud in these areas is an ongoing concern and that enforcement and program integrity efforts should continue.”

116 US Reps Sign on to Prior Authorization Letter to CMS

Even though the public comment period for CMS’ proposed prior authorization demonstration ended on April 5th, the Home Care Alliance has been active in its continuing advocacy to oppose the measure.

Joining national associations and advocates from across the country, the HCA helped spearhead a congressional letter to CMS opposing prior authorization, which gained 116 signatures and was co-led by Massachusetts Congressman Jim McGovern. All but one member of the state’s congressional House delegation signed on. The Alliance thanks Congressmen Stephen Lynch, Joseph Kennedy, Bill Keating, Richard Neal, Seth Moulton and Congresswomen Niki Tsongas and Katherine Clark for their support.

The proposed five-state pilot includes Massachusetts, Florida, Texas, Illinois and Michigan and those five states have been lobbying members of Congress, but many others nationwide have joined in the fight realizing that a demonstration could, and likely would, lead to wider implementation.

In late February, the Home Care Alliance began its advocacy of the proposal by traveling to Washington DC to deliver a letter outlining the organization’s comments to members of Congress. The HCA and all others who gathered in opposition to the prior authorization demonstration await a response from CMS.

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MHA, ONL & HCA Publish Latest Quality Measures for Hospitals, Home Health Agencies

The Massachusetts Hospital Association (MHA), Organization of Nurse Leaders of MA, RI, NH & CT (ONL) and Home Care Alliance of Massachusetts have publicly posted the latest available key national care quality performance measures for both hospitals and home healthcare agencies in Massachusetts. Data from Medicare’s Hospital Compare and Home Health Compare are now available on the PatientCareLink website for 77 Bay State hospitals and 89 Bay State home health agencies.Patientcarelink logo

Reported measures for hospitals include best practices for heart attack or chest pain, heart failure, pneumonia care, influenza prevention, surgical care improvement, stroke care and blood clot prevention and treatment. For home care agencies, the reported measures include timely initiation of care, patient/family medication education, depression assessment, and more.

To view the updated reports, visit and click on the “Healthcare Provider Data” tab and then either the “Hospital Data” or “Home Health Agency Data” link, then “Individual Hospital Performance Measures” or “Select an Agency.”

The home health agency reports now incorporate data for the period June 2014 – July 2015 for all measures, and the hospital reports cover April 2014 – March 2015. In addition to each facility’s individual performance, the PCL pages also provide a comparison to state and U.S. “peer” facility averages.

“Providing high quality, safe patient care is a top priority for Massachusetts hospitals,” said Pat Noga, PhD, RN, Vice President of Clinical Affairs for MHA. “Our hospitals are also committed to publicly posting important quality and staffing information to provide patients and caregivers alike additional confidence in their care.”

Patricia Kelleher, Executive Director of the Home Care Alliance of MA, added that the partnership between hospitals and home health agencies on PCL furthers positive working relationships along the entire continuum of care, which can only improve patient safety and quality overall.

“Choosing in-home services can be a daunting task and that’s why we’re proud that PatientCare Link (PCL) website allows patients and their families to find high-quality care in the home setting that fits their needs,” Kelleher said. “PCL includes Medicare-approved agencies that meet certain federal health and safety requirements, and provides patients, caregivers, and families the tool to easily access home health agency quality data to take control of their care and their health.”

Massachusetts was the first state to voluntarily make hospital staffing and nursing-sensitive quality information public starting in 2006. Home Care Alliance of Massachusetts joined the PCL quality and patient safety transparency effort in 2013. The PatientCareLink website is a great resource and gives patients an open and transparent view of the hospitals providing them care.

Hospitals and home care agencies welcome transparency about their performance when performance measures are grounded in good science and are designed to make fair comparisons across institutions. Publicly reported performance data can offer several benefits, including:

  • Offering useful information for making decisions about where to obtain healthcare
  • Helping healthcare professionals and institutions improve the care they deliver; and
  • Providing extra motivation to improve performance.

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Prior Authorization Demo Proposed by CMS

Piling on top of existing pilots and demonstrations, the Centers for Medicare and Medicaid Services have released another proposed program that would establish Medicare prior authorizations and a fraud measurement pilot.

Massachusetts is one of five states – along with Florida, Texas, Illinois and Michigan – selected for the prior authorization demonstration. There are no details on what the authorizations would entail in the proposed demonstration aside from CMS stating that it would be similar to “Prior Authorization of Power Mobility Device (PMD) Demonstration, which was implemented by CMS in 2012.” The rule continues that “this demonstration would also follow and adopt prior authorization processes that currently exist in other health care programs such as TRICARE, certain state Medicaid programs, and in private insurance.”

CMS’ reasoning for implementing such a program a belief that it will help assist in “developing improved procedures for the identification, investigation, and prosecution of Medicare fraud occurring among HHAs providing services to Medicare beneficiaries.”

According to CMS, Medicare contractors will request the information from home health agency providers submitting claims for payment from the Medicare program in advance to determine appropriate payment.

The second piece of the CMS’ proposal is titled the “Medicare Probable Fraud Measurement Pilot.” The pilot would establish a baseline estimate of probable fraud in Medicare fee-for-service payments for home health care.

CMS purports that this would be accomplished using, at least in part, a summary of the service history of the HHA, the referring provider, and the beneficiary to estimate the percentage of total payments that are associated with probable fraud and the percentage of all claims that are associated with probable fraud for Medicare fee-for-service home health.

HCA is currently working to get more details on this demonstration so as to devise an advocacy strategy.

Comments on the proposed demonstration are due by April 5th and details are available here on the Federal Register.

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CMS Releases Final Home Health Rule, Adds Discharge Planning Proposal

CMS published the Final Rule for Medicare Home Health PPS and VBP for CY 2016 to its website yesterday.  The official notice will be published in the Federal Register on November 5.

CMS also announced a “Discharge Planning Proposed Rule,” that is estimated to cost home health agencies nationwide about $283 million. The proposal, which the Home Care Alliance will fully analyze, will revise discharge planning processes for hospitals, long-term care hospitals, inpatient rehabilitation facilities, and critical access hospitals in addition to home health.

In terms of changes made to the Home Health Final Rule, CMS pulled back slightly regarding both payment and in the Value Based Purchasing Program. Below is an analysis from HCA staff:

Value Based Purchasing:

The final rule makes minor changes to the VBP system from the proposed rule.  The same nine states (including MA) are selected, with all agencies in the state included in the VBP system.  VBP will begin January 1, 2016, with a 2015 baseline year on performance, with all agencies within each selected state competing against each other for payment adjustments tied to quality performance measures.

CMS made a small concession to industry concerns that the proposed risk corridor was too broad, and reduced the maximum payment reduction in the first year of the VBP from the proposed 5 percent to 3 percent. The payment adjustments will be increased incrementally over the course of the model with: 

  • a maximum payment adjustment of  3-percent (upward or downward) in 2018,
  • a maximum payment adjustment of 5-percent (upward or downward) in 2019,
  • a maximum payment adjustment of 6-percent (upward or downward) in 2020,
  • a maximum payment adjustment of 7-percent (upward or downward) in2021, and
  • a maximum payment adjustment of 8-percent (upward or downward) in 2022.

CMS dropped 4 process measures and 1 of the new reporting measures. The final set of 24 measures includes 10 outcome measures, 6 process measures, 5 HHCAHPS, and 3 New Measures.

Outcome Measures

  • Improvement in Pain Interfering with Activity-M1242
  • Improvement in Dyspnea- M1400
  • Improvement in Bathing-M1830
  • Improvement in Bed Transferring-M1850
  • Improvement in Ambulation-Locomotion M1860
  • Prior Functioning ADL/IADL-M1900
  • Improvement in Management of Oral Medications-M2020
  • Discharged to Community-M2420
  • Acute Care Hospitalization: Unplanned Hospitalization during first 60 days of Home Health- (Claims)
  • Emergency Department Use without Hospitalization- (Claims)

Process Measures

  • Influenza Vaccine Data Collection Period: Does this episode of care include any dates on or between October 1 and March 31?-M1041
  • Influenza Immunization Received for Current Flu Season-M1046
  • Pneumococcal Polysaccharide Vaccine Ever Received-M1051
  • Reason Pneumococcal vaccine not received-M1056
  • Drug Education on All Medications Provided to Patient/Caregiver during all Episodes of Care-M2015
  • Care Management: Types and Sources of Assistance-M2102

Home Health CAHPS: Satisfaction Survey Measures

  • Care of Patients
  • Communications between Providers and Patients
  • Specific Care Issues
  • Overall rating of home health care
  • Willingness to recommend the agency

New Measures

  • Influenza Vaccination Coverage for Home Health Care Personnel
  • Herpes zoster (Shingles) vaccination: Has the patient ever received the shingles vaccination?
  • Advance Care Plan

CMS has modified the reporting of the New Measures; HHAs will be required to begin reporting data (through a web portal) no later than October 7, 2016, for the period July, 2016, through September, 2016, and quarterly thereafter. As a result, the first quarterly performance report in July, 2016, will not account for any of the New Measures.

CY2016 PPS Rates

Case Mix Weights:  CMS made additional minor changes to the case mix weights based on additional analysis.

Case Mix Adjustment:  In a slight concession to industry comments, CMS is phasing in their proposed 2.88% case mix adjustment over three years instead of the two years they initially proposed.  So the final rule decreases the national, standardized 60-day episode payment amount by 0.97% each year in CY 2016, CY 2017, and CY 2018, instead of 1.44% for just 2016 and 2017. 

Market Basket Update:  The final CY 2016 home health market basket (2.3 percent) combined with the multifactor productivity adjustment (0.4 percentage points) results in a 1.9 percent home health payment update percentage.

Wage Index:  CMS made additional small adjustments to the Wage Index because they used an updated database of hospital wage data.  The final wage index is slightly lower than the proposed index for every geographic region in MA except Berkshire County.

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CMS Sends Brief Response on Congressional HHPPS Letter

A letter to CMS voicing deep concerns about the Home Health proposed rule with 133 signatures from members of Congress, including all nine US Representatives from Massachusetts, was sent in mid September.

CMS issued their response, which was more brief than usual and only served to thank the signers for sharing those concerns. CMS is obviously not sharing much as the finalized regulation is set to be released on November 1st.

The original congressional letter to CMS made a few major points. Concerns about the case mix cuts centered on the data CMS relied upon to make those adjustments, which were flagged as “outdated” and illogical. CMS essentially ignored the past five years of data and instead used a decade of data in the prior time period to make projections going forward.

The letter also raised concerns about the proposed Value-Based Purchasing Program (VBP) that will take place in nine states, including Massachusetts. Specifically, the five-to-eight percent penalty/reward window was put forth as much too severe and dramatic as was the immense list of quality measures that CMS proposed that agencies would track as part of the VBP.

Among those leading on the letter were Massachusetts Congressman and home health care champion Jim McGovern. The Alliance thanks Congressman McGovern and all in the state’s congressional delegation that signed on. More information will be announced following the release of the final rule.

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HCA Returns from Productive Washington, DC Trip

Home Care Alliance staff and member agencies attended the Visiting Nurse Associations of America’s (VNAA) Public Policy Leadership Conference in the nation’s capital this past week and met with most of the state’s Congressional delegation.

Before and during the trip, the Alliance was able to secure support from eight of the nine US Reps on a letter to CMS voicing concern on case mix cuts and the impending Value-Based Purchasing demonstration. The ninth congressperson may still sign on, but it was still a productive trip where home health agencies from across the country were lobbying on the Physician Face-to-Face Requirement, allowing NP’s and PA’s to sign and certify home health plans of care, expanding palliative care career opportunities and showing the impact of proposed payment cuts.

Much of the activity was documented on the HCA’s Twitter page along with photos of congressional visits. The Alliance will be following up on our meetings and advocacy in DC and will continue to represent our members regarding the CMS proposed rule, Face-to-Face, and other federal issues. The HCA thanks member agencies that attended as well as our supportive Congressional Delegation, particularly Congressman Jim McGovern who co-led the letter to CMS.

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