CMS to Delay Expansion of Pre-Claim Review Demo

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.

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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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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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Federal Lawsuit on Face-to-Face Rule Moving Forward

In a major win for home health agencies across the country, a federal district court determined that they will hear a legal challenge presented by the National Association for Home Care & Hospice (NAHC) to the validity of the physician narrative portion of the face-to-face requirement.

According to NAHC, the court issued an order denying Medicare’s effort to have the lawsuit dismissed by the court. The face-to-face requirement (F2F) was troublesome and frustrating from the outset as CMS released no standardized form for providers to follow and provider education was insufficient at best. It took constant advocacy and education on the state and local levels and strong lobbying on the federal level from state and national home care associations and agencies to even call attention to the problem.

The physician narrative where physicians must write a detailed account of patient eligibility for home health care services proved to be the paramount concern. Although the new final rule effective 1/1/2015 removes the narrative piece of the requirement, NAHC will continue to litigate the dispute to address the past claim denials and those denials that may still come involving home health services provided prior to January 1, 2015. If the lawsuit is successful, Medicare would be required to reopen and pay any claim previously denied for an insufficient narrative and stop any further claim reviews related to the narrative requirement.

NAHC and the Home Care Alliance continue to advise home health agencies to consider appealing any narrative-related claim denials while the lawsuit is progressing. Such action will preserve the opportunity to have the claims reviewed by Administrative Law Judges and also allow for easy identification of claims that may be subject to reopening if the lawsuit is successful.

The Alliance will also continue to provide education and updates on the new rule, including an upcoming webinar in early February. The Alliance helped lead the effort on a letter from New England Senators to CMS on F2F reviews and is out front with notices to physicians and hospitals on the recent rule changes.

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“40 Hours Is Full Time” Act Reintroduced in Senate, Advances in House

With a significant number of home health agencies classified as large employers under the Affordable Care Act (ACA), home health advocates have convinced lawmakers to reintroduce legislation that would help agencies avoid penalties for failing to offer health insurance to part time workers. The US House of Representatives voted to advance their version of that legislation on January 8.U.S. Capitol Building

Currently, the provision in the Affordable Care Act (ACA) that imposes penalties on employers with more than 50 full-time equivalent employees for not providing health insurance for their “full time” workers defines an employee working just 30 hours a week as full time. This definition of full time is out-of-keeping with standard employment practices and could cause significant financial burdens for many home care agencies. That mandate is not active until 2016, but later this year, the federal healthcare law will require that companies with 100 or more employees must offer coverage to most workers or face a financial penalty.

The House voted 252-172 to approve their version of the bill with 12 Democrats joining Republicans, which is not enough for a “veto proof” majority.

On the US Senate side, a hearing on Senators Susan Collins (R-ME) and Joe Donnelly (D-IN) “40 Hours Is Full Time Act” bill is planned for later this month.

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National Association Provides Update on Rebasing, SGR

The National Association for Home Care & Hospice (NAHC) held a conference call revealing a frantic final week of advocacy activity before Congress takes its holiday recess until the New Year.

The major part of that activity for home health agencies centered around the attempt to delay the impacts of Medicare “rebasing” cuts through an amendment to the Medicare Sustainable Growth Rate (SGR) fix – also known as the physician fix.

Senator Debbie Stabenow (D-MI) offered an amendment on behalf of home care that would delay the cuts for one full year and give the industry the chance to lobby CMS to change their methodology with more updated and accurate data. Unfortunately, part of the compromise of the short -term physician fix was that it was a “clean” bill, which means no outside amendments. According to NAHC, even the hospital industry had amendments that were proposed and then withdrawn because of that agreement between Democrats and Republicans.

The short-term SGR fix will last for three months and must be offset by $7 billion. The good news there is that none of the offset is coming from the home health industry. Some of the hit is being hit is being absorbed by cuts to Long Term Care Hospitals and Disproportionate Share Hospital rates, but copays and additional reductions for home care  were avoided.

The light at the end of the tunnel comes from the fact that the Senate is working on a permanent SGR fix and the Stabenow amendment will still be in play for that effort. In addition, NAHC was successful in getting language from the FITT Act into the Senate’s proposal. The FITT Act essentially establishes a national pilot program for home-based telemonitoring provided by home health agencies. It will not be straight reimbursement, but is meant to be a shared savings approach where the providers and Medicare will share in any efficiencies gained. Moreover, if the program is successful, NAHC indicated that the program could be expanded by Medicare without going back to Congress for approval since it is a pilot and not a demonstration.

In terms of hospice care, NAHC also reported that another amendment would allow physician’s assistants to serve as the attending physician for hospice patients.

All of these wheels will be in motion in the New Year, but the main idea is that Democrats and Republicans compromised on a two-year deal that keeps the federal government running and it was done without implementing co-payments for home care. The 2% sequester cuts are extended for an additional two years, but those are not “new” cuts and are simply to make the budget scoring work. By the time the extended years are reached, the sequester could potentially be a thing of the past.

The Home Care Alliance thanks agencies for sending nearly 200 messages to the Massachusetts Congressional Delegation in two days. That education and advocacy will be critical as we move forward to fight rebasing in the New Year. Of course, further information will be provided as it becomes available.


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Advocacy Alert: Contact Congress Re: Amendment Delaying Rebasing Cuts

Congress is working in the final days before the holiday recess on a long-term Medicare Sustainable Growth Rate (SGR) process and an amendment to that process could delay the impending rebasing cut to home health care.

The Alliance is asking that agencies and advocates contact their Member of Congress TODAY to educate them about the amendment and what it means for Medicare home health agencies. U.S. Capitol Building

Senator Debbie Stabenow (D-MI) has offered an amendment that essentially delays the effects of rebasing so that CMS can hopefully adjust their methodology with updated and more accurate data. Educating the Massachusetts Congressional Delegation is crucial to getting support for the amendment as there is so much happening in the final two days of activity.

More information and a prepared email message is available on HCA’s Legislative Action Network and it only takes a minute to log on and add your voice to this critical push to delay a damaging 3.5% cut per year over the next four years.

We also urge members to call the offices of your Congressional representatives directly using the message below as a guide. Simply call the main switchboard at (202) 224-3121, request a transfer to the office of your Congressional representative, and ask to speak to the individual from that office that is responsible for health policy.Here is the text of the message to Congress if you choose to call:

The U.S. Centers for Medicare and Medicaid Services (CMS) has finalized a rule imposing unprecedented Medicare home health reductions under a process called “rebasing.” All told, the impact on providers will be a $200 million cut in each of the next four years.

We are asking for your support in backing an amendment from Senator Debbie Stabenow as well as any corresponding effort in the House to amend the Medicare Sustainable Growth Rate (SGR) process.

These are the largest cuts to home health in decades, and they will cause many agencies to close their doors, especially if these cuts are compounded by Medicare reductions via the continuing budget resolution. Such cuts are counter-productive at a time when health reform relies on cost-effective care at home to serve vulnerable citizens.

CMS’s rebasing cuts were finalized on November 22 and go into effect on January 1. This leaves little time to delay these disastrous cuts and compel CMS to conduct a more fair, accurate and thorough analysis of its fiscal assumptions.

The data is clear. Many Medicare-certified home care providers are already operating in the red across all sources of payment. These new cuts – scheduled to be compounded for each of the next four years – will cripple the industry and create barriers to care. Yet, despite similar trends across the country, CMS concludes that draconian rebasing reductions are needed to eliminate positive margins in home health. CMS’s math simply does not add up.

Many in Congress agree. A bipartisan letter sent to CMS raised strong concerns, stating that the rebasing methodology relies on “incomplete data and analysis that results in the under-counting of home health agencies’ costs per episode of care, and an inappropriately high rebasing adjustment.”

Home care providers nationwide thank you and your colleagues in Congress for your strong stance on rebasing and we ask for your continued active engagement supporting Senator Stabenow and others to delay rebasing and initiate a more rational approach from CMS.

Thank you.

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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


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Deadline is TODAY for Congressional Signatures on Face-to-Face Letter

The deadline for a Congressional letter that seeks to streamline the burdensome Medicare home health face-to-face (F2F) requirement is today. New York Congressmen Tom Reed and Paul Tonko, as well as New Jersey Congressmen Christopher Smith and Robert Andrews, are circulating the letter and we need your help in cultivating Massachusetts Congressional support.   Please act now!

Use these talking points and call your legislator’s office and ask to speak to the healthcare staffer TODAY. Phone numbers for each office are listed below and if you’re unsure which member of Congress represents you, please contact James Fuccione at the Alliance.

Massachusetts federal delegation phone numbers:

Senator Elizabeth Warren:     (202) 224-4543
Senator Edward Markey:     (202) 224-2742
Congressman Jim McGovern:     (202) 225-6101
Congresswoman Niki Tsongas:     (202) 225-3411
Congressman Joe Kennedy:     (202) 225-5931
Congressman John Tierney:     (202) 225-8020
Congressman Stephen Lynch:     (202) 225-8273
Congressman Richard Neal:     (202) 225-5601
Congressman Michael Capuano:     (202) 225-5111
Congressman Bill Keating:     (202) 225-3111

The Congressional letter is addressed to U.S. Centers for Medicare and Medicaid Services (CMS) Administrator Marilyn Tavenner. Referring to the F2F mandate, the letter describes the “complicated, confusing and overlapping documentation requirements that exceed the intent of the law passed by Congress,” and it urges CMS to allow the F2F requirement to be met through the completion and collection of the separately signed 485 form.  Such a change would significantly ease the burden of the F2F mandate.

Almost 40 state home care associations (including the Alliance) are already listed in support of the letter, but in order to have the strongest impact with CMS, we need resounding support from as many Members of Congress as cosigners to this letter.

Agency members with any questions can contact James Fuccione at the Alliance.

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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

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