Tag: Medicare

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.

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.

HCA Comments to CMS on Proposed Rule

The Home Care Alliance has submitted comments on behalf of Medicare home health agency members to the Centers for Medicare and Medicaid Services regarding Proposed Rule CMS-1510-P (Medicare Program: Home Health Prospective Payment System Rate Update [CY 2011]; Changes in Certification Requirements for Home Health Agencies and Hospices).

The comments include suggested changes on the case mix adjustment, face-to-face physician encounter requirement, 36-month Rule/Capitalization Requirements, Claims Data Collection and Processing, HHCAHPS, and the Therapy Coverage Requirement. The comments also reflect how Massachusetts agencies have case mix weights well below the national average, but that the Northeast stands to be punished severely for following guidelines set by CMS.

Click here to see the Home Care Alliance’s comments on the Proposed Rule.

Return to www.thinkhomecare.org.

CMS Offers Guidance on Hospice Care for Children in Medicaid and CHIP

The Centers for Medicare and Medicaid Services (CMS) have issued a letter to state health officials and Medicaid Directors  offering guidance on a provision of the Patient Protection and Affordable Care Act (PPACA) dealing with “Concurrent Care for Children.”

Specifically, the provision removes the prohibition of receiving curative treatment upon the election of the hospice benefit by or on behalf of a Medicaid or Children’s Health Insurance Program (CHIP) eligible child.

For more information, see the CMS memo here.

Return to www.thinkhomecare.org.

Letter Examples for CMS Proposed Rule Advocacy

Agencies in Western Massachusetts have stepped up with several letter templates for their physicians to send in to CMS and Administrator Donald Berwick regarding the Proposed Rule on case mix and Physician face-to-face visits.

Please see the letters below and feel free to edit and send as you see appropriate:

As a reminder, comments are due by September 14 to CMS and can be sent:

  1. a. By Mail: Centers for Medicare & Medicaid Services, Department of Health and Human Services, Attention: CMS-1510-P, P.O. Box 1850, Baltimore, MD 21244-1850
  2. b. Or electronically by clicking here, then clicking “submit comment.”

Return to www.thinkhomecare.org

HCA Urges Congress to Comment on Proposed Medicare Rule

The Home Care Alliance has distributed a letter to the Massachusetts Congressional Delegation, including Senators Kerry and Brown, in hopes that they will sign on and forward the comments to the Centers for Medicare and Medicaid Services (CMS) on behalf of the home health industry. The letter is in response to a CMS proposed rule that would severely threaten access to care services.

The letter urges CMS to scale back broad Medicare cuts to home health based on “case mix creep” and “upcoding,” among other factors, and alter the physician face-to-face visit requirement so that it is not a barrier between patients and the care they need.

Please contact your Congressperson TODAY, and urge them to support the comment letter.

Return to www.thinkhomecare.org.

Help Promote HOME CARE VOTES

The Home Care Alliance has prepared an awareness campaign centered on “getting out the vote” for home health and home care patients.

Patients served by home care agencies may not be able to physically get to their polling place to vote, but absentee ballots are available so that people can retain one more piece of their independence by exercising their right to vote from home.

This program involves informing patients that absentee ballots are available at their local town and city halls. All they have to do is apply by mail or have a family member apply to receive one. Your staff can help patients fill out the information to apply for the absentee ballot and even assist the patient in filling out the ballot itself, so long as the patient verifies the ballot and the fact that they were assisted with their signature.

For agencies who are interested, a press release is available upon request for local media (Note: for Medicare-certified agencies, the press release can be used as an opportunity to also raise awareness around the CMS proposed rule changes).

This program is one more way to have the voice of home care heard at a critical time. Please contact the Alliance for more information.

Return to www.thinkhomecare.org.

 

Chronology of Health Care Reform Provisions Affecting Home Care

Below is a timeline for when provisions of national health care reform impacting home care are set to be implemented.

The Table comes courtesy of the National Association for Home Care & Hospice.

January 1, 2010 

(proposed extension to January 1, 2011 by regulation)

 Sec. 6407. Face to face encounter with patient required before physicians may certify eligibility for home health services or durable medical equipment under Medicare; Sec. 10605 of Manager’s Amendment. Certain other providers permitted to conduct face to face encounter for home health services.
Face-to-face physician encounter requirement (including telehealth encounter) with patients within a reasonable timeframe as determined by the Secretary; nurse practitioners, advanced practice nurses, and physician assistants may substitute for physicians to meet the face-to-face encounter requirement.
January 1, 2010 Sec. 6406. Requirement for Physicians to Provide Documentation on Referrals to Programs at High Risk of Waste and Abuse.
Physician must maintain and provide access to documentation on Medicare home health referrals if requested. Home health agencies must maintain and provide access to documentation of certification of Medicare home health services if requested.
April 1, 2010 Sec. 3131. Payment Adjustment for Home Health Care
Sec. 3131(c). Application of the Medicare Rural Home Health Add-on Policy.
3% rural add-on for episodes and visits ending on or after April 1, 2010 and before January 1, 2016.
July 1, 2010 (regulation out July 6) Sec. 6405 Physicians who order items or services required to be Medicare enrolled physicians or eligible professionals; Sec. 10604 of Manager’s Amendment. Technical Correction to Section 6405.
Medicare enrolled physician requirement regarding care plan certification
September 30, 2010 Sec. 5101. National Health Care Workforce Commission. 

Establishes commission to review health care workforce and projected workforce needs.
October 1, 2010 Sec. 2401. Community First Choice Option. Expanded Medicaid home care through agencies and self-directed care.
October 1, 2010 Sec. 2402. Removal of barriers to Home and Community based Services.
Expanded rebalancing requirements and waiver authority and removal of restrictions on waivers.
October 1, 2010 Sec. 2403. Money Follows the Person Rebalancing Demonstration.
Extension through September 2016.
2010 Sec. 6401. Provider Screening and other enrollment requirements under Medicare, Medicaid, and CHIP.
Require background screening and credentialing of provider and supplier owners and managers, require compliance plans, gives CMS the authority to impose a temporary moratorium on new providers
2010 Sec. 3502. Establish Community Health Teams to Support Patient-Centered Medical Home. 

Grants to community-based interdisciplinary, interprofessional teams to support primary care practices; includes chronic care management.
2010 Sec. 6201. Nationwide program for National and State background checks on direct patient access employees of long-term care facilities and providers.
Extends existing pilot program for background checks on direct patient access employees of long-term care facilities and providers to a nationwide program (based on individual state choice of participation).  Definition of long-term care facility or provider includes providers of home care.
2010 – 2014 Sec. 4201. Community Transformation Grants 

Competitive grants to State and local governmental agencies and community based organizations for the implementation, evaluation and dissemination of evidence-based community preventive health activities in order to reduce chronic disease rates, prevent the development of secondary conditions, address health disparities and develop a stronger evidence-base of effective prevention programming.  Authorized appropriations for 2010 – 2014.

2010 Sec. 10501. National Diabetes Prevention Program 

Grants to entities determined by the Secretary for community-based diabetes prevention programs.
2010 – 2014 Sec. 4202. Healthy Aging, Living Well; Evaluation of Community-Based Prevention and Wellness Programs for Medicare Beneficiaries  

Grants to state or local health departments and Indian tribes to carry out 5-year pilot programs to provide public health community interventions, screenings, and clinical referrals for individuals between 55 and 64.
2010 Sec. 4204. Demonstration Program to Improve Immunization Coverage. 

Demonstration program awarding grants to states to improve the provision of recommended immunizations through the use of evidence-based, population-based interventions for high-risk populations.
2010 – 2015 Sec. 2951. Grants for Early Childhood Home Visitation. 

Grants to states to establish quantifiable and measurable 3 and 5 year benchmarks to demonstrate improvements in maternal and newborn health, prevention of child injuries and abuse, improvements in family economic self-sufficiency and school readiness/achievement, and improvements in coordination and referrals between other community resources.
2010 (authorized for five years, with option of additional five years) Sec. 2601. Medicaid Waiver Demonstration Projects for Dual Eligibles. 

Medicaid waivers for coordinating care for dual eligible beneficiaries.
January 1, 2011 Sec. 2703. Health Homes for Chronically Ill Patients 

Planning grants to states to develop a new state plan option to permit Medicaid enrollees with at least two chronic conditions, one condition and risk of developing another, or at least a serious and persistent mental health condition to select a designated provider (could include a home health agency), a team of healthcare professionals operating with such a provider, or a health team as the individual’s health home for purposes of providing the individual with health home services.  States taking up option provided with 90 percent of FMAP for two years for home health related services, including care management, care coordination, and health promotion.
January 1, 2011 Sec. 3021. Establish a Center for Medicare and Medicaid Innovation within CMS.
Opportunities for chronic care and other initiatives includes funding home health providers who offer chronic care management services to applicable individuals in cooperation with interdisciplinary teams (xiv).  Telehealth advancement opportunities through new CMS Innovations Center but no guarantee.
January 1, 2011 Sec. 3026. Community Based Transitions Program 

Funding for hospitals with high admission rates and community-based organizations that improve care transition services for high risk Medicare beneficiaries.  ($500 million total.)
January 1, 2011 Sec. 3131. Payment Adjustment for Home Health Care
Sec. 3131(b). Program Specific Outlier Cap.
Beginning in 2011, cap total outliers at 2.5%; impose individual agency outlier cap of 10%.
January 1, 2011 Sec. 3401 Revision of certain market basket updates and incorporation of productivity improvements into market basket updates that do not already incorporate such improvements.; Sec. 10319 of Manager’s Amendment. Revisions to market basket adjustments.
Reduce home health market basket update by 1 percentage point in 2011, 2012, and 2013.
October 1, 2011 Sec. 3006. Plans for a Value-Based Purchasing Program for Skilled Nursing Facilities and Home Health Agencies.
Secretary of HHS shall submit plan for value—based purchasing program for home health agencies to Congress by Oct. 1, 2011.
2011 (enroll) 

2016 (coverage begins)

 Sec. 8001. Community Living Assistance Services and Supports Act (CLASS Act).
Establish voluntary national home and community-based long term care insurance program. Beneficiaries vest after 5 years paying premiums.
January 1, 2012 Sec. 3024.  Independence at Home demonstration program.
Tests a payment incentive and service delivery model that utilizes physician and nurse practitioner directed home-based primary care teams.
January 1, 2012 – December 31, 2016 Sec. 2704. Bundled Payments Medicaid. 

Medicaid demonstration project in 8 states to pay bundled payments to hospitals for episodes of care that include hospitalizations.
January 1, 2012 Sec. 3022. Accountable Care Organizations. 

Establishes a shared savings program that rewards Accountable Care Organizations (ACO) that take responsibility for the costs and quality of care.  ACO’s may include groups of health care providers.
October 1, 2012 Sec. 3025. Hospital Readmissions and Reductions Program.
Reduce hospital payments for readmissions.
January 1, 2013 Sec. 3023. National Pilot Program on Payment Bundling.
Directs HHS Secretary to develop a national, voluntary pilot program encouraging bundled payment models for hospitals, doctors, and post-acute care providers. Entities including a hospital, a physician group, a SNF and a home health agency may apply to participate. Requires the Secretary to establish this program by January 1, 2013 for a period of five years. Before January 1, 2016, the Secretary is also required to submit a plan to Congress to expand the pilot program if doing so will result in improving the quality of patient care and reducing spending.
January 1, 2014 Sec. 3131. Payment Adjustment for Home Health Care; Sec. 10315 of Manager’s Amendment. Revisions to Home Health Provisions.
Rebase starting in 2014 phasing in through 2017; rebasing adjustment limited to no more than 3.5% reduction per year.
January 1, 2014 – December 31, 2018 Sec. 2404. Protection for Recipients of Home and Community Based Services Against Spousal Impoverishment.
Spousal impoverishment protection for home care eligibility.
January 1, 2014 Sec. 1513. Shared Responsibility for Employers.
Assess employers with more than 50 employees that do not offer coverage and have at least one full-time employee who receives a premium tax credit a fee of $2,000 per full-time employee, excluding the first 30 employees from the assessment. (Effective January 1, 2014) 

Exempt employers with 50 or fewer employees from any of the above penalties.
January 1, 2014 Sec. 10108. Free Choice Vouchers.
Require employers that offer coverage to their employees to provide a free choice voucher to employees with incomes less than 400% FPL who choose to enroll in a plan in the Exchange. The voucher amount is equal to what the employer would have paid to provide coverage to the employee under the employer’s plan and will be used to offset the premium costs for the plan in which the employee is enrolled. Employers providing free choice vouchers will not be subject to penalties for employees that receive premium credits in the Exchange. (Effective January 1, 2014) 

The term ‘full-time employee’ means an employee who is employed on average at least 30 hours of service per week.
January 15, 2014 Sec. 3403. Independent Medicare Advisory Board; Sec. 10320 of Manager’s Amendment. Expansion of the Scope of, and additional improvements to, the Independent Medicare Advisory Board.
Establish an Independent Payment Advisory Board comprised of 15 members to submit legislative proposals containing recommendations to reduce the per capita rate of growth in Medicare spending if spending exceeds a target growth rate. Beginning January 15, 2014, in years when Medicare costs are projected to be unsustainable, the Board’s proposals will take effect unless Congress passes an alternative measure that achieves the same level of savings. The Board would be prohibited from making proposals that ration care, raise taxes or Part B premiums, or change Medicare benefit, eligibility, or cost-sharing standards.
March 1, 2014 Sec. 3131(d). Study and Report on the Developments of the Home Health Payment Reforms In Order to Ensure Access to Care and Quality Services.
By March 1, 2014, HHS Secretary must report on home health rebasing and impact on access and quality.
March 1, 2014 Sec. 10315 (b).  Revisions to Home Health Care Provisions.

HHS Study and Report: By March 1, 2014, HHS must report results of a study with recommendations for legislative and administrative action, regarding home health agency costs for care provided to low-income beneficiaries or those in medically underserved areas, and those with varying levels of severity.
2014 Sec. 1302. Essential Health Benefits Requirements 

Secretary shall define essential health benefits with respect to any health plan; provides for notice and opportunity for public comment.
January 1, 2015 Sec. 3131(2)(B). MedPAC Study and Report.
MedPAC shall report by Jan. 1, 2015, on impact of rebasing.
January 1, 2015 Sec. 3401. Revision of Certain Market Basket Updates and Incorporation of Productivity Improvements into Market Basket Updates That Do Not Already Incorporate Such Improvements.
Annual productivity adjustment (estimated 1 percentage point reduction) beginning 2015.
January 1, 2015 Sec. 10315 (b) Revisions to Home Health Care Provisions.

Medicare Demonstration Project: HHS Secretary may provide for a four-year (beginning no later than January 1, 2015) $500M demonstration project to test whether making payment adjustments based on the study substantially improve access to care for patients with high severity levels of illness or for low-income or underserved Medicare beneficiaries.

Return to www.thinkhomecare.org.

NHIC Clarifies Home Health Issues

NHIC Corp, the Medicare Administrative Contractor for Jurisdiction 14 A/B/MAC, held a conference call for home health and hospice to clarify information and provide the opportunity for questions.

Change Request (CR) 6856 clarified the scope of claims editing and PECOS for home health. During Phase I (October 1, 2010-December 31, 2010), when a claim is received, the following will occur:

The RHHI will determine if an attending physician is required for the billed service; if so, that the attending physician’s NPI in on the claim. If the NPI is present,  Medicare will verify that he/she is on the national PECOS file. If the attending physician is not on the PECOS file, the claim will continue to process but a message will be included that the claim may not be paid in the future.

After January 1, 2011, if the billed service requires an attending physician and the NPI is not on the claim, the claim will not be paid.  If there is an NPI, Medicare will also verify with the national PECOS file.  If the physician is on the PECOS file but not a doctor of medicine, osteopathy, or podiatry the claim will not be paid.  CMS is still silent as to claims payment if the physician is not in PECOS or is on the “pending file” after January 1, 2011.

Providers were also reminded about CR 6960 and the timely filing requirements that were changed by the Patient Protection and Affordable care Act (PPACA).  Providers now have one year to file a Medicare claim, based on date of service.  In the case of providers that use “From” and “Through” dates, CR 7080 clarified that the “through” date is used.

Providers with questions regarding these issues or any others should contact the Customer Call Center at 866/289-0423 or for medical review-related questions, the Clinical Voice mail Box at 800/338-6101.

Check the NHIC website at http://www.medicarenhic.com to register for upcoming educational sessions including home health billing on September 15th; Clinical Medical Review Findings on November 17th; and an ACT Call (Ask-the-Contractor) on October 13th.