CMS Delay’s Issuing Final PPS Home Health PPS Rule

CMS is blaming the partial government shutdown as the reason for delaying the issuance of the Final Home Health PPS Rule for 2014. The final rules should have been issued on by November 2, 2013. They claim they will issues the final rules on or before November 27, 2013.  The Final Home Health PPS Rules will go into effect on January 1, 2014.

Home health agencies patients admitted on or after November 3^rd (who have a full 60 day episode) will be impacted by these final payment rules.  You will not know your actual reimbursement rate until after the final rule is published for these episodes.  The proposed rules reduces your net episode payments by an average of 1.5%, change case mix codes, and eliminate 170 diagnoses from the case-mix codes.  I guess we will all be flying by the seat of your pants for a few weeks. 

We will provide more information when it becomes available

For more information please use the following link:

http://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html

CMS Clarifies “Confined to the Home” Definition

On October 18, 2013 CMS issued Change Request # CR 8444 to clarify the definition of “Confined to the Home”.  CR8444 clarifies the definition of the patient being "confined to the home" to more accurately reflect the definition as articulated at Section 1835(a) of the Social Security Act (the Act). In addition, the Centers for Medicare & Medicaid Services (CMS) removed vague terms, such as "generally speaking", to ensure the definition is clear and specific.

In the Calendar Year (CY) 2012 Home Health (HH) Prospective Payment System (PPS) proposed rule published on July 12, 2011, CMS proposed their intent to provide clarification to the Benefit Policy Manual language regarding the definition of "confined to the home". In the CY 2012 HH PPS final rule published on November 4, 2011 (FR 76 68599-68600), CMS finalized that proposal. In order to clarify the definition, CMS is amending its policy manual as follows:

For purposes of the statute, an individual shall be considered “confined to the home” (homebound) if the following two criteria are met:

Criteria-One:

The patient must either: Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and of residence:  OR Have a condition such that leaving his or her home is medically contraindicated. If the patient meets one of the Criteria-One conditions, then the patient must ALSO meet two additional requirements defined in Criteria-Two below.

Criteria-Two: 

There must exist a normal inability to leave home: AND Leaving home must require a considerable and taxing effort.

This policy becomes effective on November 19, 2013.  For more information please view the CMS MLN Matters Link and Medicare Benefit Policy Link below:

CMS MLN Matters Link

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM8444.pdf

Pub 100-02 Medicare Benefit Policy Transmittal 172 Link

http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R172BP.pdf

CMS Adds Another Medical Review Contractor

The Centers for Medicare & Medicaid Services (CMS) has contracted with Strategic Health Solutions, LLC, a Supplemental Medical Review/Specialty Contractor (SMRC) to perform and/or provide support for a variety of tasks aimed at lowering the improper payment rates and increasing efficiencies of the medical review functions of the Medicare and Medicaid programs.

One of the primary tasks will be conducting nationwide medical review as directed by CMS. The medical review will be performed on Part A, Part B, and DME providers and suppliers. Services/Provider Specialties to be reviewed will be selected by CMS, Provider Compliance Group/Division of Medical Review and Education (DMRE).  The SMRC will evaluate medical records and related documents to determine whether Medicare claims were billed in compliance with coverage, coding, payment, and billing practices.

The focus of the reviews may include, but is not limited to vulnerabilities identified by CMS internal data analysis, the Comprehensive Error Rate Testing (CERT) program, professional organizations and Federal oversight agencies.

Robert Liles has published a good article regarding Strategic Health Solutions.  He will be speaking in February at our Stepping Up For Home Health and Stepping Up For Hospice on the topic of “Preparing and Responding to an Audit by RACs or ZPICs”.  I am sure he will also cover this new audit contractor.  We have listed a link below to Robert’s article.

CMS Link

http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medical-Review/SMRC.html

Robert Liles Article Link

http://www.lilesparker.com/2013/05/09/strategic-health-solutions-2/

Is America Waking Up To Medicare Advantage Plan Pitfalls?

America’s seniors are constantly bombarded by insurance company’s selling Medicare Advantage Plans to replace their current Medicare coverage.  These plans offer lower copayments and more services like free health club memberships.  Most of our senior’s live on a fixed income.  Their income has not kept up with real inflation.  The older and sicker Medicare beneficiaries spend a much higher percent of their income on health care.  This has attracted approximately 12.7 million Medicare beneficiaries to switch to Medicare Advantage Plans.  One study estimated the Medicare Advantage plans cost Medicare an extra $34.1 billion in 2012. 

It appears some of the people have finally noticed the problems with Medicare Advantage Plans.  The Attorney General for the state of Minnesota is asking the federal government to investigate Humana for denying legitimate claims.  They have been accused of pattern of denying claims and overcharging enrollees.  The Attorney General’s office compiled several hundred pages of affidavits that it presented to the federal government on Friday.  This proves Humana has been improperly handling insurance claims by dozens of Minnesotan enrolled in it's Medicare Advantage plans.

A United Healthcare Medicare Advantage plan that covers 35,000 beneficiaries in southwest Florida is dropping at least 300 doctors and hard-to-find medical specialists from its Southwest Florida network.  This will create problems for the beneficiaries to find physicians and healthcare providers. 

Home Health and Hospice providers have long known the problems of dealing with Medicare Advantage insurance companies.  They may require prior approval for services, limit the amount of services for seniors, delay payments, pay lower rates or require home health agencies and hospices to be members of their network. 

Home health agencies, hospices, other providers, suppliers and physicians should become advocates for their Medicare patients.  They should explain the limitations that will be imposed by Medicare Advantage Plans. They should join with other senior organizations and advocate for their patients.  We all need to pull together to stop this exploitation of our seniors. 

Medicare Advantage Plan Study Link

http://www.pnhp.org/news/2013/may/Private-insurers-Medicare-Advantage-plans-cost-Medicare-an-extra-$34.1-billion-in-2012

Minnesota Attorney General Article Link

http://kstp.com/article/stories/s3195872.shtml

United Healthcare Article Link

http://www.news-press.com/article/20131018/HEALTH/310180009/United-Healthcare-drops-300-Southwest-Florida-doctors?nclick_check=1

Medicare Amount in Controversy Threshold Amounts Calendar 2014

The Medicare program requires a claim to have a certain dollar value that exceeds the Medicare amount in controversy to allow the provider or the beneficiary to appeal a claim.  The amount in controversy threshold for calendar year 2014 will be $140 to appeal Medicare claims in all appeal levels up to and including Administrative Law Judge Hearing.  The amount in controversy threshold for calendar year 2014 to take an appeal beyond Administrative Law Judge Hearing to Federal District Court will be $1,430.

OIG Reports on Timeliness of First Level Appeals

On October 13, 2013 the Office of Inspector General (OIG) issued a report on “The First Levels of the Medical Appeals Processes, 2008-2012: Volume, Outcomes, and Timeliness”.  The process focused on redeterminations process for Medicare Parts A and B during 2008-2012.  The surveyed 18 contractors that process redetermination for Medicare Parts A and B and interviewed 5 of them to learn more about how they process redeterminations.

They found in 2012 contractors processed 2.9 million redeterminations, which involved 3.7 million claims, and increase of 33 percent since 2008.  80% of all determination in 2012 involved Part B services, but appeals involving Part A services has risen more rapidly.  In 2012 appeals involving recovery audit contractors accounted for 39 percent of all Part A claims.  Contractors decided in favor of Part A appellants at a lower rate than that for Part B appellants. The contractors largely met the required timeframes for processing redeterminations and paying appeals decided in favor of appellants, but fell short of meeting timeframes for transferring case files for second-levels appeals.

The OIG recommends (1) CMS utilized the Medicare Appeals System (MAS) to monitor contractor performance, (2) continue to foster information sharing among Medicare contractors, and (3) monitor the quality of redetermination data in MAS.

For more information please utilize the following link:

http://oig.hhs.gov/oei/reports/oei-01-12-00150.pdf

Limit of 2 Episodes per Beneficiary per Year In House Bill H.R. 3245

If things were not tough enough on the home health industry (constant Medicare payment cuts, over reaching regulations face-to-face, HIPAA, RACs, ZPICs just to name a few)  H.R. 3245 bill has been proposed, titled “Medicare Home Health Fraud Reduction Act”.  Certainly the home health industry wants to eliminate fraud in home health.  But a bill to limit the home health episodes to 2 per beneficiary per year is ludicrous.   A Medicare Beneficiary’s episodes should be limited based on the need of the patient, not some arbitrary limit proposed by a group who definitely does not fully understand the home health industry. 

I guess we could go into a tirade detailing all the problems in the US House of Representatives and the US Senate.  They cannot pass a budget, live by budgets they pass, they exempt themselves from any laws that they enact, or even speak to each other.  It does not matter which party. They are all an abysmal failure.  America deserves better, but until the next election, I recommend you contact your US House Representative and explain that this is not the way to reduce Medicare Fraud.  What will happen to these Medicare beneficiaries when they cannot obtain their needed home health?  They will either be readmitted to the hospital, forced into a nursing home, or just pass away. 

You are not just advocated for your industry, you are an advocate for the millions of United States citizens who have paid into a system of Medicare that is supposed to provide their health care.  Our seniors are constantly being misled, over promised, targets of deception, and abused.  When I think of our senior citizens I constantly think of the quote of the late Andy Rooney “the best classroom in the world is at the feet of an elderly person”.  Our senior citizens need your help.  Let’s all call our Congress person and stop this insanity.

It is time to get on our Soap Boxes for our Seniors.

To view the actual proposed bill utilize the following link:

http://www.gpo.gov/fdsys/pkg/BILLS-113hr3245ih/pdf/BILLS-113hr3245ih.pdf

Hospice’s Must Furnish Vaccines

On May 3^rd 2013 CMS issued Transmittal 1217.  This update states that a hospice can provide vaccines (Influenza, Pneumococcal, and Hepatitis B vaccines) to those beneficiaries who request them, including those who have elected the hospice benefit.  These services are only covered when provided to hospice beneficiaries by their hospice provider.  This Change Request (CR) updates Medicare systems to prevent non-hospice providers from providing vaccines to hospice beneficiaries.  The effective date is October 1, 2013 and the implementation date is October 7, 2013. 

To obtain direct reimbursement from Medicare for providing vaccines they must be enrolled in the Medicare Part B Program.  These vaccines cannot be billed to Medicare on the UG04 Hospice Claim.  They must be billed on the Form CMS-1500.  If a hospice does not have a Medicare supplier number, they should contact their Medicare Administrative Contractor (MAC) to obtain the number.

For more information please utilize the following link for CMS Transmittal:

http://www.cms.gov/regulations-and-guidance/guidance/transmittals/downloads/r1217otn.pdf

For Information on Hospice Billing for Vaccines see the following link:

http://www.cgsmedicare.com/hhh/education/materials/BIIPPV.html

Government Issues Final Rule on Companionship Exemption

On October 1, 2013 the Department of Labor published a final rule regarding the companionship services exemption to clarify and narrow the duties that fall within the term: in addition third party employers, such as home health agencies, will not be able to claim the exemption.  The major effect of this Final Rule is that more domestic service workers will be protected by the Fair Labor Standards Act (FLSA) minimum wage, overtime, and recordkeeping provisions.  The rule goes into effect on January 1, 2015.

If a person is employed directly by the person, they have the opportunity to obtain a companionship exemption if the personal care services are less than 20% of the total amount of services provided. 

This is a very detailed ruling.  We will be adding this to one of our new DixonHSI-LIVE events.  Look for more information about this topic in the future.

For more information please utilize the following link:

http://www.gpo.gov/fdsys/pkg/FR-2013-10-01/pdf/2013-22799.pdf

Government Shutdown Will Not Delay Medicare Payments

The Government Shutdown that went into effect at Midnight on October 1, 2013 will not delay Medicare Payments.  A short memo on the CMS Medicare Learning Network this morning stated that Medicare Administrative Contractors will continue to perform all functions related to Medicare fee-for-service claims processing and payments. 

It is unclear if this will impact state survey activities or appeal reviews by administrative law judges.  We will notify you in a future email blast when these issues have been clarified.