Showing posts tagged with: CMS

Top 5 Questions Home Health Providers Ought To Be Asking About HHGM

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Healthcare, HHGM, OASIS-C2

Top 5 Questions Home Health Providers Ought To Be Asking About HHGM

HHGM-Game Changer?

 
HHGM proposal is expected to reduce Medicare payment to providers by up to $4 billion. Unlike the current system, the groupings model doesn’t rely on the number of therapy visits performed to influence payment. It instead will rely heavily on clinical characteristics and other patient information such as diagnosis, functional level, comorbid condition and admission source according to CMS. The changes to the payment system would address the issues MedPAC identified in the home health PPS March 2017 report that noted both the incentives and the payment levels in the current payment system needed to be overhauled. Following the recommendations from the MedPAC report, Congress is attempting through new legislation to provide the Secretary of DHHS the authority to make assumptions about provider behavior, provide notice of those assumptions and implement them through comment rule-making in CY 2019. Top 5 questions Home Health Providers ought to be asking
  1. Is Congress giving the secretary authority to set payment without constraints? According to H,R. 3992 which was introduced in the House of Representatives on October 6, the Secretary would have the authority to set payments for 30 day periods and to revise that model through notice and comment rule-making.
  2. What consequences have occurred with the MedPAC reporting? It was MedPAC who suggested to Congress that providers had been adjusting their services based on reimbursement to increase financial margin. MedPAC has stated that the ACA rebasing provisions aren’t enough and that the appearance is that home health growth is slowing, it is still growing and only appears that way statistically because five states under pre claim review and increased scrutiny have decreased their utilization. MedPAC will continue to assess for trends related to reimbursement and provider response to those patterns.
  3. Is our industry under fire because of expected industry growth? Over the past decade, a lot of attention has been paid to the baby boomers turning the Medicare age of 65. This increase in potential patients is one of the reasons home health is expected to be the fastest growing marketplace in all of healthcare for the next decade. With 82.6% of Home Health patients over the age of 65, Medicare or a Medicare Advantage plan is responsible for a large portion of payments, as such the government has a vested interest in controlling costs. Healthcare costs are controlled by decreasing the volume of people using the service, decreasing reimbursement for the service and decreasing the cost of doing business.
  4. Can HHGM actually give me greater control over my payment? The higher degree of differences in potential payment, the more control over reimbursement received. What on the surface appears to be a model composed of more straightforward categorizations is, in fact, a differentiator. Does this mean the HHGM is without problems, no, but this will most likely be ironed out over the next year.
  5. What should I do in 2019? According to Elevating Home, an agency may expect a decrease in their Medicare reimbursement up to 17% with the new HHGM payment model. The new bill proposes that HHGM be delayed until CY2020 to provide organizations with the opportunity to prepare for the changes coming, but many providers may not know where to start.
Select Data has created SmartCare which has an HHGM predictive analytics model formed by our data science team that analyzes your historical episodes and compares them to the HHGM model to identify potential loss in revenue. SmartCare will be able to provide indicators to support these predictions and will have the capability to offer observations to prevent potential loss using prescriptive analytics. With the information SmartCare can produce, providers have the opportunity to start implementing changes needed to combat the future decline in revenue. Some agencies may be more prepared than others, but with the significant impact HHGM will make, isn’t it worth a conversation? Visit us at Booth 530 at NAHC to find out how to winFREE HHGM analysis.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar. 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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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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New CoPs and Your Agency: Patient-Specific, Individualized Care, and QAPI- Take a Deep Breath

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Clinical Practices, Healthcare

New CoPs and Your Agency: Patient-Specific, Individualized Care, and QAPI- Take a Deep Breath

An overview of the Conditions of Participation (CoP) revisions

 
It has been decades since the Conditions of Participation for Home Health have been significantly revised. The last time it was attempted, Bill Clinton was President. The new rule expands patient rights, care planning, and care coordination standards. The changes require much education and planning. It requires the agency governing body to take responsibility for the new required QAPI program. The theme throughout the rule and CMS response to comments is quality, individualized care and patient engagement. They stated they expect, “patient-centered, data-driven, outcome-oriented processes that promote high quality care at all times for all patients.” An overview of the CoP revisions are highlighted below. For a full review see the 375 page final rule, effective as of July 13, 2017 or contact Select Data. A focus, per CMS, is to improve the quality of home health care services for patients and to strengthen patient rights. Patient Rights CMS expects patients to be made aware of their rights in a form that can be understood by the patient and their representative (if they have one). The written patient rights forms must be given prior to any care being administered. If a patient does not wish their non-legally appointed representative to have a copy of the rights, the agency must note that fact in the clinical record. If a patient has a legally appointed representative, they must receive a copy of the rights prior to the patient receiving any care. In addition, the patient is to be made aware of the name of the clinical manager and their business phone number so clinical questions may be directed to that person. In addition, CMS is requiring that home health agencies be given the name and contact information of the agency administrator so complaints may be made directly to them. Comprehensive Assessment CMS is seeking “a more holistic patient assessment.” The intent is to develop a more complete understanding of the patient that “will enable HHAs and physicians to develop a plan of care that is more comprehensive and more likely to achieve desired outcomes.” To achieve this goal, CMS has some new requirements that include:
  • Adding a psychosocial, functional, and cognitive status assessment to the overall comprehensive assessment of the patient.
  • Assessing and identifying the patient’s strengths, goals, and care preferences including progress toward goal achievement stated in the clinical record.
  • Assess the patient’s primary caregivers
  • Identify the patient’s representative
  • Assess the patient’s risk for hospitalization/rehospitalization, require for ALL HHA admissions.
The individualized care plan must include “patient specific measureable outcomes which the HHA anticipates would result from its implementation.” The agency must provide written instructions regarding care, tasks, or schedules so they have a tool to reference between visits. CMS did not restrict the agencies on the written instructions. Calendars for schedules could be used as well as checklists, or handwritten notes. CMS wants agencies to use patient strengths and engage the patients so they are actively involved in their care. The belief is that the likelihood of positive outcomes is greater. Care Coordination Care coordination is the driver toward quality with CMS stressing a focus on the patient as an active participant on the interdisciplinary team. It is obvious that the team is being encouraged to develop very patient-specific plans of care playing to each patient’s strengths and level of involvement. CMS expects each visit note to identify what skill was completed, but what skilled service is needed for the patient. They also expect progress toward goal attainment to be well documented. Quality Assessment and Performance Improvement This new 484.65 CoP, Quality Assessment and QAPI will replace two CoPs, namely Group of Professional Personnel and Evaluation of the Agency Program. CMS expects HHA to identify their own agency-specific risk areas with a focus on high risk, high volume problem areas. The program is to be agency wide and the Governing Body must approve details of areas chosen, dates/frequency of data collection, and review results. Because this program will take time to be fully operational, CMS is giving this CoP and extension of time, making it required January 13, 2018. Agencies will be responsible for documenting the number of QI projects undertaken coupled with reasons chosen and results of each project. Infection Control Agencies must institute a strong surveillance, identity, prevention, and intervention infection control program. Education is expected to be seen throughout this program establishment. Skilled Professional Services Combining the CoPs Skilled Nursing Services, Therapy Services, and Medical Social Services, CMS is stressing an ongoing interdisciplinary assessment of the patient. They identify an expectation of development and evaluation of the POC in partnership with the patient, their representative (if any), their caregivers, and the HHA personnel. The professional services are expected to provide counseling, patient education, prepare clinical notes, communicate with the physician, participate in the QAPI program and participate in HHA sponsored inservice trainings. Of course there remains specific direction regarding each service entity such as an RN supervising and LPN/LVN. Those types of items have not changed. Home Health Aide This new CoP has nine specific standards. A significant change allows an agency to accept a certified nurses aide for a home health aide position provided they completed their training and competency and remain in good standing on the state registry. Of course, any specific training necessary for the aide to perform safely in the home with a particular patient is the responsibility of the HHA. It was stressed that the aide is a member of the interdisciplinary team. They are to have training as to how to document and communicate with/to patients, family members, and other members of the team. There is also a new requirement that an annual onsite visit be performed at a location where a patient is receiving care to assess and observe care delivery. Also, under the new CoPs, home health aides may receive assignments by an RN or any other skilled professional also delivering care; PT, OT, or S/LP. Summary These new CoPs signal a shift from problem-focused care, that CMS acknowledged had “inherent limits” to quality focused care. The new CoPs actively involve the patient, capitalizing on their strengths, uses tools and communication methods the HHA identifies as best for the patient. CMS is encouraging HHA to establish a meaningful QAPI program that identifies agency specific issues rather than mandating prescriptive dictated problems to address. Though NAHC has sent a letter to CMS advising a delay until July, 2018 to institute the new CoPs, agencies should not delay in establishing a team to conduct a gap analysis, identify needs, and institute education programs for all CoPs mandated for July 13, 2017. They must also initiate planning for the indepth QAPI program that will take the extra time given by CMS to be fully functional.
For further information or consulting needs, contact Select Data at 1.800.332.0555

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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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Credit Balance Overpayment Refunds: Auditing and Documenting Best Practices

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Clinical Practices, Payment Updates

Credit Balance Overpayment Refunds: Auditing and Documenting Best Practices

Do you have Risk? High risk is not the way you want to start out in the New Year. Free Auditing & Best Practices Documentation Checklist!

 
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. To download the Auditing & Documentation Best Practices Checklist fill out the information below

For more information regarding Revenue Cycle Management and billing/collection for your agency, contact Carla Putnam at Select Data 1.800.332.0555
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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Select Data Improves Star Ratings For Home Health and Hospice Agencies

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Clinical Practices

Select Data Improves Star Ratings For Home Health and Hospice Agencies

Star Ratings...stuck at a 3? See How Select Data Improves Ratings.

 

The Overall Star Rating gives an overall rating of the plan’s quality and performance for the types of services each plan offers. For plans covering health services, this is an overall rating for the quality of many medical/health care services that fall into 5 categories:
  • Staying healthy: screening tests and vaccines. Includes whether members got various screening tests, vaccines, and other check-ups to help them stay healthy.
  • Managing chronic (long-term) conditions: Includes how often members with certain conditions got recommended tests and treatments to help manage their condition.
  • Member experience with the health plan: Includes member ratings of the plan.
  • Member complaints and changes in the health plan’s performance: Includes how often Medicare found problems with the plan and how often members had problems with the plan. Includes how much the plan’s performance has improved (if at all) over time.
  • Health plan customer service: Includes how well the plan handles member appeals (Medicare.gov, 2016).
Select Data's OASIS Review and Coding services improve the agency’s Star Ratings by ensuring the patient’s fragility is captured appropriately with each quality episode.  This allows the patients that can improve to be reflected in the STAR Rating calculation and those patients who are not likely to improve in that outcome measure to not be calculated in the agency’s Star Ratings.
For more information regarding Star Ratings and OASIS Review and Coding services for your agency, contact Select Data 1.800.332.0555

References

Medicare.gov (2016). Star Ratings: Overall Star Ratings. Medicare.gov. Retrieved from: https://www.medicare.gov/find-a-plan/(S(4emd5e55lrt5j22pu5kbpv55))/staticpages/rating/planrating-help.aspx?AspxAutoDetectCookieSupport=1
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar on February 15, 2017. 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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Four New G Codes effective January 1, 2017

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Coding, Compliance, G-Codes, OASIS-C2

Four New G Codes effective January 1, 2017

Are you Ready?

 
It seems like it is becoming an annual event. Last year, CMS announced two new G Codes and the retirement of one effective in January. Last month, CMS announced that effective January 1, 2017, there are four new G codes to be used and the retirement of G0163 and G0164. Though organizations have complained about the short notice, the date remains in effect. Change request 9736 states the following: “Analysis of calendar year 2015 data indicates there is a significant variation in the visit length by discipline for outlier episodes. Those agencies with 5% or more of their total payments as outlier payments are providing shorter but more frequent skilled nursing visits than agencies with less than 5% of their total payments as outlier payments.” The Change Request further states Effective January 1, 2017 CMS is retiring G0163 and G0164 and replacing them with: G0493- Skilled services of an RN for the observation and assessment of the patient’s condition, each 15 minutes (the change in the patient’s condition requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment in the home health or hospice setting). G0494- Skilled services of a licensed practical nurse (LPN/LVN) for the observation and assessment of the patient’s condition, each 15 minutes (the change in the patient’s condition requires skilled nursing personnel to identify and evaluate the patient’s need for possible modification of treatment in the home health or hospice setting). G0495- Skilled services of an RN in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes. G0496- Skilled services of an LPN/LVN in the training and/or education of a patient or family member, in the home health or hospice setting, each 15 minutes. CMS further states that these new codes were necessary as CMS annually recalibrates case-mix weights for home health agencies and weights are determined by calculating the cost of the episode, grouping similar episodes by similar levels of resource use, and comparing the group’s average use to the overall mean. The cost of the episode is calculated using the average hourly wage rate for the discipline that performed the visit multiplied by the minutes per visit reported on the claim. CMS believes it is necessary to differentiate G0163 and G0164 so they no long have to assume a certain percentage of visits are performed by an RN vs an LPN/LVN. Since there will no longer be a need to use an assumption in calculating the cost per episode when the two services are performed, this will allow greater payment precision. Agencies must be certain their clinicians and billing department understands the CMS Change request and the appropriate G code is used depending on the personnel performing the skilled services. Download the complete guide for New and Revised G-Codes below

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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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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