Posts Tagged ‘Outlier Payments’

Helpful Home Care Websites at Your Fingertips

Monday, September 20th, 2010

Never before has a home health agency leader required such close contact with so many industry regulatory bodies and changes. Operationally, clinically, and financially the need to keep current is fierce. This week we are providing a handy list of key homehealth related websites. You may have websites you think should be added. Please let us know.

ABN, HHABN, and the Notice of Medicare Non-Coverage, aka Expedited Determination Notice:
http://www.cms.gov/BNI/

Abt Associates- “Analysis of Home Health Case-Mix Change 2000-2008:
www.cms.gov/center/hha.asp

Billing in Home Health- Chapter 10 Medicare Claims Processing Manual:
www.cms.hhs.gov/manuals

CASPER Reports:
http://www.cms.gov/HomeHealthQualityInits/16_HHQIOASISOBQI.asp

CMS new URL-
www.cms.gov

CMS Sponsored Calls:
http://www.cms.gov/HomeHealthQualityInits/02_CMSSponsoredCalls.asp#TopOfPage

CMS Website Wheel:
http://www.cms.gov/MLNProducts/02_Catalog.asp

CMS ICD9-CM Coding Guidelines:
http://www.cms.gov/ICD9ProviderDiagnosticCodes/

CMS Interpretive Guidelines:
http://www.cms.gov/GuidanceforLawsAndRegulations/06_HHAs.asp

Conditions of Participation (CoPs):
http://www.cms.gov/CFCsAndCoPs/12_homehealth.asp#TopOfPage

CY2011 HHPPS Proposed Rule:
http://edocket.access.gpo.gov/2010pdf/2010-17753.pdf

False Claims Act:
http://www.cms.gov/smdl/downloads/SMD032207Att2.pdf

Food and Drug Association Safety Communications:
www.CMS.gov/Drugs/DrugSafety/PostmarketdrugSafetyInformationfor PatientsandProviders/ucm204882.htm

GROUPER effective October 1, 2010:
www.cms.gov/homehealthpps/05_casemixgroupersoftware.asp/

HHCAHPs:
Proposed PPS Rule
http://edocket.access.gpo.gov/2009/pdf/R9-18587.pdf
CAHPs Survey
https://www.homehealthcahps.org

Home Health Quality Improvement National Campaign (free resources):
www.homehealthquality.org/hh/about/default.asp
http://www.cms.gov/HomeHealthQualityInits/Downloads/HHQIOBQIManual.pdf

Medicare Administrative Contractors (MACs):
http://www.cms.gov/GuidanceforLawsAndRegulations/06_HHAs.asp

MAC Protest: www.palmettogba.com/palmetto/providers/providers.nsf/DocsCatHome/Jurisdiction%2011%20Pa520A%20B
Medicare Learning Network (MLN): Web-based training courses:
www.cms.hhs.gov/MLNProducts/downloads/NPIBooklet.pdf

Medicaid Integrity Contractors (MICs):
http://www.cms.gov/ProviderAudits/Downloads/mipmicontractors.pdf

New York Compliance Program for hints of what may be coming nationally: www.omig.state.ny.us/data/images/stories/provider_compliance/adopted_regulations_521.pdf

OASIS-C:
http://www.cms.gov/HomeHealthQualityInits/12_HHQIOASISDataSet.asp#TopOfPage

Office of Civil Rights (OCR): HIPAA:
http://www.hhs.gov/ocr/office/index.html

OIG 194 page report:
www.oig.hhs.gov/publications/docs/compendium/compendium2010.pdf

Physician certification Limitation of Liability Language, CMS Publication 100-4, Chapter 30, 10
www.cms.hhs.gov/manuals/downloads/clm104c30.pdf

Potentially Avoidable Event Report (Formerly, the Adverse Events Report):
www.cms.gov/HomeHealth QualityInits/18_HHQIOASISOBQM.asp

Quality Measures- HHQI Home Health Quality Measures
www.cms.gov/HomeHealthQualityInits/10_HHQIQualityMeasures.asp
http://www.cms.gov/HomeHealthQualityInits/15_PBQIProcessMeasures.asp#TopOfPage

Recovery Audit Contractors (RACs):
http://www.cms.gov/rac/

Red Flags Rule:
http://www.ftc.gov/opa/2008/10/redflags.shtm

Zone Z-PICs:
http://www.cms.gov/manuals/downloads/pim83c04.pdf

Wound, Ostomy, Continence Nurses (WOCN)
http://www.wocn.org/

Medicare Outlier Caps Change for 2010

Friday, March 12th, 2010

In this months E-zine article, we discussed the changes that were made to outlier payments which became effective Jan 1, 2010. One of the interesting points that was brought up is how outliers were calculated prior to the changes. What was clear when writing the article was that outliers, while valuable to bridge the gap on high utilization on episodes, it never completely covered the cost in providing care. Some agencies have heard that many organizations have been using outlier payments to help increase their overall revenue intentionally. However, many times they are a cost of doing business. This is why there is additional reimbursement available to help accommodate for those situations.

The problem is that you only receive 80% of the difference of the additional cost associated for those services. If you would like examples of these calculations and definitions, please read our latest E-Zine article here. This is why it is important to always diligently assess the patient but at the same time, make sure you are addressing the correct utilization for the patient.

With Medicare now only allowing outlier payments to be made for those that equal 10% of the total PPS payments year to date of that claim, it will be wise to monitor and closely manage this practice. So remember, outliers should be exceptions to the rule and not the rule.

Jeff Brittain
CTO, Executive Vice President
Select Data