Crossroads for Hospice

Hospices are under intense pressure from numerous federal rules and regulations.  Medicare reimbursement for Hospices is not keeping up with inflation. CMS is targeting hospices that have a high percentage of long length of stay patients.  Several of the Medicare Administrative Contractors (MACs) have initiated special audit steps to review hospice claims that have high length of stay to ensure they have the proper documentation and were good candidates for hospice when they were admitted.

Many hospices have been audited by Zone Program Integrity Contractors (ZPICs) and Recovery (RACs) for various claim issues. Always remember that ZPICs and RACs are bounty hunters.  They get paid for what they deny.  In my opinion auditors should not be paid bounties.  This creates a need to find problems whether they exist or not.  A very large percentage of these denials are overturned when they are taken through the appeal process.  Unfortunately many hospices do not have the funds or the expertise to complete the appeals process.

CMS in the proposed hospice rules and rates for 2014 have really hit the diagnosis issue hard.  They have removed adult failure to thrive and debility as primary hospice diagnosis, even though these were both in the top 5 hospice diagnosis last year.  There is no waiting period for this rule.  CMS stated that this was simply a clarification of existing rules.  They will allow adult failure to thrive and debility as secondary diagnosis.  CMS reported that most hospice claims had only one diagnosis.  They want hospices to include all secondary diagnosis related to the terminal condition.  This is a large change and will require intense staff training.

Hospices have to comply with the revised HIPAA rules.  Failure to comply can lead the excessive fines and penalties.  The Healthcare Reform Bill will eventually cost hospices cash and will require additional administration expense.  There are also fines for hospices that fail to comply.  Have you noticed all of the various fines and penalties?  This appears to be a new found revenue source for Medicare and other government programs.

Hospices are at a crossroads.  They must either learn to comply with the new rules and regulations or they will be forced out of business.  Successful hospices will know the rules, regulations, and will implement plans to ensure they are complying.

We are having an excellent seminar on September 18 to 20 that will discuss all of the above issues and much more.  It will be held at the Hilton Waikoloa Village on the Big Island of Hawaii.  The room block will be released on August 15.  Make your reservations prior to that date.

Crisis in Home Health

Home health agencies are under intense pressure from numerous federal rules and regulations.  Actual Medicare episode reimbursement has increased less than 2% since home Heath began PPS in 2000, while inflation for the same period has increased over 35%.  The face-to-face encounter rules have caused friction between the referring physicians and home health agencies. Most if not all of the education regarding the face-to-face encounters has been left to the home health agencies and their staff.  Several of the Medicare Administrative Contractors (MACs) have initiated special audit steps to review home health claims to ensure the home health agencies have the proper documentation.  They claim there is a high level of non-compliance to the face-to-face encounter documentation.  CMS is even planning to educate the physicians this fall.  That is like closing the barn door after the horses have escaped.

Many home health agencies have been audited by Zone Program Integrity Contractors (ZPICs) and Recovery (RACs) for various claim issues. Always remember that ZPICs and RACs are bounty hunters.  They get paid for what they deny.  In my opinion auditors should not be paid bounties.  This creates a need to find problems whether they exist or not.  A very large percentage of these denials are overturned when they are taken through the appeal process.  Unfortunately many home health agencies do not have the funds or the expertise to complete the appeals process.

There are proposed cuts in home health reimbursement again this year.  They have also proposed additional cuts for 2015, 2016, and 2017.  They are proposing to remove 170 codes from obtaining points in the HIPPA Grouper software.  The impact of removing these codes will impact every home health agency differently bases on the makeup of their patients.

Home health has to comply with revised HIPAA rules.  Failure to comply can lead the excessive fines and penalties.  Home health survey deficiencies could lead to fines, penalties, and removal from Medicare program.   The Healthcare Reform Bill will eventually cost home health agencies cash and will require additional administration expense.  There are also fines for home health agencies that fail to comply.  Have you noticed all of the various fines and penalties?  This appears to be a new found revenue source for Medicare and other government programs.

Home Health Agencies are at a crossroads.  They must either learn to comply with the new rules, regulations, and reduced payment rates or they will be forced out of business.  Successful home health agencies will know the rules, regulations, and will implement plans to ensure they are complying.

We are having an excellent seminar on September 23 to 25 that will discuss all of the above issues and much more.  It will be held at the Hilton Waikoloa Village on the Big Island of Hawaii.  The room block will be released on August 15, be sure to make your reservations before that date.

Hospice Claim Submission Guide

NHIC, Corp a Medicare Administrative Contractor (MAC) issued a twenty two page hospice claim submission guide.  This guide provides complete field by field instructions for hospice billing.  This is a valuable resource for all hospice employees who bill Medicare regardless of which (MAC) serves your hospice.

You can download the guide by using the following link:

http://www.medicarenhic.com/providers/pubs/HospiceClaimBG.pdf

Temporary Moratorium

CMS Administrator issued a Temporary Moratorium to prohibit enrollment of new home health agencies in Miami-Dade County, Florida and surrounding counties and Cook County, IL and surrounding counties.  They have also issued a Temporary Moratorium to prohibit enrollment of new ambulance providers in Harris County, TX and surrounding counties.  This authority was granted as part of the Patient Protection and Affordable Care Act and the Health Care and Education Reconciliation Act of 2010.  These are also known as the Affordable Care Act.  This moratorium applies to the Medicare Program, the Medicaid Program, and the Children’s Health Insurance Program. 

A final rule was published in the Federal Register on February 2, 2011 titled “Medicare, Medicaid, and Children’s Health Insurance Programs; Additional Screening requirements, Application Fees, Temporary Enrollment Moratoria, Payment Suspension and Compliance Plans for Providers and Suppliers. The final rule states CMS may impose a temporary moratorium on newly enrolling Medicare Providers and Suppliers if they  determine that there is a significant potential for fraud, waste, or abuses with a particular provider or supplier type or particular geographic areas or both.  The Moratorium is for a six month period, but may be extended beyond for additional six month periods if CMS determines it needs to remain in place.

The moratorium for new home health agency enrollment applies to Miami-Dade County and Monroe County in Florida.  The moratorium for new home health enrollment applies to Cook, DuPage, Kane, Lake, McHenry, and Will Counties in Illinois.  The moratorium for new ambulance suppliers in Harris, Brazoria, Chambers, Fort Bend, Galveston, Liberty, Montgomery, and Waller counties in Texas.

For more information please use the following temporary link:

http://www.ofr.gov/(S(ga215hcckaqho1kou2yohgph))/OFRUpload/OFRData/2013-18394_PI.pdf

Success with ADRs

All of us feel bombarded by Additional Document Requests (ADR) for our Medicare Administrative Contractors (MACs) or other Medical Record Request from other program reviewers.  CGS which is the MAC for 15 states has developed a new tool to help providers succeed with Medicare Records Request.  They have come up with an acronym that spells success.  Their key words are Success, Understand, Contact, Coordinate, Expect, Submit, and Send (SUCCESS).

This would be a great tool for all home health agencies and hospices to utilize to help them respond to ADRs and other medical record request.  It actually gives you the Program that is requesting the documents (CERT, ADR, RA, or ZPIC) and the timeline to submit records.  Some of the addresses are incorrect if you are not served by the CGS MAC, but this report gives you great information.

For more information please uses the following link:

http://www.cgsmedicare.com/hhh/education/materials/pdf/Success_MR_Requests.pdf

Some Pioneer ACOs Exit Program

CMS issued a press release on July 16, 2013 detailing results from the Pioneer Accountable Care Organizations.  The report showed positive results for some of the Pioneer ACO’s who both higher quality care and lower Medicare expenditures.  Made possible by the Affordable Care Act, the Pioneer ACO Model encourages providers and caregivers to deliver more coordinated care for Medicare beneficiaries. This model, launched by the CMS Innovation Center, is part of the Affordable Care Act’s efforts to realign payment incentives, promoting high quality, efficient care for Medicare beneficiaries.  ACOs, including the Pioneer ACO Model and the Medicare Shared Savings Program, are one way CMS is providing options to providers looking to better coordinate care for patients and use health care dollars more wisely.  

The news was not all positive.  7 Pioneer ACOs that did not produce savings have notified CMS that they intend to apply to the Medicare Shared Savings Program – another ACO model.  2 Pioneer ACOs have indicated to CMS their intent to leave the program.  Overall, more than 250 organizations participate in the Pioneer ACO Model and the Medicare Shared Savings Program, serving 4 million Medicare beneficiaries, and more ACOs can join the Shared Savings Program each January.

For more information please uses the following link:

http://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-Releases/2013-Press-Releases-Items/2013-07-16.html

11 States Limited Home Health Access

The Office of Inspector General issued a letter to CMS concerning States that improperly restrict eligibility for Medicaid Mandatory Home Health Services.  In July of 2000, CMS released a State Medical Director letter summarizing it efforts to review Federal policies to ensure fulfillment of the Americans with Disabilities Act.  The letter stated that, although Medicare requires beneficiaries to be homebound to qualify for home health services, imposing a homebound requirement on Medicaid home health benefits violates Medicaid regulations related to “amount, duration, and scope of services.  In July of 2011, CMS published a Notice of Proposed Rulemaking that would review Medicaid regulations to clarify that home health services cannot be restricted to individuals who are homebound or to services furnish in the home.  This rule has not been published in final form as of this date. The eleven states that the OIG listed as violating parts of this requirement are Alabama, Arkansas, Indiana, Montana, Nebraska, New Mexico, North Dakota, Pennsylvania, South Dakota, Utah, and West Virginia.

For more information please utilize the link below:

http://oig.hhs.gov/oei/reports/oei-07-13-00060.pdf

More Rules for Healthcare Reform

This final rule addresses various requirements applicable to Navigators and non-Navigator assistance personnel in Federally-funded Exchanges, including state partnership exchanges, and to non-Navigator assistance personnel in State Exchanges that are funded through federal Exchange Establishment grants.  Navigators and similar in-person assisters will provide unbiased information to consumers about health insurance, the new Health Insurance Marketplaces, qualified health plans, and public programs including Medicaid and the Children’s Health Insurance Program.

In addition to Navigators, Marketplace consumers will have access to assistance through services such as a call center, where consumers can receive help with the eligibility and enrollment process. The call center will also provide referrals to the appropriate state or federal agencies, or other assistance programs including in-person assistance personnel, certified application counselors, and agents and brokers. The final rule also outlines the standards for certified application counselors, including training, qualifications, and requirements to ensure that they provide quality, sound, consumer-protective assistance.

Currently 26 states have elected not to set up their own exchanges and will be under the federal exchange program.  Seven other states have agreed to partner with the federal government to set up their exchanges.  The published rule will apply to all federal exchanges and federal/state partner exchange.  The 17 states plus the District of Columbia which have established their own exchanges have the option of using these regulations as guidance for their own exchanges.

For more information please utilize the temporary link below:

http://www.ofr.gov/inspection.aspx

This will be published in the federal register on July 17, 2013. At that time you can obtain a final link to the rule.

Millions in Overpayments Not Collected

The Office of Inspector General published a report that millions of Medicaid Overpayments remain uncollected.  Between 2000 and 2009 the OIG recommended that States refund in $1,213,085,167 Medicaid overpayments.  At the time CMS agreed with the OIG that these were indeed overpayments. As of December 31, 2012 CMS collected $947,481,600.  As of December 31, 2012 $225,603,567 remains uncollected.  CMS has agreed with most of the OIG report, but does indicate some of the items that are not collected are still under review. 

For more information please utilize the link below:

https://oig.hhs.gov/oas/reports/region5/51100071.pdf

AHA Final Health Insurance Marketplace Rules

CMS published a final rule for Strengthening Medicaid, The Children’s Health Insurance Program and the Health Insurance Marketplace on July 5, 2013.  It will be published in the Federal Register on July 15, 2013. 

The final rule addresses aspect of the Medicaid, (CHIP) and Marketplace eligibility notices and appeals process.  Some of the key provisions are listed below:

•               Coordination of Appeals of Eligibility Determinations
•        Changes in Medicaid Benefits
•        Changes in Medicaid Cost Sharing
•               Open enrollment period for Medicaid, CHIP, and Exchanges
•        Verification of employer-sponsored coverage
•        Presumptive Eligibility

For more information please utilize the temporary link below:

http://www.ofr.gov/(X(1)S(1dtx2qisx2r5f5wtwiilfqf4))/OFRUpload/OFRData/2013-16271_PI.pdf

Final Rule Hospice Patients in Long Term Care Facilities

CMS published a final rule in the Federal Register on the “Requirements for Long Term Care Facilities: Hospice Services”.  This will require all Long Term Care Facilities (that is, SNF’s and NFs) that chose to arrange for the provision of hospice care through an agreement with one or more Medicare-Certified hospice providers would have in place a written agreement with the hospice that specified the roles and responsibilities of each entity.  The rule was proposed on October 22, 2010 and the final rule was published on June 24, 2013.  The effective date of the final rule is August 26, 2013. 

We have listed two links below.  The first link is the proposed rule and the second link is the final rule.  We are showing both links because it is easier to read the first rule, because it is not cluttered with comments and responses.  There are only minor changes between the proposed rule and the final rule.  On page 38603 of the Final Rule it lists the changes it makes to the proposed rule.  If you provide hospice services in Long Term Care Facilities, we encourage you to closely review the proposed and final rule. 

Link to Proposed Rule

http://www.gpo.gov/fdsys/pkg/FR-2010-10-22/pdf/2010-26395.pdf

Link to Final Rule

http://www.gpo.gov/fdsys/pkg/FR-2013-06-27/pdf/2013-15313.pdf

170 Codes Removed From Home Health PPS Grouper

CMS proposed ICD-9-CM Grouper Refinements effective January 1, 2014.  They have identified two categories of codes that will be removed from the Home Health PPS Grouper.  The first category contains 162 codes based upon CMS’s clinical judgment are “too acute”, meaning that this condition could not be appropriately care for in a home health setting.  They believe the patients may have had these conditions while in the hospital, but would be substantially improved before they were transferred into home health care.  The second category contains 8 codes that based on CMS’s clinical judgment would not require the intervention of a home health agency.  CMS has removed a total of 170 codes that would no longer be part of the home health PPS grouper.    This will impact every home health agency.  The actual impact will vary based on each agency’s utilization of the 170 codes that will no longer receive points in the Home Health PPS Grouper Software. 

For more information on the codes please utilize the revised link published in the Federal Register on July 3, 2013 on the Proposed Home Health PPS Rules and Rates for 2014:

http://www.gpo.gov/fdsys/pkg/FR-2013-07-03/pdf/2013-15766.pdf

Employer Mandate Enforcement Delayed Until January 1, 2015

Valerie Jarrett Senior Advisor to President Obama published a White House Blog concerning the Employer Mandate required by The Affordable Care Act at 6:00 PM EDT on July 2, 2013.  She stated they have decided to revise and revamp the employer reporting process.  Some of the items in the reporting may be unnecessary for businesses that more than meet the minimum standards in the law. They will work with employers, insurers, and experts to propose a smarter system and, in the interim, suspend reporting for 2014. 

Second she stated since they are making changes to the reporting requirements they will need to give businesses more time to comply.  Since the employer responsibility payments can only be assessed based on this new reporting, payments for any penalties will not be collected for 2014.  This will allow employers the time to test the new reporting systems and make any necessary adaptations to their health benefits while staying the course toward making health coverage more affordable and accessible to their workers.

This did not actually change the law of the Affordable Care Act Law only the enforcement of the Employer Mandate Provision.  The administration expects to fully enforce the employer mandate provision beginning on January 1, 2015. 

Home Health Rates 2014

On Friday we published an Email Blast about the Proposed Home Health PPS Rates for 2014.  This is the second article about the Proposed PPS Rates.  Today we will list the actual episode payment rates, LUPA payment rates and Non Routine Medical Supply Rates.  Look for more Email Blast this week about the Proposed Home Health PPS Rules and Rates for 2014.

Base Urban Episode Rates Before Case Mix and Wage Index Adjustments
Description	2014	2013	Variance (*)	% Variance
Standard Episode Payment Rate	$2,860.20	$2,137.73	$722.47	33.80%

(*) CMS increased the base rate by 35.17% as part of standardizing the case mix rate.  The 33.80% increase is really a decrease because of the artificial increase of 35.17% in the base rate to account for the 35.17% decrease in case mix rate.  Remember your episode case mix rates will be decreased by 35.17% so for example C1F1 with 0 to 5 therapy visits will go from 0.8186 case mix rate in 2013 to 0.6056 in 2014.

LUPA Rates Urban Agencies Before Wage Index Adjustments
Description	2014	2013	Variance	% Variance
Skilled Nursing	$121.23	$114.35	$6.88	6.02%
Physical Therapy	$132.56	$125.03	$7.53	6.02%
Occupational Therapy	$133.46	$125.88	$7.58	6.02%
Speech Pathology	$144.03	$135.86	$8.17	6.02%
Medical Social Work	$194.34	$183.31	$11.03	6.02%
Home Health Aide	$54.91	$51.79	$3.12	6.02%

Medicare has proposed a change to the LUPA Add-On payments instead of a flat LUPA Add-On payment Medicare will base the LUPA-Add On payment based on which discipline makes the initial visit. 

LUPA Add-On Payment Amounts Before Wage Index Adjustments
Description	Base 2014 Rate	Add-On Factor	Revised Rate 1st Visit
Skilled Nurse makes initial visit	$121.23	1.8714	$226.87
Physical Therapist makes initial visit	$132.56	1.6841	$223.24
Speech Pathologist makes initial visit	$144.03	1.6293	$234.67

Medicare has proposed a cut of 2.4% for Non-Routine Medical Supplies 2014, 2015, 2016, and 2017.

Non-Routine Medical Supply Base Rate
Description	2013 Factor
2013 Rate	$53.97
2014 Rebasing adjustment (x 0.9742)	$52.58
2014 HH Market Basket (x 1.024)	$53.84

Proposed 2014 Non-Routine Medical Supply
Severity	Points	Relative Weight	Proposed NRS Payment Amount
1	0	0.2698	$14.53
2	1 to 14	0.9742	$52.45
3	15 to 27	2.6712	$143.82
4	28 to 48	3.9686	$213.67
5	49 to 98	6.1198	$329.49
6	99+	10.5254	$566.69

Remember that all rates must be adjusted for urban and rural home health agencies.  LUPA Rates and Episodes Rates must be adjusted by wage index.   Episode rates must be adjusted by wage index and case mix.  Home health agencies that do not submit quality data will receive an additional 2 percent cut in payments. 

We sent a note out to home health agencies last week titled “It is Time to Step Up or Fall Behind”.  We stated that your home health agency is currently going up the down escalator.  The current momentum of the health care industry is constantly pushing your company down, just like a down escalator is constantly moving down.  To step up to the next star, you adapt and embrace the changes or place your head in the sand and move further down the escalator. 

If you would like to step up instead of falling behind attend our Home Health Leadership Conference on September 23^rd to September 25^th at the Hilton Waikoloa Village on the “Big Island” in Hawaii. We will cover the home health proposed PPS Rule and methods to successfully adapt the changes.

For more information use the temporary link below (The final link will be available on July 3^rd when proposed rule is published in the Federal Register):

https://s3.amazonaws.com/public-inspection.federalregister.gov/2013-15766.pdf