Tag: Medicare

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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One Care Program Extended Through 2018

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.

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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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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.

Return to www.thinkhomecare.org.

Notice of Observation Status Law Signed by President

Legislation requiring hospitals to notify Medicare beneficiaries when they are technically in an outpatient “observation” status was recently signed into law by President Obama.

The NOTICE ACT (Notice of Observation Treatment and Implication for Care Eligibility) requires hospitals to inform patients of their status when they are in observation, but not officially admitted, for more than 24 hours and classified as an outpatient. A written notice must, among other points, state that the beneficiary’s outpatient stay will not count toward the three-day inpatient stay required for the individual to be eligible for Medicare coverage of a stay a skilled-nursing facility. Hospitals will have until August 2016 to comply with the new law.

The NOTICE Act is good news for the home health agencies because tracking the status of the patient hospital stay proved to be a challenge. Patients were often unaware of whether their stay with the hospital was an inpatient admission or an observation stay leaving the HHA uncertain if Transfer/ROC OASIS were needed. Now with the implementation of this notice the HHA will be able to determine an observation stay and know that a Transfer/ROC OASIS is not needed. An Agency may choose to complete a “Significant Change in Condition” OASIS (Reason for Assessment, 5- Other follow-up) based on their agency policy.

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Advocacy Alert: Urge your US Rep to Support HHPPS Proposed Rule Letter

With another $350 million cut to Medicare home health payment and Massachusetts selected as one of nine states for a “Value-Based Purchasing” Pilot, it is important that a strong message is sent to CMS and that means getting strong support from our state’s Congressional Delegation.

A new message is posted on the Home Care Alliance’s Advocacy Center that you can easily send to your federal elected representative to gain support for a Congressional sign-on letter to CMS. Just fill out the contact information, hit “send” at the bottom of the page, and the message will automatically go to your member of Congress.

The letter, which can be seen below, voices concern about the burdensome payment reductions and severe Value-Based Purchasing penalty in CMS’ proposed rule. Home health care champion Congressman Jim McGovern is co-leading the effort – known as a “dear colleague” letter in Congress – and the Alliance continues to appreciate his ongoing support of our issues.

Here is the text of the letter:

The Honorable Andy Slavitt
Acting Administrator
Centers for Medicare and Medicaid Services
7500 Security Boulevard
Baltimore, Maryland 21244-1850

Dear Acting Administrator Slavitt:

We are writing today to express our concern with Medicare home health funding cuts set forth in the Home Health Prospective Payment System (HHPPS) proposed rule for 2016. Home healthcare is a vital service that allows millions of the most vulnerable senior citizens and disabled individuals to receive the treatment they need in the cost-effective environment they most prefer – their home. As a result, we request a careful reconsideration of two of the draft policy changes in light of their anticipated impact on homebound Medicare beneficiaries and the home health delivery system upon which they depend.

First, we are concerned with the draft HHPPS rule’s proposal to cut home health payment rates by an additional 1.72 percent in 2016 and again in 2017. This proposed “case mix” reduction is of concern because it appears to be based on a 2000-2010 case mix weight change analysis rather than changes in the condition of beneficiaries during the 2012 to 2014 period that Medicare proposes to address.

Second, the draft rule proposes a Home Health Value-Based Purchasing (HHVBP) program that would impose an incentive/penalty range of as much as 5 to 8 percent over a 5-year period. We are very concerned with the aggressive nature in which the Secretary intends to ramp up HHVBP. Implementing a VBP program with a 5 percent withhold that increases to 8 percent just three years later is too much too fast. We are also concerned that the Secretary is proposing 25 measures for use in the HHVBP— far too many for providers to focus on.

In closing, we wish to express our concern that, in its current form, the draft rule may drive Medicare reimbursement to unsustainable levels for thousands of small, rural and other home health providers across the country, impacting the care upon which many of the most vulnerable Medicare beneficiaries, as well as their communities, depend. As a result, we request that the Agency reconsider its proposed case mix cut until it evaluates the specific causes of case mix weight changes from 2012 to 2014 and consider a more reasonable implementation schedule for the proposed withhold amount in the HHVBP program.

We thank you for your attention to this critical matter.

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