HCA Submits Comment on Medicare Changes; Submit Your Comments Now!

On July 1st, 2018, the Centers for Medicare and Medicaid Services (CMS) issued a proposed rule which includes several changes to the home health benefit for 2019 and beyond. The public comment period closes this Friday August 31, 2018, at 11:59 p.m. As of this blog posting, 760 comments have been submitted to CMS which is encouraging, but far from the more than 1,300 comments submitted last year in response to the HHGM proposal which was ultimately withdrawn.

You can view the HCA’s written comments here and can download the word document here.

You may submit your own comments to CMS here.

Here are some of the key changes proposed, and an overview of HCA’s response:

Home Health Wage Index Changes

  • The 2019 proposed payment rates increase by 2.1% which represents a $400 million increase.
  • HCA of MA has long expressed concerns to CMS over inequities in how the wage index is calculated for home health agencies compared to hospitals. HCA urges CMS to adjust the 2019 home health agency wage index to reflect a policy to limit the wage index disparity between provider types within a given CBSA.

Proposed Patient Driven Groupings Model (PDGM) for CY 2020

  • Implementation: As the proposed PDGM would mark a major change in the way home health agencies will be reimbursed, the HCA urges CMS to delay implementation by one year to ensure that there is no disruption in access to services for beneficiaries and evaluate the accuracy of the model and its effect.

  • LUPA Thresholds: CMS proposes to set the LUPA visit threshold at the 10th percentile for each payment group. HCA believes this is complex and will complicate the care planning process for home health agencies. HCA urges CMS to retain the current LUPA thresholds and revisit them in future years.

  • Behavioral Assumptions: CMS proposed three ‘behavioral assumptions’ in the PDGM totaling -6.42%. However, these assumptions are not based in data or evidence. HCA believes that two of the three assumptions already exist in the current PPS methodology including; that agencies are already incentivized to both report the highest playing diagnosis codes and to develop and deliver plans of care that exceed the LUPA threshold. This could result in an over estimated impact of behavioral assumptions and the HCA urges CMS to eliminate the Clinical Group Coding and LUPA threshold assumptions.

  • Split percentage payment approach: HCA believes that changing from a 60 to 30 day billing period will be very disruptive to agencies’ operations and increase back-office costs. Therefore, HCA urges CMS to continue the split payment approach at the current 60/40 and 50/50 splits for early and late periods, respectively, to give agencies cash flow breathing room.

  • Certification and Re-certification of Patient Eligibility: HCA has long advocated for regulatory language to align with sub-regulatory guidance as it relates to documentation of the patient’s eligibility. HCA is encouraged by CMS’ proposal to eliminate the requirement that the physician provide an estimate of how much longer skilled services are required and we request that CMS consider revisions to the physician’s burden of the F2F encounter as a condition of payment. 
  • Remote Patient Monitoring: HCA strongly supports the proposal to recognize remote patient monitoring costs as an administrative cost on the HHA cost report. HCA does recommend however that CMS remove the regulation that does not allow remote patient monitoring to be used as a substitute for in-person home health services. 
  • Home Health Value Based Purchasing Model: HCA has long supported the HHVBP model aiming to improve quality by giving HHAs incentives to provide better quality care. However, HCA urges CMS to modify the HHVBP to recognize stabilization in the scoring because in many cases, stabilization (instead of improvement) is an appropriate goal for some patients.

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.

Return to www.thinkhomecare.org

Alliance Statement on CMS’ Final Rule Slashing Home Health Care Payments

The following is a statement from the Home Care Alliance regarding the CMS Final Rule on Home Health Rebasing. The Alliance invites its members and advocates to share this with their local media:

In a final rule released last Friday, the Centers for Medicare and Medicaid Services (CMS) have implemented a home health payment that will result in a 3.5 percent cut per year for the next four years.

It would be easy based on history to view the recent final rule from the Centers for Medicare and Medicaid Services (CMS) as “another year, another cut.” This year, however, is different.

The home health industry has absorbed $78 billion of cuts since 2009, which will be executed over the better part of the next decade. Those cuts come from the Affordable Care Act, other CMS final rules over recent years, and sequestration. The latest cuts amount to an additional and an untenable 14 percent – or $22 billion – reduction over the next four years.

These total reductions since 2009 and including the CMS final rule are comparable to the combined 2013 budgets of the federal departments of education and homeland security.

With an aging population and home health agencies caring for sicker patients that are released from the hospital at an earlier stage of recovery, the federal Medicare program is making it nearly impossible for quality providers to continue delivering effective services that end up saving taxpayers by preventing costlier facility-based health care under these circumstances.

The Home Care Alliance of Massachusetts joined providers and associations from across the country, as well as many members of Congress, in urging CMS to revisit what they had proposed back in July. Those calls and letters went disregarded and it is evident that CMS is trying to attain a numerical target in their budget ignoring logic at the expense of American seniors who benefit from care at home. CMS claims the cuts amount to a 1.05 percent reduction, which is a slight improvement over the proposed rule, but the cumulative impact of continued cuts scheduled for 2015, 2016, and 2017 drive the cut deeper.

The Home Care Alliance will be assembling with other advocates in Washington DC and online in a campaign to persist in opposing the cuts from CMS.

About the Home Care Alliance:

With a mission to unite people and organizations to advance community health through care and services in the home, the Home Care Alliance of Massachusetts is a non-profit trade association and advocacy group representing the voice of the state’s home-based health and care services. Founded in 1969, the Alliance represents 200 home care and home health agencies. For more information, visit www.thinkhomecare.org.


Return to www.thinkhomecare.org.

Alliance Submits Comments on PPS Rule

The Home Care Alliance of MA today submitted comments to CMS on the proposed rule setting Medicare home health rates for 2014. CMS has proposed cutting rates by 3.5% for each of the next four years.

Citing data concerns, inadequate allowances for increasing regulatory costs and operating margins, inequities in the proposed wage index, and an incomplete analysis of the impact on both agencies and Medicare patients of CMS’s proposal to cut rates for each of the next four years, the Alliance urges CMS to go back to the drawing board on 2014 rates.

The Alliance’s comments are available here.

Comments to CMS on the proposed rule are due TODAY at 5:00 p.m., and can be submitted online at www.regulations.gov.  Enter “RIN 0938-AR52” in the search box to find the proposed rule.

Proposed PPS Rule for Home Care and a Call to Action

In the July 3rd Federal Register, The Centers for Medicare and Medicaid Services (CMS) released the proposed Medicare Home Health Rule for 2014.  A key provision of this rule is the first year of a multi-year planned adjustment of home health prospective payment rates, otherwise known as “rebasing”.

The directive to rebase the home health PPS rates comes from language in the Affordable Care of 2010 that was a reaction to multiple years of MEDPAC Reports to Congress calling for dramatic steps to reform the home health payment system, which they claim have widely exceeded  program costs almost from the 2001 launch of the current PPS system.

Starting with 2014 rule and going forward through 2017, CMS plans to impose a 3.5% rebasing adjustment to the home health base rate.  This 3.5% reduction is based on CMS’ projection of an average home health profit margin of 13.63% in 2013 (calculated from 2011 data trended forward as the difference between the average national episode revenue in home health and the average national episode cost). The 2014 rule does include a 2.4% market basket update as well.

The phase-in of this rebasing cut and the inclusion of a market basket update is in conflict with what MEDPAC had recommended to Congress (no update and deeper and faster rebasing cuts) and is direct result of industry advocacy form these mitigating factors during the ACA debate.

Now, that type of industry advocacy is needed once again.  While eliminating any rebasing cut may well be impossible, it is possible that with strong Congressional support, we can challenge the CMS calculation and achieve some decrease in the 2014 cut.   Particularly subject to challenge is CMS’ calculation of industry profit margins from which the rebasing number are derived.

We also know the following about CMS’ calculations on profit margins:

  • Only freestanding and not hospital base agency cost reports are considered
  • They are at odds with what MEDPAC’s and NAHC’s numbers show
  • They may fail to adequately capture industry costs around mandates such as the Face to Face requirement, the ICD-10 implementation and investments in electronic health records .

The Alliance believes that we can make a strong case to Congress, but we need members to be engaged as advocates and as sources of information for us.

Please use the questions below as a guide to provide information on the anticipated impact of the CMS Proposed Rule by Friday, July 26th at 12pm. Alliance staff is traveling to Washington DC to meet with members of congress and the national associations, so please have information in ASAP:

  • What is the impact on your agency’s bottom line (in dollar amount and percent loss)?
  • What is the impact on staff, including reducing staff time, cutting jobs, or halting new hires?
  • Do you anticipate cutting or reducing service lines, particularly MassHealth/Medicaid?
  • What is the impact on innovative service lines, like hospital readmission, dementia, chronic disease management, falls prevention and etc?
  • How will the proposed rule affect other ways your agency does business?

Answers to the above can be emailed to James Fuccione at the Alliance

Return to www.thinkhomecare.org.

CMS Rescinds Reporting Modifier for Home Health Claims

Good news for Home Health Agencies…

CMS will no longer require home health agencies to apply a modifier to changes/additions to the plan of care by a physician other than the certifying physician for episodes starting on or after July 1. That’s the result of an April 3rd transmittal published on the CMS website. CMS states, “Transmittal 2650, dated February 1, 2013, is being rescinded and replaced with Transmittal 2680, to remove… instructions regarding reporting a new modifier.”

HHA are still required, effective July1, to report on claims the location where services were provided using one of three Q-codes.

  • Q5001: Home health care provided in patient’s home/residence
  • Q5002: Home health care provided in assisted living facility
  • Q5009: Home health care provided in place not otherwise specified

Return to www.thinkhomecare.org.

CMS Notification: April 2013 Quarterly System Release – Claim Hold

CMS issued the following notification; home health final claims with a through date of April 1st or after will not be released into processing until April 15th; this is due to a problem with the quarterly release that will not be fixed until April 14th.

The Centers for Medicare & Medicaid Services (CMS) has identified technical issues with certain parts of the April 2013 quarterly systems release.  For claims with dates of service or “Through Dates” on or after April 1, 2013, the issues affect (1) all Home Health final claims, (2) outpatient Critical Access Hospital (CAH) and Rural Health Clinic (RHC) claims where dollars have been applied to the beneficiary deductible, and (3) the remittance advice summary payment amount for Medicare Advantage inpatient prospective payment system (IPPS) claims with indirect medical education (IME).  Actual payments and the claim-level payment amounts on the remittance advice are correct for these Medicare Advantage IPPS IME claims.  Final home health, outpatient CAH and RHC, and Medicare Advantage IPPS IME claims with dates of service or “Through Dates” prior to April 1, 2013, are unaffected.  In addition, for claims pending with or received by the Medicare claims administration contractors on or after April 1, 2013, the issues affect (1) all claims for assistant-at-surgery services, and (2) all Ambulatory Surgical Center claims.  As a result of these issues, CMS has instructed its Medicare claims administration contractors to hold all of these specific claim types until April 14, 2013, when system fixes are expected to be implemented.  These claims will be released into processing on April 15, 2013.  The claim hold should have minimal impact on provider cash flow because, under current law, clean electronic claims are not paid sooner than 14 calendar days (29 for paper claims) after the date of receipt.

CMS regrets any inconvenience and is working to resolve these issues as quickly as possible.

Return to www.thinkhomecare.org.

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.

Return to www.thinkhomecare.org.

Alliance Submits Comments on PPS and Survey Rules

The Alliance today submitted comments to CMS on the proposed changes to the Medicare PPS rates for 2013 and the proposed new alternative sanctions in the survey enforcement process.  Specific issues that the Alliance addressed include the case mix creep adjustment, wage index concerns, proposed changes to the face-to-face and therapy reassessment requirements, and proposed Alternative sanctions—including civil money penalties – for agencies with condition-level deficiencies.  The Alliance’s comments are available on our website here

Alliance members are strongly encouraged to submit their own comments on the federal Regulations website.  Enter “CMS-1358-P” in the search box to find the PPS regulation, and follow the instructions to submit your comments.  Comments are due by September 4.

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.

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