CMS to Delay Expansion of Pre-Claim Review Demo

September 20, 2016

CMS announced yesterday afternoon that they are delaying the expansion of the Pre-Claim Review Demonstration for Home Health Services which began in Illinois on August 3, 2016.

According a notice on CMS’s website, based on early information from the problems encountered in Illinois, CMS believes additional education efforts will be helpful before expansion of the demonstration to other states; therefore, they will not move forward with initiating the demonstration in Florida in October.  This education effort will focus on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation.

According to the notice, CMS views these efforts as crucial to the long-term success of the demonstration for beneficiaries, providers, and the Medicare program. CMS will therefore take additional time prior to expanding to other states.   The start dates for Florida, Texas, Michigan, and Massachusetts have not been announced; however, CMS will provide at least 30 days’ notice on this website prior to beginning in any state.  CMS continues to expect a staggered start, beginning with Florida.

The Alliance has been working closely with the state associations in the other demonstration states and national home health groups to advocate for major changes to the project.  Building off of this short-term victory, HCA will continue those efforts and is also briefing our Congressional delegation on the issue. HCA will, of course, keep members informed of any changes in the demonstration.

Return to www.thinkhomecare.org.


Proposed Changes Prep Mass. for Nurse Delegation

September 6, 2016

The Massachusetts Board of Registration in Nursing (BORN) has released proposed regulations that sets guidelines for, among other activities, delegation by nurses to “unlicensed personnel.” These guidelines are NOT a change in the nursing scope of practice around medication delegation, which requires a law  approved by the legislature and signed by the Governor.

The BORN is merely aiming to establish a nurse delegation framework inclusive of much more specificity in areas such as training, supervision and documentation should nurse delegation practices become allowable in Massachusetts.

The proposed regulations also protect nurses by setting criteria for delegation that includes the following:

  • Ensuring that the delegating nurse would not bear any responsibility for any deviation by the unlicensed personnel from the nursing directive, instruction, or plan of care.
  • Formalizes the nurse’s role in knowing what is within the ability of the unlicensed personnel to carry out and what can be delegated that would not require judgment or assessment by the unlicensed personnel.
  • The final decision to delegate is made by the nurse and not the employing healthcare provider.
  • The employing healthcare provider must have the competencies of the unlicensed personnel documented for each nursing activity along with periodic validation of those abilities.
  • The nurse can determine at any time that an activity can no longer be delegated based on the health status of the patient, the unlicensed personnel’s performance of the activity, or any other reason the nurse believes would jeopardize the health and safety of the patient.

The proposed regulation follows years of discussion and a BORN subcommittee report on the state’s readiness for potential changes to nursing practice.

One of the possible changes is a longstanding policy priority of the Home Care Alliance, which is to allow home health care nurses to delegate certain medication administration tasks to a trained and certified home health aide. The HCA has dubbed the proposed policy as the “Nurse Delegation Bill.”

This bill will not pass in the current legislative session that ends with the New Year in 2017, but the HCA plans to continue pursuing a change that would allow – not mandate – that home health and home care agencies can implement proper training and procedures to maximize the efficiency of their direct care staff.

It should be noted that this bill includes protections, such as the fact that delegation is limited to medications which are NOT controlled substances and are administered in the following methods:

  • Oral
  • Ophthalmic
  • Otic
  • Topical
  • Internasal
  • Transdermal
  • Suppository
  • prefilled auto-injectables designed for self-administration
  • Products which are administered by inhalation.

The legislation states that “delegation of intramuscular, subcutaneous, intradermal, intraosseous or intravenous administration of medication shall not be permitted.”

Although the Alliance has comments and suggestions for the BORN’s proposed regulations, HCA fully supports the move to ensure the state is prepared for laws that promote nurses practicing at the top of their licenses. The Alliance appreciates the BORN’s thoughtful approach that further solidifies the importance of nurses in healthcare delivery.

The BORN will hold a public hearing on October 4th and will accept written comments until October 11th.

Return to www.thinkhomecare.org.


Home Care’s Part in the CMS Bundled Payment Program for Cardiac Care

August 15, 2016

Though no final announcements on participants have been made, several areas of Massachusetts were declared “eligible” by CMS for random selection of nearly 100 metropolitan statistical areas (MSA) across the country for a new innovation initiative that offers bundled payment for cardiac care.

CMS released the proposed rule on July 25th where the hospital in which a patient is admitted for care for a heart attack, bypass surgery, or surgical hip/femur fracture treatment would be accountable for the cost and quality of care provided to Medicare fee-for-service beneficiaries during the inpatient stay and for 90 days after discharge.

As with many similar alternative payment programs, established quality metrics would help determine whether the hospital would be required to pay Medicare for poor performance or receive reward payments for higher-quality care. CMS chose July 2017 to March 2018 as the “performance year” and then a gradual increase in the gains and downside risk for hospitals beginning at 5 percent in 2018 and capped at 20 percent in 2020-2021.

CMS is encouraging collaboration with other providers, including home health care and other post-acute providers. Equally important are a list of waivers this program will grant relative to the provision of post-acute care. Some notable highlights are listed below, with explanatory excerpts from the proposed rule, but the full list of waivers can be found in the proposed rule under “Subpart G” on page 885.

  • Waiver of direct supervision requirement for certain post-discharge home visits:
    • “CMS waives the requirement in  § 410.26(b)(5) of this chapter that services and supplies furnished incident to a physician’s service must be furnished under the direct supervision of the physician (or other practitioner) to permit home visits as specified in this section.  The services furnished under this waiver are not considered to be “hospital services,” even when furnished by the clinical staff of the hospital.”
  • Waiver of certain telehealth requirements:
    • “Except for the geographic site requirements for a face – to – face encounter for home health certification, CMS waives the  geographic site requirements of sec tion 1834(m)(4)(C)(i)(I) through (III) of the Act for episodes  being tested in an EPM, but only for services that  (1)  May be furnished via telehealth under existing requirements; and (2)  Are included in the episode in accordance with  § 512.210”
    • The Alliance is researching whether this is restricted to physicians performing telehealth or whether home health agencies would be allowed to engage in remote patient monitoring.
  • Waiver of the SNF 3-day rule
    • Only applies to the AMI (Acute Myocardial Infarction) model.

There is a 60-day public comment period and it is unlikely that the participating MSAs will be revealed before the final rule, but the “eligible” areas in Massachusetts are included below:

  • Barnstable Town, MA
  • Boston-Cambridge-Newton, MA-NH
  • Providence-Warwick, RI-MA

Based on CMS’ selection criteria, the Pittsfield and Springfield Metropolitan Statistical Areas are “excluded” from selection eligibility.

Return to www.thinkhomecare.org.

 


MassHealth Announces Home Health Agency Audit Results

August 5, 2016

Though a statement published in a Boston Globe online article, MassHealth revealed that their first round of home health agency audits uncovered $22.5 million in improper billing.

Nine home health agencies were involved in the initial audits conducted in response to steep spending growth in the MassHealth home health program. As the Globe article points out, the majority of that spending growth is driven by 62 companies that have come online since 2013.

In response, the Home Care Alliance is making its statement on the audits available. The full text of the statement is copied below:

Home Care Alliance of MA Statement on MassHealth Audits

BOSTON, MA – MassHealth announced today that audits of home health providers have uncovered more than $22 million in improper payments. The audits were initiated in an effort to identify the sources of recent dramatic spending growth on MassHealth home health services.

The Home Care Alliance of Massachusetts, a nonprofit trade association representing home health and home care providers, has been working side-by-side with the state Medicaid office staff since these audits were announced. The Alliance supported and continues to support MassHealth’s efforts to ensure appropriate services are being provided. This includes a temporary moratorium on new providers, and a prior authorization process for approving home health care services. In the months since the latter measure was put in place, both sides are in constant communication to relay concerns and suggestions. After years of lax oversight, Governor Baker’s administration has put a long-overdue emphasis on program accountability to assure that only eligible MassHealth members receive the in-home services they need to preserve their health and well-being.

“Massachusetts is fortunate in having some the best home health providers in the country and we support MassHealth in these efforts because we want to preserve the high standards of quality that patients and their families should expect,” said Patricia Kelleher, Executive Director of the Home Care Alliance of MA. “These audits only help to prove what our organization has been saying for years: There needs to be better state oversight as well as a higher bar of entry into the market.”

“Many of the MassHealth enrollees that our member agencies see have severe and persistent mental illnesses, and the multiple medications that they take can cause additional medical problems that require ongoing medical attention,” added Kelleher. “The agencies who do this work feel that they are a huge part of the health care safety net, providing valuable services to patients and families who otherwise would be placed in costlier care settings and/or become a detriment or even threat to their communities.”

The decision to add new management controls was driven by growth in utilization of the benefit particularly between FY 2013 and FY 2015. At present approximately 32,000 MassHealth enrollees are using home health services on an annual basis. Of these approximately 7,000 are receiving home health to assist in managing a mental or behavioral health condition, 4,000 are under age 21 and 9,300 are over age 61.

“Although MassHealth has not shared the specific audit results with us, we will continue to push for better standards and support program integrity efforts on behalf of all agencies that are playing by the rules and providing great care,” said Kelleher.

Return to www.thinkhomecare.org.


Moratorium on Home Health Agencies Extended by CMS, MassHealth

August 3, 2016

Both the state and federal governments are extending moratoria on new home health providers.

MassHealth will be extending the six-month moratorium on new home health providers, which will become effective on August 12 for an additional six months, according to MassHealth. The Home Care Alliance has been supportive of the measure and has collaborated with the state Medicaid office on program integrity efforts, but attempts to kick-start a state oversight policy for home care agencies have been unsuccessful.

In a letter requesting the initial stoppage on new providers from Massachusetts Health and Human Services Secretary Marylou Sudders to federal HHS Secretary Sylvia Mathews Burwell, it was noted that home health spending under MassHealth increased 41% from fiscal years 2014 to 2015. The letter continued to explain that 85% of that growth was driven by providers that were new to the MassHealth program since 2013.

Meanwhile, the Centers for Medicare and Medicaid Services (CMS) announced that they will be not only  extending their temporary moratoria on enrollment of specific locations within Florida, Illinois, Michigan, Texas, Pennsylvania, and New Jersey, but will also be broadening moratorium across each of those states.

Below is an excerpt from the Federal Register with CMS’ reasoning in announcing the extension and expansion:

CMS has determined that the factors initially evaluated to implement the temporary moratoria show that a high risk of fraud, waste, and abuse exists beyond the current moratoria areas, which may suggest that a high risk of fraud, waste, or abuse exists due largely to circumvention of the moratoria by some providers and suppliers.

The primary means of circumvention includes enrolling a new practice location outside of a moratorium area and servicing beneficiaries within the moratorium area. Additionally, CMS has continued to see areas of saturation that exceed the national average in the moratoria states. As a result, CMS, in consultation with the OIG, has determined that it is necessary to expand the temporary moratoria on a statewide basis, by implementing temporary moratoria on all newly enrolling HHAs in the remaining counties in Florida, Illinois, Michigan, and Texas, and on all newly enrolling Part B non-emergency ground ambulance suppliers in the remaining counties in Texas, New Jersey, and Pennsylvania, in order to combat fraud, waste, or abuse in those states.

Return to www.thinkhomecare.org.


Medicare Proposed Home Health Payment Rule

July 26, 2016

Home Health Payment Update

HCA of MA has posted to its website, a summary of the Home Health Prospective Payment System (HHPPS) changes that are to be effective  on January 1, 2017. The proposed rule implements the last year of the 3.5 percent rebasing adjustments required by the Affordable Care Act; implements the second year of the three year phase-in of a case-mix adjustment; changes the methodology for outlier payments; proposes payment changes for Negative Pressure Wound Therapy (NPWT); discusses monitoring and research regarding the impact of the changes; seeks comments on a potential process for grouping claims centrally during processing; and proposes changes to the Home Health Value-Based Purchasing (HHVBP) Model; and updates the Home Health Quality Reporting Program (HH QRP).  The Alliance has prepared a PPS Rates spreadsheet with all of the HHRG rates in each county in MA.

Comments are due no later than August 26, 2016 no later than 5:00 p.m.


One Care Program Extended Through 2018

July 25, 2016

MassHealth announced that the One Care Program for individuals dually eligible for Medicare and MassHealth and between the ages of 21 and 64 has been extended through 2018.

Part of this new agreement with the Centers for Medicare and Medicaid Services (CMS) is that MassHealth will be accepting letters of intent (LOI) from entities interested in becoming One Care Plans effective January 1, 2018.

Beginning in 2013, the One Care program included several plans that were whittled down to what is now Commonwealth Care Alliance and Tufts Health Plan, which began participation in the initiative as Network Health. Funding issues were at the center of why other plans could not sustain covering One Care enrollees, although adjustments have been worked out that are intended to help plans better predict costs and assess financial risk. Fallon Total Care was the latest to drop their participation in June 2015.

Out of 103,041 eligible individuals, MassHealth reports that 13,038 are covered by the two One Care Plans. Commonwealth Care Alliance covers the bulk of that total with 10,050 enrollees as of June 1, 2016. According to the latest enrollment report, more than 30,000 individuals have “opted out” of the One Care Program.

Return to www.thinkhomecare.org.


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