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.
The Home Care Alliance of MA put together a COP Task Force consisting of an expert team of home health professionals. This task force developed guidelines to assist Home Health Agencies with the understanding on the new standards in order to stay in compliance.
Guest: William Dombi was appointed as NAHC’s interim president this past August, and served as its vice president for law since 1987. He is also director of the Center for Health Care Law, a nonprofit, public interest law firm established by NAHC, and executive director of the Home Care and Hospice Financial Managers Association. Additionally, he is a member of the advisory board of Bloomberg BNA’s Medicare Report.
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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.
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
Based on CMS’ selection criteria, the Pittsfield and Springfield Metropolitan Statistical Areas are “excluded” from selection eligibility.
MassHealth announced that the One Care Program for individuals dually eligible for Medicare and MassHealth and between the ages of 21 and 64 has been extended through 2018.
Part of this new agreement with the Centers for Medicare and Medicaid Services (CMS) is that MassHealth will be accepting letters of intent (LOI) from entities interested in becoming One Care Plans effective January 1, 2018.
Beginning in 2013, the One Care program included several plans that were whittled down to what is now Commonwealth Care Alliance and Tufts Health Plan, which began participation in the initiative as Network Health. Funding issues were at the center of why other plans could not sustain covering One Care enrollees, although adjustments have been worked out that are intended to help plans better predict costs and assess financial risk. Fallon Total Care was the latest to drop their participation in June 2015.
Out of 103,041 eligible individuals, MassHealth reports that 13,038 are covered by the two One Care Plans. Commonwealth Care Alliance covers the bulk of that total with 10,050 enrollees as of June 1, 2016. According to the latest enrollment report, more than 30,000 individuals have “opted out” of the One Care Program.
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.
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.
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.”