On June 27, 2013, CMS released the proposed home health prospective payment rule (the “PPS Rule”) for calendar year 2014. While refinements to the ICD-9-CM and discussions of ICD-10-CM implementation are of interest, the most notable change to the PPS Rule for 2014 is CMS’s long-awaited proposal for rebasing home health payments. Once it is in effect, rebasing will have a severe impact on home health reimbursement over the next four years. In addition to rebasing, the proposed PPS Rule addresses several other areas of the home health payment system. The proposed PPS Rule outlines certain home health quality reporting requirements beginning in 2014 and provides clarification regarding state Medicaid programs’ financial responsibility for state survey agency activities.
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The Centers for Medicare & Medicaid Services (“CMS”) recently released a Survey and Certification letter updating the State Operations Manual (“SOM”) guidelines on surveys of deemed status long-term care (“LTC”) providers when the provider has been found to have a condition level instance of noncompliance, including immediate jeopardy (“IJ”), in a complaint survey. This change in policy only applies to “deemed status providers.” Deemed status is available when an approved accrediting organization (“AO”), separate from CMS, determines the provider is in compliance with Medicare conditions. This “deemed status” will largely exempt the provider from routine surveys by the State Agency (“SA”) but still requires the provider to comply with all applicable Medicare conditions. Nursing facilities are largely not eligible for deemed status; however, home health agencies (“HHAs”) and hospice and rehabilitation agencies are eligible.
In a transmittal issued on April 5, 2013, CMS provided guidance on survey activities that will be affected by the sequestration cuts. The transmittal provides guidance on several areas that will have an immediate and potentially negative effect on nursing homes and post-acute care providers. These changes will affect the survey process as conducted by the state survey agencies.
Data collected and analyzed by the Office of Inspector General (OIG) since 2010, indicate that home health agencies (HHAs) are predisposed to commit Medicare fraud, waste and abuse. In 2010, Medicare inappropriately paid $5 million for erroneous claims submitted by HHAs. With one in four claims being suspect, the OIG established six (6) criteria that identify HHAs submitting potentially fraudulent claims and/or employing questionable billing practices. Primarily, these criteria are based on higher than average payments, visits, late episodes, therapy visits and Medicare payment amounts per beneficiary, as well as a higher than average number of beneficiaries. Continue Reading →
The Centers for Medicare & Medicaid Services (CMS) just released the 2012 Nursing Home Action Plan; a guide for CMS’ efforts to continue to improve nursing home safety and quality. The plan features 5 actionable strategies, including: enhance consumer engagement; strengthen survey processes, standards, and enforcement; promote quality improvement; create strategic approaches through partnerships; and advance quality through innovation and demonstration. Continue Reading →
Consumers can now compare results from home health agencies (HHA) patient surveys on the Quality Care Finder website. These results are designed to create incentives for HHAs to improve quality of care, as well as to give patients additional information as to the type of care they will receive from a particular agency. The Centers for Medicare & Medicaid Services (CMS) also states one of the goals of such public reporting is to enhance accountability by increasing transparency. Continue Reading →
The Centers for Medicare & Medicaid Services (CMS) has issued revisions to the process Home Health Agencies (HHA) must undergo prior to initial certification. The revised process adds an additional review of enrollment criteria performed by the Regional Home Health Intermediary (RHHI) or Medicare Administrative Contractor (MAC). Continue Reading →
The Department of Labor published a Notice of Proposed Rulemaking in late December aimed at giving the nation’s nearly two million home care workers minimum wage and overtime protections. These workers have long been working under an exemption from the Fair Labor Standards Act (FLSA) as “companion” employees. Continue Reading →
A Medicare beneficiary is not liable for custodial care services rendered by a Mississippi nursing home because the facility failed to give adequate notice the services were not covered by Medicare, a federal appeals court panel ruled on October 25. The case (Mississippi Care Center of Morton LLC, Sebelius, 5th Cir., No. 10-60595, Oct. 25, 2011) concerned the application of 42 C.F.R. 411.404, which states a beneficiary is considered to have known custodial care or services that are not reasonable and necessary are not covered services under Medicare, provided the beneficiary received adequate notice the services are not covered under Medicare. Continue Reading →
On October 5, 2011, the Office of Inspector General (OIG) published its proposed Work Plan for Fiscal Year 2012. As in the past, the Work Plan continues to identify compliance risk areas that subject Medicare and Medicaid providers to audit and enforcement initiatives. The 2012 Work Plan contains several new areas of focus by the OIG that potentially will impact current operating practices of nursing homes and hospices and the relationships between these types of providers. More specifically, areas of increased scrutiny are (i) nursing home compliance plans; (ii) billing patterns of Part B provider services during non-Part A nursing home stays; and (iii) hospice marketing practices and financial relationships with nursing facilities.
The OIG will review Medicare- and Medicaid-certified nursing homes to ensure the implementation of compliance plans as a part of their day-to-day operations. The compliance plans will be reviewed to ensure they contain the required elements of the OIG’s compliance program guidance. Under the Affordable Care Act, nursing facilities must operate a compliance and ethics program to prevent and detect criminal, civil and administrative violations and to promote quality of care. The Centers for Medicare & Medicaid Services (CMS) is charged with overseeing the program and incorporating the requirements into the Medicare Requirements of Participation. CMS also must issue regulations by 2012, and nursing facility providers must have compliance programs in place by 2013.
Billing patterns of nursing facilities and Medicare Part B providers will be scrutinized to confirm that services provided by Part B providers to nursing facility residents during a non-Part A stay are billed directly by suppliers and providers. More particularly, the OIG will analyze podiatry, ambulance, laboratory and imaging services for conformity with this requirement.
Lastly, the OIG will closely examine and monitor hospices’ marketing materials and practices and their financial relationships with nursing facilities. Recently, the OIG reported that a high percentage of hospice claims for services to Medicare Part A-eligible nursing facility beneficiaries did not meet the Medicare coverage requirements. Observations by MedPAC, an independent congressional agency that advises Congress on issues affecting Medicare, suggest that hospices and nursing facilities may be involved in inappropriate enrollment and compensation relationships. Consequently, practices of hospices with a high percentage of their patients in nursing facilities will undergo increased inspection as well as those hospices that aggressively market their services to nursing facility residents.
A complete copy of the 2012 Work Plan can be accessed at http://www.oig.hhs.gov/reports-and-publications/archives/workplan/2012/Work-Plan-2012.pdf
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