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CMS Finalizes PDGM: PPS Final Rule Increases HHA’s Payments for 2019

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Clinical Practices, Healthcare, Legislation, Payment Rates, PDGM, Value-Based Purchasing

CMS Finalizes PDGM: PPS Final Rule Increases HHA's Payments for 2019

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

 
Wednesday, October 31, 2018, according to Decision Health, CMS has finalized a plan to launch a budget-neutral payment model for home health that utilizes 30-day periods of care and stops using the number of therapy visits to determine payment. That’s according to the 2019 PPS final rule posted Oct. 31 on the Federal Register website. The Patient-Driven Groupings Model (PDGM) will launch “on or after” Jan. 1, 2020, according to the final rule. That language differs from the proposed rule, when CMS indicated PDGM would start on Jan. 1, 2020 (Decision Health, 2018). Additionally, another major change with the final rule is that PDGM will have 432 HHRGs - which is of course double the number of HHRGs outlined in the proposed rule. Home health agencies have spoken and CMS has listened. The change is also likely to the 12 clinical groups that capture the most common primary diagnoses in home health. In the proposed rule, CMS only had sought six clinical groups: musculoskeletal rehabilitation, neuro/stroke rehabilitation, wounds, behavioral health care, complex nursing interventions and medication management, teaching and assessment (MMTA) (Decision Health, 2018). CMS wrote, “We note that although we are categorizing patients into [12] groups according to the principal diagnosis, these groups do not reflect all the care being provided to the home health patient during a 30-day period of care,” CMS states in the final rule. “Home health care remains a multidisciplinary benefit. Additionally, as stated in the CY 2019 HH PPS proposed rule, we will continue to examine trends in reporting and resource utilization to determine if future changes to the clinical groupings are needed after implementation of the PDGM in CY 2020” (Decision Health, 2018).

Payments to Rise in 2019

Decision Health writes, "Adjustments to Medicare’s home health payments under the final rule will increase agencies’ total reimbursement by 2.2%, or $420 million. What this increase means is that the effects of a 2.2% home health payment update percentage are now reflected from a 0.1% increase in payments due to decreasing the fixed-dollar-loss ration mandated by the Bipartisan Budge Act of 2018. Additionally, in order to pay no more than 2.5% total payments as outlier payments, a 0.1% decrease in payments due to the new rural add-on policy by the mandate. In contrast, the 2018 PPS final rue included a 0.4% or $80, payment reduction. The PPS final rule for 2019 now opens the  door for home health agencies to get paid by Medicare Part B to administer home infusion therapy for certain payments who don't qualify for the home health benefit. However, that change would not benefit home health agencies until 2021.

Other Changes Finalized in the Rule

  • No more requirement for a physician estimate - On or after Jan. 1, 2019 the requirement that the certifying physician estimate are required to estimate how much longer skilled services are needed for continued care. Thank you CMS.
  • Value-base purchasing changes (again) - Among the biggest changes to value-based purchasing is CMS’ decision to remove two OASIS-based measures and replace three other, existing OASIS-based measures with two new composite measures designed to evaluate improvement in activities of daily living (ADLs) (Decision Health, 2018).
  • Remote patient monitoring update - It seems CMS is embracing innovation and modernization of health care by allowing the cost of remote patient monitoring to be reported by home health agencies as allowable coast on the Medicare cost report. CMS stated in the final rule, “This is expected to help foster the adoption of emerging technologies by home health agencies and result in more effective care planning, as data are shared among patients, their caregivers and their providers" (Decision Health, 2018).
Read the final PPS rule at: https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24145.pdf Resources Centers for Medicare & Medicaid Services (2018). Center for Clinical Standards and Quality /Quality, Safety & Oversight Group. Department of Human and Health Services. CMS.gov. Retrieved from: https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/QSO-18-13-HHA-.pdf Cornell Law School (2018). 42 CFR 484.60 - Condition of participation: Care planning, coordination of services, and quality of care. Legal Information Institute. Retrieved from: https://www.law.cornell.edu/cfr/text/42/484.60
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians 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 Quality Measures to be Publicly Reported

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Hospice, Legislation

Hospice Quality Measures to be Publicly Reported

Start Preparing now - Providers should review the data about their agency!

 
June 1, 2017, CMS plans to give preliminary reports in advance of the Hospice Compare launch to occur this summer.  These initial reports will include seven Hospice Item Set (HIS) quality measure results. The Hospice Quality Reporting Program (HQRP) currently has two requirements currently: the patient HIS and the CAHPS Hospice Survey. Medicare certified hospices must be in compliance with these two reporting requirements. A Bit of History The Affordable Care Act requires that the Secretary and CMS report Quality Measures provided by hospice programs on a CMS website. That website is to include the HIS Quality Measure results along with results from the CAHPS Hospice Survey. The public reporting is to begin in the summer, 2017 and be presented on the new Hospice Compare Website. The Site That site will reflect scores for each of the seven assessment-based Quality Measures (QM). Those seven measures include:
  • Treatment Preferences NQF 1641
  • Beliefs/Values Addressed (if desired by the patient) NQF 1647
  • Pain Screening NQF 1634
  • Pain Assessment NQF 1637
  • Dyspnea Screening NQF 1639
  • Dyspnea Treatment NQF 1638
  • Patient treated with an opioid who was given a bowel regimen NQF 1617
The Regulations The Affordable Care Act requires that agencies have the opportunity to preview the quality data before it is made public so, CMS has developed the Preview Reports which will reflect the data much like it will appear on the Hospice Compare.  They will be automatically generated and saved into the provider’s shared folder in the CASPER application. The reports will be available about 8 months after the end of each data collection period.  Providers will have 30 days to review the reports. Hospice Report Specifications include a report run date June 1, 2017 for a reporting period for HIS Quality Measures: Patients discharged October 1, 2015- September 30, 2016. Providers should review the data about their agency. If you have a question and want CMS to review the data you must follow the procedures found at https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/Hospice-Quality-Reporting/Hospice-Quality-Public-Reporting.html If a provider disagrees with the data contained within the preview report, they will have an opportunity to have CMS perform a review but all requests must be made within the 30 day preview period. For more information on CASPER Reporting Provider User Guidance see https://www.qtso.com/hospice train.html  or QIES technical help desk at help@qtso.com  1-877-201-4721.  Hospice Quality questions may be directed to the Quality Help Desk at HospiceQualityQuestions@cms.hhs.gov For your Hospice coding, document review, and billing needs, contact Select Data at 1-800-332-0555. Our All American based specialists are here to assist you as we have been assisting Hospice and Home Health agencies for over 25 years.

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CoPs Delayed a Proposed 6 Months. Breathe a Sigh of Relief, but Don’t Relax as You Have Much Work to do.

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Clinical Practices, Conditions of Participation (CoPs), Healthcare, HIPPA, Legislation, Uncategorized

CoPs Delayed a Proposed 6 Months!!!

Breathe a Sigh of Relief, but Don’t Relax as You Have Much Work to do.

 
CMS has proposed delaying the new Conditions of Participation (CoPs) for six months, until January 13, 2018.  QAPI  implementation would be required in July, 2018. Though a 60 day comment period is required, it is unlikely that home health agencies will complain and demand to implement the new CoPs sooner, so industry experts are saying we can presume the delay will occur. Agencies have expressed relief as the CoP changes were significant and many HHA expressed concern that there was inadequate time to prepare.  But don’t sit back with this postponement. You have much work to do. The Changes in General The organizational structure of the regulations was changed dividing the general provisions into three subparts: general provisions, patient care, and organizational environment. Certain CoPs were consolidated; i.e. Skilled Nursing, Therapy Services, and Medical Social Services were consolidated into Professional Services. Two CoPs were added; Quality Assessment and PI (QAPI) and Infection prevention and control. Many of the remaining standards were revised significantly: Patient Rights, Comprehensive Assessment, Care Planning/Care Coordination, Home Health Aide, Organization and Administration, Clinical Records, and Personnel Qualifications. The CMS Focus The focus is one of integrated care processes including:
  1. A patient-centered assessment with measureable outcomes.
  2. Patient-specific care planning and service delivery
  3. Agency-specific processes for Quality Assessment and Performance with active Governing Body involvement
  Transforming the CoPs CMS has found that directing a QA approach toward identifying providers that furnish poor quality or failed to meet minimum Federal standards does not always  work. CMS stated, “We have found that this problem-focused approach has inherent limits.” CMS wants to stimulate broad-based improvements in the quality of care delivered to all patients.  They want “Patient-centered, data-driven, outcome-oriented processes promoting high quality care for all patients at all times.” Surveyors are undergoing intensive new training. Some of the Action Items that an Agency May Need to Complete Intensive education for all personnel especially in the areas of patient rights, comprehensive assessment with ongoing POC updates, and patient engagement. Active patient involvement in their POC. New updated Patient Rights Forms with names and addresses and phone numbers of care givers.  Have space on the form for the Patient/Legal Representative to sign. Make certain the new CoP language is included in the Patient Rights form. Have copies of policies regarding admission, transfer, and discharge available for patients that reflect the new standards. Be certain the patient knows the Clinical Manager’s name and number to call with any clinical questions. It is now required under the CoPs to provide the Administrator’s name and number to call with any complaints. CMS is seeking a more “holistic patient assessment.” This means they expect the agency to develop a better understanding of the patient; knowing their strengths and abilities for active involvement in their own care plan and ultimate outcomes. How will your agency ensure this process?  Will it be Integrative Care Management?  Is education and training needed? Educate personnel to identify signs and symptoms of stress in the caregiver as well as how to speak with the caregiver re strain and burdens of care. Will you use a screening tool? Identify where you will note the education and training for patients and their specific needs. A one- size fits all care plan for a specific diagnosis will no longer be sufficient. How will revisions to the care plan be flagged so clinicians know they are working with the most current POC? The POC is to become an “evolving document.” CMS is stressing team care. The new CoPs require agencies to coordinate care delivery. How will your HH interdisciplinary team communicate? “Coordinated care requires communication with integration of orders with all physicians.” A patient hospital risk assessment is required for all HHA admissions.” All patient orders, including verbal orders must be recorded in the POC. They must have not only the date, but the time of the order noted. “The HHA must develop, implement, evaluate, and maintain an effective ongoing, HHA-wide, data-driven program. The HHA governing body must ensure that the program reflects the complexity of its organization and services, involves all HHA services including those services provided under contract or arrangement, focuses on indicators needed to improve outcomes, including hospital admissions and readmissions and takes actions that address the HHA performance across the spectrum of care including the prevention and reduction of medical errors. The HHA must maintain documentary evidence of the QAPI program and be able to demonstrate its operation to CMS.” A plan to educate/ consult with the Governing body re the new CoPs as well as each QAPI project is required. Agency must create new policies and procedures, modify and/or update certain old P&P in keeping with new CoPs and consolidation of certain old standards. Are new job description modifications needed? As to infection control; what new P&P are needed? What surveillance, identification, prevention, control, and investigation program will be put in place to meet the new standard?  Of course this will require further education and training for personnel. As to home health aides: What education and training modifications will be required to meet the new communication requirements? What changes will be needed to the policies, procedures, and job descriptions? What about your agency cybersecurity and Emergency Preparedness Plans? Your system must include a system of medical documentation that preserves patient information, protects confidentiality, and maintains availability of records. So, you may think of the postponement as a reprieve, but it is a short one. As you can see…there is much to do, so get started now. For assistance with your coding, documentation review, and revenue cycle management needs, contact Select Data at 1.800.332.0555. We are  100% USA based, here to assist you.
Related articles New Conditions of Participation (CoPs) and Your Agency 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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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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Credit Balance Overpayment Refunds: Auditing and Documenting Best Practices. Starting the New Year Right!

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Audits, Clinical Practices, Compliance, Legislation, Payment Updates

Credit Balance Overpayment Refunds: Auditing and Documenting Best Practices. Starting the New Year Right!

Do you have Risk? High risk is not the way you want to start out in the New Year.

 
Failure to return an overpayment can be a violation of the False Claims Act. CMS expects agencies to have indicators of overpayments in place. Ignorance is not an acceptable excuse. Agencies are to return an overpayment within 60 days of identification or face serious potential consequences. What is an Overpayment? According to the Social Security Act, Section 1128J, any funds that a person/agency receives or retains under Title XVIII or XIX to which the person, after applicable reconciliation, is not entitled, constitutes an overpayment. These can include claims for services after benefits have been exhausted, payment for non- medically necessary services, duplicate payments, and payment of claims that exceeded a reasonable charge. Watch out for Credit balances! These are usually caused by contractual “over adjustments,” misapplication of payments, and overpayments. Your agency should have policies and procedures in place to identify and analyze your current credit balance landscape. Create a report with the current aging balance, account identifiers such as account numbers, list all payors whose funds were credited to the account, list dates of service and all charges coupled with payment dates, names and amounts. Periodically perform an audit of your agency processes to be certain any overpayments in the credit balance landscape are identified. You must consider, if the individuals conducting the audit are qualified to do so, what methodology will be employed to identify the overpayments, and do you have a current process to return the overpayments? Do you have adequate QA and root cause oriented processes? Evaluate the sufficiency and effectiveness of the controls necessary to ensure refund and reporting within the 60 days of identification. Be certain your agency can validate the accuracy of the credit balance reports used for operational management and agency compliance oversight. Monitor on an ongoing basis. Be certain policies and procedures meet current regulation requirements. Make certain resolutions are accurate and be certain the controls are functioning as expected. Be certain to note how each error was found, as required in the 60 day repayment rule. Complete the Corrective Plan of Action and the reason for the refunding of the overpayment. Have the OIG Self Disclosure protocol in place with the description of the methodology used. Under the Final rule providers may use “an applicable claims adjustment, credit balance, self-reported refund or another appropriate process to satisfy the obligation to report and return overpayments.” Remember, lack of compliance with the regulation can result in fines of up to $11,000 for EACH improper payment received and not returned going back 6 years. For more information regarding Revenue Cycle Management and billing/collection for your agency, contact Carla Putnam, VP, RCM, Select Data 1.800.332.0555
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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New Changes for OASIS C2 Data Sets Revision

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Compliance, Events, Legislation, OASIS, OASIS-C2

New Changes for OASIS C2 Data Sets Revisions

New OASIS C2 Revisions: Thinking about finalizing your OASIS-C2 forms? Read this before you do.

 

November 8, 2016, new revisions to OASIS-C2 item set. Select Data’s very own Compliance Officer, Susan Carmichael, MS, RN, CHCQM, and VP of Services Integration, Pam Hernandez, found an issue with multiple OASIS answers in the latest release from CMS for the OASIS-C2 Guidance Manual 6-29-16. Carmichael notified the Centers for Medicare & Medicaid Services of these inconsistencies last month. A corrected version of the OASIS C-2 Item Set, correcting 2 minor typos on page 3 of the all-time points version, has been posted on the OASIS Item Set page. The document can be found in the Downloads section (CMS, 2016).

For a full review of these OASIS-C2 corrections and more, attend our free 30-minute Select Connects with Clinicians webinar on December 14, 2016. Click here to read more.

Sources

Centers for Medicare & Medicaid (2016). OASIS Data Sets. CMS.gov. Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/OASIS-Data-Sets.html
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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New Bundled Payment Projects

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Legislation, Payment Updates

 

New Bundled Payment Projects: Get Prepared Now or Risk being Passed Over by the Hospitals

Agencies should prepare NOW developing Cardiac and/or Orthopedic Best Practice programs if they are not already present. Conduct statistical analysis reflecting outcomes. Demonstrate your agency’s value and strengths to that acute care hospital. If you already have a program, run the analytics. Show the value of your Agency’s specific care.

 

On July 25, 2016, CMS released the proposed rule stating they intend to test new bundled payments to Hospitals for the following diagnoses: Myocardial Infarcts (MIs), Coronary Artery Bypasses (CABGs), and Surgical Hip/Femur fractures. This proposal is similar to the Comprehensive Care for Joint Replacement (CJR) model that began the Spring of 2016. That proposal made hospitals responsible for the first 90 days of cost following hospital discharge for that condition. CMS has been pleased with the results thus far.

The new models would run from July, 2017- 2021 and like the CJR model, the hospital providing the procedure would be held accountable for costs and quality of care from surgery through 90 days post acute care. Of course, the hospital will be able to choose the post acute providers.

Agencies should prepare NOW developing Cardiac and/or Orthopedic Best Practice programs if they are not already present. Conduct statistical analysis reflecting outcomes. Demonstrate your agency’s value and strengths to that acute care hospital. If you already have a program, run the analytics. Show the value of your Agency’s specific care.

How to Show YOUR AGENCY’s Value

Gather emergent and rehospitalization data such as number of patients cared for and the resulting rehospitalization admission rate. Be prepared to discuss what makes your Cardiac program successful and why your agency will be an excellent partner.

CMS will choose 98 markets by random selection. Those hospitals working with post acute care providers including physicians are expected, by CMS, to deliver care that is at a “quality adjusted target price, while meeting or exceeding quality standards, and would be paid the savings achieved.”

For the Surgical Hip/Femur Fracture Treatment, that model will be placed in 67 areas where the CJR is ongoing. This looks to be an add-on to the present project. This diagnosis is the eighth most common discharge diagnosis for Medicare fee for service patients in a hospital. CMS has noted that mortality rates associated with this diagnosis is 5%- 10% after 1 month and approximately 33% at a year.

Sources

Centers for Medicare & Medicaid (2016). Bundled Payments for Care Improvement (BPCI) Initiative: General Information. CMS.gov. Retrieved from: https://innovation.cms.gov/initiatives/bundled-payments/
For clinical record document review and coding services that can assist you with these models and more, CONTACT SELECT DATA at 1.800.332.0555

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Pre-Claim Review Demonstration

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Legislation, MACs, OASIS, Payment Updates

 

Pre-Claim Review Demonstration

Effective August 1, 2016, CMS institutes Pre-Claim review in Five States. The demonstration will begin no earlier than August 1, 2016 in Illinois, no earlier than October 1, 2016 in Florida, and no earlier than December 1, 2016 in Texas. The demonstration will begin in Michigan and Massachusetts no earlier than January 1, 2017.

 

Pre-Claim Review Begins in Five States: August 1st is the First Date, Illinois is the First State

Effective August 1, 2016, Home Health Agencies in five states will begin the three year Medicare pre-claim review demonstration by which an agency will complete the patient assessment, initiate procedures, and establish services then submit a request via fax, mail, or electronic submission of medical documentation to the respective MAC for approval prior to the submission of the final claim. The MAC is expected to provisionally approve or disapprove the services within 10 business days. If the MAC denies the payment, the agency can resubmit a new request

What is the Difference between Pre-Claim and Prior Authorization?

Per CMS, with a Pre-Claim review, services have already begun and the request is submitted after assessments and services have been completed or begun. Prior Authorization requires a request prior to services being initiated. CMS states this new requirement is not creating new documentation requirements. The agencies are to submit the same information they currently submit for payment, but do it earlier in the process.

What States are Included in the Demonstration?

The demonstration will begin no earlier than August 1, 2016 in Illinois, no earlier than October 1, 2016 in Florida, and no earlier than December 1, 2016 in Texas. The demonstration will begin in Michigan and Massachusetts no earlier than January 1, 2017. (Pre-Claim Demonstration for HH FAQ, 6/8/2016)
The demonstration is expected to have minimal effect on beneficiaries per CMS. The Pre-Claim request is submitted after a RAP but before the submission of the final claim. However, some agencies have expressed concern, stating that in an already fragile bottom line market, any further delay of payment could be harmful to the agency’s financial health.
CMS states the five states chosen “show extensive evidence of fraud and abuse in the Medicare home health benefit for treatment performed in these states” (CMS Pre-Claim Demonstration for HH, FAQ, 6/8/2016).

Decision, Documents Needed, and Options

For pre-claim review, the MAC will make the determination using regulation, National Coverage Determination, and Local Coverage Determination requirements. The MACs will be expected to respond within 10 business days for an initial request and 20 business days for a resubmitted request following a denial.
Resubmissions may be sent an unlimited number of times as necessary, but obviously, the agency will want to get the appropriate information submitted up front to minimize payment delays. There will be a tracking number on each decision notice and that number will be used on the claim.
CMS states that, generally those claims that had the provisional review will not have additional review. However, note that Z-PICs conduct targeted prepayment and post payment review which will continue and CERTS review a stratified random sample of claims annually to identify improper payments. That CERT sample may include the pre-claim reviewed items also.
If an agency would be denied payment and after resubmission still receives denial, they could follow the appeal process. If an agency submits a claim without a pre-claim review, per CMS, if that claim is deemed payable, it will be paid at a 25% reduction of the full claim benefit. Obviously, an agency would have serious financial if that became the agency process.

Sources

Centers for Medicare & Medicaid (2016). Pre-Claim Review Demonstration for Home Health Services. CMS.gov. Retrieved from: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review-Initiatives/Overview.html
For Start of Care document reviews that includes OASIS review, H&P, med profile, clinician visit assessment and visit documentation review, as well as F2F comment along with ICD-10 coding, CONTACT SELECT DATA at 1.800.332.0555

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The Skilled Home Healthcare Integrity and Program Savings Act (SHHIPS)

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Legislation

Fraud and abuse are very strong topics everywhere. In 2009, it was proposed that a 10% cap could be placed on Medicare outlier claims to stem one example of fraud and abuse. Included in the Affordable Care Act (ACA), this one reform is expected to save $11 billion over the next 10 years.

Building on that outlier initiative, additional program integrity reforms are underway. These reforms include requiring background checks for direct care home health employees, background screenings of owners and managing employees, as well as requiring new owners to secure a $100,000 surety bond.

Payment integrity has necessitated more stringent payment processes requiring construction of in-depth algorithms to fight fraud, alerts for aberrant claims, and establishment of uniform processes that ensure claims are legitimate before they are paid. In support of the government urge for heightened fraud and abuse intervention, the Partnership for Quality Home Healthcare has proposed the Skilled Home Health and Integrity Program Savings. This program wants to promote savings by shifting CMS away from the model they term, “pay and chase.” They propose tough measures to identify aberrant claims, stronger review processes, and even tighter program participation standards.

The Partnership is pushing for value-based purchasing and post-acute care reform. They believe now is the time for pay-for-performance. They are loudly advocating for the Bundling and Coordinating Post- Acute Care Act (BACPAC) of 2014.

The Partnership has an innovative approach based on data from CMS that reveals the following:

Of the 3,143 counties in the nation, MEDPAC has identified only 25 counties in 5 states where the vast majority of the abuse appears to occur.

The Partnership promotes targeted solutions to those counties rather than “indiscriminate across-the-board cuts, such as the 14% rebasing cut,” stated Partnership CEO Eric Berger.

What are your thoughts?

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