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Prepping for PDGM

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Clinical Practices, Coding, Payment Rate Updates, PDGM

Prepping for PDGM

PPS final rule increases agencies' payments for 2019, finalizes PDGM

 
Now in the third week of January, 2019 and the PDGM model will be here in less than a year. Medicare-certified home care agencies need to begin NOW to prepare for the 2020 transition to a Patient-Driven Groupings Model. The proposed PDGM model, required by the Bipartisan Budget Act of 2018, is intended to remove current incentives to over-provide therapy services and changes the 60-day episode of care unit of payment to 30 days according to CMS. Also, a new set of groupings for the patient – diagnosis and functional levels – will be introduced that determines the patient’s reimbursement for the new 30-day episode. The PDGM model is planned for implementation on January 1, 2020 (Harris, 2018). Home care agencies should focus on several areas within their agency in order to prepare for PDGM. The fits area of concern should be the referral systems. According to Home Health Care News' Kaitlyn Mattson, "CMS’ move to shake up case mix specifically in regard to referral source is, at least in part, due to data and the agency’s belief that patients coming from institutional settings are typically sicker and, thus, need more care and resources." Moreover, "“60% of referrals come from the community,” Gina Mazza, director of the regulatory and compliance division at Fazzi Associates, told HHCN. “Every agency needs to understand how they specifically will be impacted by this new payment model. This is an area agencies really need to think about—what’s my patient population look like? Where do my referrals come from? Are there opportunities for me to make any changes?” Mazza added, “Referral source is always an area agencies want to work on, cultivate” (Mattson, 2018). Another area is staff education which is key to smoother PDGM transitions. Supporting on-the-ground staff may be the key to an easier PDGM transition. “Having the resources available to do the education—to stay on top of making sure nurses understand and are able to still spend the amount of time they want with their patients while fulfilling all the new requirements [will be paramount],” Susan Adams, vice president and administrator at Masonicare Home Health and Hospice (Mattson, 2018). Now finalized by CMS, there will be a learning curve with PDGM until staff becomes more comfortable with the intricacies of the rule. Agencies need to set aside a significant amount of time and attention so they can work with staff, so that assessments and documentations are really tight, Joy M. Cameron, vice president of policy and innovation at ElevatingHom said (Mattson, 2018). Confused? Frustrated? Not sure where to begin prepping for PDGM? Don't worry. SelectData has you covered. Contact our Business Development team to find out how SelectData can help you smoothly transition into PDGM today! Call 800-332-0555 or email info@selectdata.com and ask about our PDGM solution today! Resources Harris, T. (2018). OASIS-D GG0100B OASIS Home Health - Prior Mobility Functioning and Physical Therapy. Home Health Blogger. Retrieved from: http://go.myhomecarebiz.com/blog/oasis-d-gg0100b-prior-mobility-functioning-is-the-key-indicator-for-physical-therapy Mattson, K. (2018). PDGM Likely to Shake Up Patient Populations for Home Health Agencies. Home Health Care News. Retrieved from: https://homehealthcarenews.com/2018/08/pdgm-likely-to-shake-up-patient-populations-for-home-health-agencies/

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Home Health Value Based Purchasing Model: It’s One Year Old and Growing

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Clinical Practices, The Affordable Care Act (ACO), Value-Based Purchasing

Home Health Value Based Purchasing Model: It’s One Year Old and Growing

Successfully Navigating the Home Healthcare Industry to Value Based Purchasing

 
Last January, 2016, the CMS Innovation Center launched the Home Health Value Based Purchasing (HHVBPM) aka VBP Model in the following nine states:
  • Arizona
  • Florida
  • Iowa
  • Maryland
  • Massachusetts
  • Nebraska
  • North Carolina
  • Tennessee
  • Washington
This is part of a larger movement across the healthcare system in the US. CMS, as well as other payors want payment tied more closely to the quality of care delivered.  CMS wants to reward those Medicare certified agencies that perform well on select quality measures. The belief is that those agencies that perform well under VBP will have an increase in revenue and those agencies that cannot perform well with the identified quality measures will be penalized by shrinking margins. The maximum payment adjustments are planned as follows:
  • 3% upward or downward in 2018
  • 5% upward or downward in 2019
  • 6% upward or downward in 2020
  • 7% upward or downward in 2021and
  • 8% upward or downward in 2022
CMS expects to expand the VBP model to other states in the future. There were originally 24 quality measures proposed for review, however in June, 2016, CMS proposed dropping four of those measures.  Using data from OASIS, Medicare claims, HHCAHPS surveys, and other reported data, agencies will be evaluated quarterly receiving reports on their performance compared to their baseline in previous quarters as well as how their performance stands up against other agencies within their state. There are nine quality outcome measures used to determine payment awards:
  • Improvement in Ambulation
  • Improvement in Dyspnea
  • Improvement in Bed Transferring
  • Improvement in Bathing
  • Improvement in pain interfering with activity
  • Improvement in Oral Medication Management
  • Emergency department use without hospitalization
  • Acute Care Hospitalization
  • Discharge to the Community
There are three quality process measures used to determine payment awards:
  • Influenza immunization received
  • Pneumococcal vaccine received
  • Medication education
There are five consumer outcome measures used to determine payment awards
  • Care of patients
  • Specific Care issues
  • Communication between the patient and the care provider
  • Patient willingness to recommend the provider of care
  • Patient’s overall rating
There are three new additional measures used to determine payment awards:
  • Influenza vaccination for provider’s home health personnel
  • Herpes zoster vaccination for provider’s home health personnel
  • Advanced care planning
Using the above measures, agencies will receive an “achievement score” that compares an agency to peer agencies and an “improvement score” that compares the agency with their baseline year. For each process and outcome measure, those two scores will be calculated and the higher of the two scores will count toward the agency’s overall “Total Performance Score (TPS).”  The three new measures count toward 10% of the total score. What can your agency do to positively impact the agency’s score?
  • Your agency must become educated in the HHVBP model and the measures.
  • Industry experts believe CMS will implement this nationwide sooner than anticipated. Look at each item and hone in on 1-2 items at a time. Consider focusing on the process measures, as they are seen to be easier to affect change.
  • If you are a high performing agency, then more opportunity may exist with achievement scores.
  • If your agency has consistently struggled, focus on the improvement scores.
  • Conduct a gap analysis as to clinician understanding of each OASIS and HHCAHP item.
  • Provide OASIS education specifics. Hone in on SOC opportunities for assessment evaluation.
  • Provide clinician education regarding HHCAHPS and the questions that will impact your agency.
  • Be certain your agency’s software has the capability to assist in analysis of clinical documentation analytics and reporting regarding OASIS and Claims data.
Don’t wait, if you are an agency in one of the 41 states not yet officially affected. VBP is here to stay. Payors other than CMS are also looking at patient outcomes by diagnoses and using that factor as a guide as to whether or not they wish to contract with a provider. For a small Medicare certified agency, a 3% reduction in payment will be painful and a 5% reduction could be unsustainable. You need to be active in VBP education NOW! You may need to designate a position only for data analytics. You need to have strong partners whether in your EMR, your coding and document review, or in analyzing and providing the best plan of care for the patient in order to meet the VBP outcome level goals. Consider Select Data as a partner in achieving the best patient plan of care for the diagnoses to be coded and the goals needed to achieve those high quality goals and succeed with the CMS quality measures. Call Select Data at 1.800.332.0555 for more information.
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555. Click here to contact us.

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NAHC to File Lawsuit to Stop Pre-Claim Review Demonstration

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Legislation

NAHC to File Lawsuit to Stop Pre-Claim Review Demonstration

The Empire strikes back? No wait National Association is striking back against the "failed" Pre-Claim Review Demonstration. Read more.

 
On October 25, the National Association for Home Care & Hospice (NAHC) announced that its board authorized a lawsuit against the Centers for Medicare and Medicaid Services (CMS) in connection with CMS’ Pre-Claim Review (PCR) Demonstration for Home Health Services. The National Association is striking back against the “failed” Pre-Claim Review Demonstration (PCRD) with a plan to file a lawsuit against the Centers for Medicare & Medicaid Services (CMS). The board of directors of the National Association for Homecare & Hospice (NAHC) has authorized a lawsuit against CMS, which the association says
“is currently ravaging our Illinois members and threatening to do the same across the country.”
The lawsuit likely will be filed within weeks and will seek an injunction to stop pre-claim in Illinois, William Dombi, NAHC’s vice president for law, told Home Health Care News.

CMS Announced Delay In PCRD

Five states were originally scheduled to participate in the demonstration, with Florida and Texas beginning this year after Illinois, followed by Michigan and Massachusetts in 2017. Six weeks after the demonstration started in Illinois on August 1st, CMS announced a delay in the rest of the states, subject to a 30-day notice to resume (Oakes, 2016).

CMS Stands Behind Data

While CMS delayed implementing the demonstration to the other four pilot states, the agency has made no moves to stop the model in Illinois. It appears likely, at this point, the demonstration will be implemented in the other pilot states in the future.

NAHC Strikes Back

NAHC has been extremely vocal that the demonstration is harmful to the home health care industry, causing punishing administrative burdens and delaying care in Illinois. Home health providers across the country and in Illinois have also spoken up about their concerns over the demonstration, with one provider calling it the “worst regulation” he has ever seen. Agencies have also voiced their discontent with CMS (Baxter, 2016). Whether your agency is for or against Pre-Claim Review Select Data’s got your back. Coming in 2017, Select Data will be launching a series of services surrounding Pre-Claim Review and Pre-Rap Review to empower your coding team with our tailored review services. Contact Services@SelectData.com for more information.

Related Articles

Need A Refresher On Pre-Claim Reveiw Demonstration? See Related article click here.
References Baxter, A. (2016). NAHC to File Lawsuit to Stop Pre-Claim. Home Health Care News. Retrieved from: http://homehealthcarenews.com/2016/10/nahc-to-file-lawsuit-to-stop-pre-claim/ Oakes, R. (2016). NAHC Considers Suit to Halt Pre-Claim Review Demonstration Project. McKesson Healthcare Talk. Retrieved from: http://www.mckessonhomecaretalk.com/regulatory-news/nahc-considers-suit-halt-pre-claim-review-demonstration-project/ Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Hospice and Medicare Part D: Get the Facts

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Hospice, OIG

Hospice and Medicare Part D: Get the Facts

Hospice and Medicare Part D: Get the Facts. New CMS Guidance.

 
Medicare Part D is a Federal program designed to subsidize the costs of prescription drugs and prescription drug insurance premiums for Medicare beneficiaries.  In 2014 Medicare paid over 77 billion dollars in Part D benefits serving more than 37 million beneficiaries.  Part D administration depends on extensive coordination and information sharing between the Federal and State agencies, healthcare providers, drug plan sponsors, contractors and third-party payers. Hospice programs are required to provide individuals receiving Hospice care with drugs and biologicals related to the palliation and management of the terminal illness defined in the Hospice plan of care.  Medicare pays the Hospice agency for each day in which the patient is receiving hospice care, regardless of the amount of care received on a given day.    Hospice is a Medicare Part A benefit and drugs provided by the hospice are covered under the Medicare payment to the hospice program and not covered under Part D. Prescription drugs may be covered under the Part D benefit for the patient receiving Hospice care if the drug is unrelated to the terminal prognosis of the individual.   In 2012 the Office of the Inspector General (OIG) identified situations in which Medicare was paying twice for prescription drugs for hospice beneficiaries, and those beneficiaries may be paying unnecessary copayments for prescription drugs.  The report indicated that most hospice beneficiaries generally experience common symptoms during the end of life regardless of the terminal diagnosis.  These symptoms include pain, nausea, constipation and anxiety.  The OIG worked with the National Hospice and Palliative Care Organization (NHPCO) to identify 4 common categories of prescription drugs that are typically used to treat these symptoms:  antinauseants, laxatives, analgesics, and antianxiety drugs.  These categories of drugs should be covered under the Hospice benefit; however, some instances occur in which 1 or more of these drug categories may be unrelated to the terminal diagnosis of the beneficiary.  In these situations the Part D benefit is responsible for coverage of the drug and the patient assumes any copayment required. It is beneficial for the provider to understand the steps involved from the Medicare Part D plan sponsor in the coverage or rejection of the claim.
  1. Once the plan sponsor receives a pharmacy claim, for the beneficiary who has elected Hospice and the drug falls into the 4 common categories, the claim may be rejected using the National Council for Prescription Drug Programs (NCPDP)-approved reject coding.
Code Description
A3 This product may be covered under Hospice-Medicare A
75 Prior Authorization Required
569 Provide Notice:  Medicare Prescription Drug Coverage and Your Rights
2. Plan sponsors are required to provide a point of sale message that states: “Hospice Provider- Request Prior Authorization for Part D Drug Unrelated to Terminal Illness or Related Conditions” This message should also include the 24 hour pharmacy help desk number to call with questions. 3. The beneficiary, beneficiary’s representative, or prescriber may contact the plan sponsor to request a coverage determination.
  • The sponsor can contact the prescriber to complete the Prior Authorization (PA) form.
  • The prescriber can provide a verbal explanation to the sponsor as to why the drug is unrelated to the terminal illness or related conditions or complete the PA form and submit it to the sponsor by fax or mail.
  • If the prescriber is unaffiliated with the Hospice provider and is unable or unwilling to coordinate with the Hospice provider to provide the statement, the plan sponsor can contact the Hospice Provider for the statement that the drugs are unrelated to the terminal illness or related conditions or complete the PA form.
In some instances the plan sponsor may contact the Hospice provider and receive information that the drug is related to the terminal illness or related condition but it has been determined to be a beneficiary liability.  Once the plan sponsor has received the statement that a drug is unrelated to the terminal illness or related conditions the adjudication process can take no more than 24 hours for expedited requests or 72 hours for standard requests.  (Section 30.2 Chapter 18 Medicare Drug Benefit Manual) Beneficiary liability indicates that the patient is assuming responsibility for the cost of the drug.  Beneficiary liability can occur when the Hospice interdisciplinary group has determined, after discussion with the patient and family, that the existing medication/s may no longer be effective in the intended treatment and/or may be causing negative symptoms in the individual.  The medications would not be covered under the Medicare Hospice benefit as they would not meet the requirements of reasonable and necessary for palliation of pain and/or symptom management.  The patient may choose to have these medications filled through their pharmacy, if this occurs then the medications then become a beneficiary liability for payment and the cost of the medication would not be covered under Medicare Part D.  A patient may also request a drug for his/her terminal illness that is not included in the Hospice formulary and the beneficiary refuses to try a formulary equivalent first; or the drug has been determined by the Hospice provider to be unreasonable or unnecessary for the patient’s palliation of pain and/or symptom management.  The drug then becomes a beneficiary liability and no payment for the drug will be made under the Part D benefit. Hospice providers are encouraged to use the PA form prospectively to prevent the drug claim from rejecting at the point of sale for those drugs that fall into the 4 common categories that are unrelated to the terminal prognosis and the patient is prepared to obtain the drug.  Section II of the PA form is not required, however, as Part D plan sponsors complete retrospective reviews of medications covered under the Part D benefit that fall into the 4 common categories while the patient receives care under the Hospice benefit, the provider would find that incorporating the completion of section II in their practice would mitigate any questions in the future. The information covered in this article represents a fraction of the complexities associated with regulations that govern payment under Medicare benefits.  Select Data is dedicated to assisting your agency in answering these questions to enable you to meet the needs of your patients.  As an expert in the language of CMS, Select Data has over 25 years of preparation to service you.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar on December 14, 2016. Click here to read more. Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Hospice Documentation Checklist: Is Your Present Documentation at Risk?

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Clinical Practices, Coding, Compliance, Hospice

Hospice Documentation Checklist: Is Your Present Documentation at Risk?

Hospice Documentation Supports Your Agency's Services. Is Your Agency at Risk? Read this.

 

Supporting Hospice Documentation

Supporting Medicare Hospice Services requires proper documentation so an agency, when paid, retains that payment. The following list is a guide to assist Hospice agencies in that endeavor. It may not be all inclusive, but it provides to an agency a format to present the portrait of each patient and their specific needs. Select Data provides professional coding services to Home Health and Hospice agencies and are industry experts in the language of CMS. We assist agencies with the accurate representation of their patient. To find out how Select Data can help you improve coding accuracy check out our OASIS review and coding services. To download the Hospice Documentation Checklist fill out the information below

   
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar on December 14, 2016. Click here to read more.
 
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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Home Care and Home Health…What’s the difference?

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Frequently Asked Questions

Home Care and Home Health…What’s the difference?

Skilled care givers verus unksilled care providers. Which type are you looking for?

 
Home health care is an umbrella term that describes a wide range of health care services that can be provided in your home. Home health care can be divided into two additional descriptors “Home Care” and “Home Health” Home Care describes unskilled care provided by caregivers, usually referred to as home health aides, personal care givers, or homemakers. These individuals are trained in the intricacies of senior care. Home care aides can provide assistance with activities of daily living or provide companionship. Home care is classified as personal care or companion care and is not considered “skilled” care. Home Health is a phrase that describes clinical medical care provided by a Registered Nurse, Occupational Therapist, and Speech Therapist, Physical Therapist or other skilled medical professionals. Home Health is typically prescribed as part of an interdisciplinary, multi-setting approach to medical care following an acute illness, exacerbation of chronic illness or surgery. The fundamental difference between Home Care and Home Health is who pays for the service. Due to its unskilled nature Home Care is typically privately paid with some state programs providing assistance with the cost. Home Health is a service that is paid for by Medicare, Medicaid and private insurance. Agencies can find it difficult to meet the regulatory demands of the Centers for Medicare/Medicaid Services (CMS). CMS doesn’t recognize the patient as Jane Smith but instead views Jane Smith through a series of codes. These codes are diagnosis codes, OASIS items, G-codes from claims, and procedure codes. These codes are also used in different formulas that are important in measuring outcomes and re-hospitalizations. Select Data provides professional coding services to Home Health agencies and are industry experts in the language of CMS. We assist agencies with the accurate representation of their patient. To find out how Select Data can help you improve coding accuracy check out our OASIS review and coding services click here.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar on December 14, 2016. Click here to read more.
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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RACs are Gearing Up to Audit Medicare Advantage, Part D, and MEDICAID

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Audits

And yet another RAC audit… Section 1902(a)(42)(B)(i) of the Social Security Act requires states to contract with Recovery Audit Contractors (RACs) to identify underpayments and to recoup overpayments as part of the state plan. The Patient Protection and Affordable Care Act required the states to have contracted with one or more RACs by December 31, 2010.  Scheduled to begin April 1, 2011, the Medicaid RACs will be a bit different because of the different focus that could be seen by each state. There will be a large list of Medicaid auditors approved by each state. In the September, 2010 Federal Register, CMS posted an “information collection request” about Medicaid RACs. They identified that contracts should be similar to those of the Medicare program. However, states may tailor the Medicaid RAC activities to the specific aspects of the Medicaid program in each state and collectively “propose targeted areas of susceptibility regarding improper payments.” Each state was required to amend their state plans reflecting the RAC program and attesting to a plan in place. This plan must also include Medicaid waiver contracts. The RAC Medicaid requirements remain separate from the Medicaid Integrity Program (MIC) audits, which will continue. The RAC audits are additional Medicaid audits that the law requires to ensure plans under Parts C and D  have claims examined for reinsurance payments to determine if the claims costs are in excess of allowable reinsurance costs.  RACs are also to look at prescription drug plans for high cost beneficiaries. New York State Medicaid Inspector General is leading the charge in attacking waste, fraud, and abuse, recently reminding home health agencies they “cannot bill for excluded providers or accept orders from excluded providers.” He has identified that many agencies were not appropriately verifying physicians approved for Medicaid payment. In addition, the pressure is on to be certain that diagnosis codes, hospital admission and discharge codes, and procedure codes are all in order in all areas of health care. Coding, once again is at the forefront of audit review for all areas of healthcare. Health care entities should review the annual OIG workplan, and besides the understood areas of risk; diagnoses coding, rehabilitation services, medical necessity, and adequate documentation, they might wish to add Medicaid Hospice services and being certain a process is in place to verify physician orders are not taken from Medicaid excluded physicians. How frequently is the exclusion list reviewed? Risk areas identified by corporate compliance necessitate a policy and procedure to be in place with a method of verifying compliance to reduce corporate risk. Mandated corporate compliance programs are to become a reality in all areas of health care within the next few years. However, more and more organizations realize they need a corporate compliance program in place now. In case of a RAC, MAC, MIC, and especially in case of a Z-PIC or HEAT audit, establishing the view that you are compliance oriented with a compliance plan in place sends a far stronger positive message than you are waiting until a plan is actually mandated. The OIG recently announced they will be reviewing “Medicaid Program Integrity Best Practices” in state Medicaid agencies especially in the areas of coding and payment risks. You may well have Best Practices in clinical areas but do you know that your billing practices follow Best Practices in Medicaid billing? You need to have this assurance. For additional information: http://www.cms.gov/ www.cms.gov/RAC/01-Overview.asp www.RACmonitor.com www.oig.hhs.gov Reminder: RAC facts RACs can review via automated review (no medical record from the agency required) or a complex review which entails a medical record request. The four present CMS approved RACs include: RAC B: CGI Federal http://racb.cgi.com racb@cgi.com RAC C: Connolly, Inc www.connollyhealthcare.com/RAC RACinfo@connollyhealthcare.com RAC D: HealthDataInsights http://racinfo.healthdatainsights.com racinfo@emailhdi.com

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