Tag: Federal Regulations

CMS Releases New MLN Article

On November 26th, CMS released the Medicare Learning Network  Article- (SE1237) Importance of Preparing/Maintaining Legible Medical Records. This article highlights the importance of legible documentation in avoiding claim denials. The key points highlighted:

  1. General Principles of Medical Record Documentation
  2. Medicare Signature requirements
  3. Amendments, Corrections and Delayed Entries

If you are looking for more facts on amendments, corrections and delayed entries see the Medicare Program Integrity Manual Section 3.3.2.5. The MLN article, Complying with Medicare Signature Requirements, provides a question and answer format for information on signature regulations

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Medicare Home Health Final Rule Issued

The Centers of Medicare and Medicaid (CMS) issued the Home Health Final Rule on Friday, November 2nd.  The Rule updates the HH PPS rates, including the national standardized 60-day episode rates, the national per-visit rates, the low-utilization payment amount (LUPA), the non-routine medical supplies conversion factor, and outlier payments. These rates will be effective January 1, 2013. This Rule also establishes requirements for the Home Health and Hospice quality reporting programs, important policy changes on CoP Non-compliance Sanctions, and improvements on Face to Face Encounter and Therapy Assessment Rules.

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Guest Post: Utilization of Post-Acute Services by ALF Residents

The following is a guest blog post on the utilization of post-acute services by residents of an assisted living facility written by Elizabeth Hogue, Esq. The author plans future articles on this subject so be sure to check back for updates!

As the number of years in which they have been in business increases, ALF’s are more eager to help their residents to “age in place.”  ALF’s often view availability of services from post-acute providers; including Medicare home care, private duty home care, hospice, and home medical equipment (HME); as essential to allow them to achieve this goal.  While ALF’s want to encourage utilization of these types of services by residents, ALF’s cannot lose sight of the fact that the healthcare industry is highly regulated.  With ever-increasing emphasis on fraud and abuse compliance, ALF’s and post-acute providers cannot afford to violate the law.

How can ALF’s encourage the use of services available from post-acute providers by residents?  What are the potential legal pitfalls that ALF’s and post-acute providers must avoid?  The most effective way to maximize utilization of these services may be to take a multi-pronged approach that includes:

1. Assignment of liaisons/coordinators from post-acute providers to ALF’s

Use of coordinators/liaisons at ALF’s raises issues related to violation of the federal anti-kickback statute.  This statute generally prohibits providers from either offering to give or actually giving anything to referral sources in order to induce referrals.  Consequently, liaisons and coordinators must be scrupulous about avoiding the provision of free services to ALF’s and/or their residents.  Possible violations include “staffing” an office with an RN who responds to requests from residents in their apartments or has “office hours” to address health conditions of residents.

Continue reading “Guest Post: Utilization of Post-Acute Services by ALF Residents”

New OASIS Guidance from CMS

CMS has just released the latest guidance for OASIS, October 2012 Quarterly Q&As.  This quarterly update contains 11 new Q&As including the latest CMS OASIS-C guidance with a special item about selecting fall risk assessment tools based on standardization, validation and multi-factor requirements.Other highlighted items:

  • situations where the physician-ordered ROC date is outside the assessment time frame
  • selecting a response for patient confusion when confusion level varies
  • how/when bipolar disease and other psychiatric diagnoses might impact the depression process measure.

CMS Releases Proposed PPS rates for 2013

CMS on Friday released an advance copy of the proposed regulation for changes to the home health PPS rates for calendar year 2013.

Brief highlights:

• The proposal increases the national base episodic rate by 0.16%, from $2,138.52 to $2,141.95.  (calculated using a 2.5 percent inflation update, a 1 point reduction mandated by the health care reform law, and a 1.32 percent case mix creep adjustment.)

• The portion of the rate adjusted by the wage index is increased from .77082 to .78535

• The county wage index is available here (click on the “download” at the bottom of the page).:

Here are changes for MA counties:

Current                2013

Barnstable                        1.2838                   1.2872
Boston                              1.2283                   1.2394
Middlesex                         1.1210                   1.1285
Essex                               1.0698                   1.0575
erkshire                            1.0616                   1.0745
Bristol                               1.0639                   1.0718
Springfield                        1.0247                   1.0390
Worcester                         1.1076                   1.1230
Dukes/Nantucket              1.3962                   1.3570

The proposed rule also:

  • allows certain non-physician practitioners in inpatient settings to conduct the required Face-to-face encounter;
  • increases flexibility in complying with the therapy reassessment requirements;
  • establishes hospice quality reporting requirements to begin in 2014, including various proposed measures to report;
  • creates an Informal Dispute Resolution process that agencies can use to dispute survey deficiencies;
  • establishes a range of “Intermediate Sanctions” for non-compliance with the Medicare Conditions of Participation, including civil money penalties, suspension of payment for new admissions, and temporary management.

The Alliance will conduct a thorough analysis of the proposed rule and prepare comments.  Watch for additional details in the next few weeks.

Comments are due by Sept. 4.

Medicare Home Health Proposed Rule Issued: Clarifications and Improvements on Therapy Assessment Rules

The  Medicare Home Health Proposed Rule was release last week. Among proposed payment changes, Face to Face clarifications, and new sanctions for non-compliance with federal requirements, the Therapy Assessment Rule is also slated for changes and improvements. But are all of these proposed changes really improvements to this Therapy Rule?

Clearly an improvement to the rule—CMS proposes to revise the regulations to state that if a qualified therapist missed a reassessment visit, therapy coverage would resume with the visit during which the qualified therapist completed the late reassessment, not the visit after the therapist completed late reassessment.— Currently, when a qualified therapist misses one of the required reassessment visits, once the therapist has completed the required reassessment, coverage resumes after this reassessment visit.

In addition, CMS proposes to revise the regulations to state that” in cases where multiple therapy disciplines are involved, if the required reassessment visit was missed for any one of the therapy disciplines for which therapy services were being provided, therapy coverage would cease only for that particular therapy discipline”. Therefore, as long as the required therapy reassessments were completed timely for the remaining therapy disciplines, therapy services would continue to be covered for those therapy disciplines. Again this change appears to work in favor of the provider. — Currently the regulation states,  even if qualified therapists from the other therapy disciplines have completed all their required reassessment visits, therapy visits for these disciplines would not be covered until the qualified therapist who missed the reassessment visit has completed the previously missed reassessment visit.

This last change has potential to cause headaches for scheduling the multi-therapy visits. —CMS is proposing a change to allow “flexibility” and guidance to the provider.  This change would be applicable in cases where beneficiaries are receiving more than one type of therapy; the qualified therapists could complete their reassessment visits during the 11th, 12th, or 13th visit for the required 13th visit reassessment and the 17th, 18th, or 19th visit for the required 19th visit reassessment. — Currently the regulation states that therapist’s visit need only be “close to” the 13th and 19th visits. This proposed revision does not appear flexible but rather has great potential for scheduling patients’ visits for three disciplines to be extremely inflexible. Hopefully stakeholders will comment on this proposed change.

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Home Care Alliance, National Organizations Make Statements on Supreme Court Decision

In light of the Supreme Court’s decision to uphold the Affordable Care Act, the Home Care Alliance of Massachusetts and other organizations representing health care providers and consumers had this to say:

“Today’s decision of the US Supreme Court has established the Affordable Care Act as the law. With their ruling, the Supreme Court has removed enormous uncertainty – particularly in states other than Massachusetts and for those involved in ACA funded demonstrations – as to whether to move forward. They now can, and we think they must.  While some parts of the law will impact Massachusetts far less directly than other states, there is evidence that our state has already benefited by some provisions. Most notably, 62,000 seniors and people with disabilities in Massachusetts have seen significant savings on their prescription drugs because the law was upheld.

All providers, including home health care, were subject to Medicare rate reductions in the ACA in order to expand coverage and pay for reform demonstrations.  These cuts have not been easy to absorb. With this ruling, we must now get to work to deliver on the promise in our state not just of universal access to insurance, but to a better coordinated, and ultimately more cost effective delivery system.”

-Patricia Kelleher, HCA Executive Director

Statement from the National Association for Home Care & Hospice (NAHC):

“NAHC has long supported reforms that increase access to health care for all in the United States and supports health delivery reforms and the expansion of Medicaid eligibility. The ACA rightly shifts the focus of care from inpatient services and institutional care to the community setting, which home health agencies and hospices have effectively served for decades.

NAHC believes that the Affordable Care Act can and should be improved. Accordingly, NAHC will continue to work with both Democrats and Republicans to improve the legislation. NAHC will ask that its implementation date be delayed for two years so that states have the time to prepare for implementation, including the creation of exchanges. This delay will also save approximately $200 billion, which can be applied to deficit reduction, extending the SGR “doc fix” and avoiding the need for any further cuts to Medicare. NAHC will continue to argue that home health care has been cut disproportionately and will oppose the imposition of copayments or additional cuts. NAHC believes that a good case can be made for expanding the scope of Medicare home health services to reduce hospitalization costs and improve services for the 5 percent of Americans who are responsible for 50 percent of total U.S. health care costs.”

-Val Halamandaris, NAHC President

Here are other statements from the following organizations:

And statements from political leaders:

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CMS Releases Updated Information about PECOS

Are your ordering/referring  physicians enrolled in PECOS?

On June 20th CMS released a revised MLN Matters article with updated information regarding PECOS and Phase 2 of the Ordering/Referring Physician Requirements.

During Phase 2, Medicare will deny Part A HHA claims that fail the ordering/referring provider edits. CMS has not announced a date when the edits for Phase 2 will become active. CMS will give the provider community at least 60 days notice prior to turning on these edits. Physicians and others who are eligible to order and refer items or services need to establish their Medicare enrollment record (PECOS).

It is possible that it could take 45-60 days, sometimes longer, for Medicare enrollment contractors to process enrollment applications. All enrollment applications, including those submitted over the web, require verification of the information reported. Sometimes, Medicare enrollment contractors may request additional information in order to process the enrollment application.

Waiting too late to begin this process could mean that physicians’ enrollment applications will not be able to be processed prior to the implementation date of Phase 2 of the ordering/referring provider edits. In Phase 2, if the Ordering/Referring Provider does not pass the edits, the claim will be denied.This means that the billing provider will not be paid for the items or services that were furnished based on the order or referral. For more information Click Here

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Hospice Quality Reporting Program Update

Hospices will be mandated-for the first time-to collect data on specific quality measures during the final calendar quarter of 2012 as part of the Hospice Quality Reporting Program. Failure by a hospice to submit the required data will result in a 2 percent reduction to that hospice’s payments during fiscal year 2014

In the June 4, 2012 Federal Register there is a notice regarding the data submission form to be used for reporting the required quality data. The Hospice Quality Reporting Program submission forms is now available, once you download the form click on “Hospice Mandatory Data Submission Form”.

For additional information about the Hospice Quality Reporting Program Click Here

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HHAs Must Ensure Physician Enrollment in Medicare

 CMS Releases:  Ordering and Referring Physician Final Rule

On Tuesday, CMS posted for public inspection the final rule “Medicare and Medicaid Programs: Changes in Provider and Supplier Enrollment, Ordering and Referring, and Documentation Requirements; and Changes in Provider Agreement” This document was published in the Federal Register on 04/27/2012.

This rule requires enrollment of physicians ordering home health and other services to be enrolled in the Provider Enrollment, Chain, and Ownership System (PECOS). Work is underway to transition all physicians enrolled in other systems, such as the Legacy system, to PECOS. This process is being expedited by CMS through physician Medicare re-validation.

Home health agencies should  begin checking every physicians Medicare enrollment status in the Ordering and Referring Physician report. Through this report CMS has made available the National Provider Identifier (NPI) and the name (last name, first name) of all physicians and non physician practitioners who are of a type/specialty that is eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS that contain an NPI).
A new file will be made available periodically that will replace the posted file; at any given time, only the most recent file will be available. It can also be used to search for a particular physician or non physician practitioner by NPI number or by name.
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