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Effective date of service on or after April 1, 2020.

The new ICD-10 code for COVID-19 (U07.1) is effective April 1, 2020. This diagnosis should not have been used when submitting March claims as the code did not exist in March. To help allay confusion (and avoid denials) it is important to understand that the April 1st date is for dates of service, not date of the claim. And, U07.1 (COVID-19) is only to be assigned and reported with confirmed cases of the COVID-19 coronavirus. 

Read More:

 https://cdn.ymaws.com/www.thinkhomecare.org/resource/resmgr/docs/ICD-10_coding_for_COVID_0401.pdf

The Centers for Medicare & Medicaid Services (CMS) announced that non-skilled in-home care will be included in Medicare Advantage plans in 2019 as a supplemental benefit.

The CMS decision is an important change to supplemental benefit because it allows payers to cover services like non-skilled in-home support for daily maintenance and activities, which is a first. CMS will also include portable wheelchair ramps and other assistive devices and modifications, as necessary, in the supplemental benefit. These benefits are meant ameliorate the damage caused by physical injuries and ailments and prevent hospitalization or re-hospitalization.

The CMS announcement will allow supplemental benefits if they “compensate for physical impairments, diminish the impact of injuries or health conditions, and/or reduce avoidable emergency room utilization.”

Read More

The Effective Date is January 1, 2022.  

Medicare-certified Home Health Agencies are encouraged to update their Billing Team on the changes.  Learn More

·       Primary data collection and analysis. To understand how the model may affect the home health environment, we will review the literature around home health and interview national and regional stakeholders. We will investigate the model’s impact in intervention states via interviews with HHA staff and with clinicians and others who refer patients to HHAs. Finally, we will administer surveys to HHA staff and beneficiaries in both intervention and comparison states.

·       Secondary data analysis. We will use Medicare claims data, HHA cost reports and self-reported measures, HHCAHPS survey data, Medicare enrollment data (MBSF), Medicare billing data (MDM), OASIS survey data, and facility-level data (POS) to analyze the impact of the HHVBP demonstration. This will help us discern the demonstration’s impact on HHA performance, Medicare costs, beneficiary experience, and several other outcomes of interest.

·       Ongoing reporting. We will present evaluation results in quarterly and annual reports to CMS. Quarterly reports will provide timely and concise findings on a key set of quality, utilization and spending metrics and highlight areas of interest or concern. Annual reports will provide a comprehensive annual evaluation of the effects of HHVBP on all outcomes of interest.

Share Your Comments

AAHC Executive Director, Marie Fredette meets regularly with the contractor to share feedback from members on this program.  Members are encouraged to submit their comments to AAHC who will share the comments anonymously with the contractor.

• Provider Members may click here to access the online comment form.

The Centers for Medicare & Medicaid Services (CMS) has issued a notice announcing the Provider Enrollment Moratoria Access Waiver Demonstration (PEWD) of Part B Non-Emergency Ground Ambulance Suppliers and Home Health Agencies (HHAs) in six states. The demonstration gives CMS the authority to grant waivers to the statewide enrollment moratoria on a case-by-case basis in response to access to care issues, and to subject providers and suppliers enrolling via such waivers to heightened screening, oversight, and investigations.

Concurrent with this announcement CMS issued a notice for a statewide expansion of the temporary moratorium on the enrollment of non-emergency ambulance suppliers and HHAs in Medicare, Medicaid, and the Children’s Health Insurance Program in six states. For HHAs, the moratorium includes the states of Florida, Texas, Illinois, and Michigan. 

Since the moratorium extends statewide, CMS has concerns regarding beneficiary access to care in areas where there is not an oversaturation of HHAs. However, CMS does not have the regulatory authority to implement an exception process for a moratorium. The PEWD will allow CMS to implement an access of care–based exception to the moratoria in limited circumstances. 

In order to qualify for a waiver, a provider must demonstrate that an access to care issue exists, and will be subject to heightened screening measures. The waiver will limit an agency’s service area to the area with access to care issues and prevent it from furnishing services in locations that are already oversaturated with HHAs.

The CMS Center for Program Integrity will review all PEWD applications. The primary determining factor for approval will be a determination regarding beneficiary access to care based on:

• provider saturation;
• provider to beneficiary ratios; and
• claims data.

The PEWD went into effect July 29, 2016; however, the application form for the demonstration is subject to approval by the Office of Management and Budget under the Paper Work Reduction Act. Therefore, the form will not be available until that process is completed.

Although it is unclear whether waivers under this demonstration will be necessary, the National Association for Home Care & Hospice supports the waiver demonstration. The PEWD will be necessary if beneficiaries who reside in the moratoria states begin to have difficulty accessing home health care.

• http://www.cdc.gov/phpr/healthcare/planning2.htm

The Long-Term, Home Health, and Hospice Care Planning Guide for Public Health Emergencies was developed to help improve the planning efforts of these healthcare entities and their coordination and integration within the community. This Planning Guide focuses on six topic areas: situational awareness, continuity of operations, facility or agency operations, crisis standards of care, staffing, and fatality management. Each topic area is presented in a manner that allows the user to develop needed sections in a facility or agency’s emergency preparedness and response plan.

It would be a mandatory program in all the affected states. The proposed states are: Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska, and Tennessee. CMS says it selected these states randomly from the 10 HHS regions. CMS says that the final states in the pilot may change.

The VBP model follows a path previously traveled with hospitals, but with some significant variation. Generally, a VBP program establishes a financial bonus pool funded by payment reductions to the provider group involved. Performance and outcome standards are established to determine which providers receive bonus payments. Those that do not meet the standards are left with lower payment revenues. Those that outperform the standards receive financial rewards.CMS has proposed to move forward with a VBP pilot program in 2016. CMS proposes to use 2015 as the baseline year for performance with 2016 as the first year for performance measurement. In 2018, HHAs will see the payment consequences of their 2016 performance.  Read More

Originally published by NAHC on June 24, 2015

The National Association for Home Care & Hospice (NAHC) recently joined over 60 organizations—including AARP and the American Medical Association (AMA)—in supporting separate payment for advance care planning codes (ACP). In a letter addressed to Secretary of Health and Human Services Sylvia Burwell, NAHC and the other organizations urged the Administration to start making separate payment for these ACP codes in CY 2016.

AMA through the Current Procedural Terminology (CPT) Editorial Panel developed two new codes—99497 and 99498—for complex ACP.  NAHC endorsed the thorough process undertaken by the AMA to craft the codes to ensure they address the needs of both caregivers and patients.

Complex ACP is defined to include at least one voluntary 30-minute meeting designed to discuss and document the patient’s preferences for their treatment plan, thereby helping the patient make decisions for their future care. The patient has the option of including his or her family or caregiver in the process.

“Published, peer‐reviewed research shows that ACP leads to better care, higher patient and family satisfaction, fewer unwanted hospitalizations, and lower rates of caregiver distress, depression and lost productivity,” NAHC and the other organizations wrote in the letter. “ACP is particularly important for Medicare beneficiaries because many have multiple chronic illnesses, receive care at home from family and other caregivers, and their children and other family members are often involved in making medical decisions.”

In the letter, NAHC and the other organizations further argue that making separate payment for ACP would promote ACP services. In addition, payment for ACP would allow Medicare to better track these services as well as the extent to which the services improve quality of life and effectiveness of care. Payment for ACP would align with existing quality reporting programs, such as the physician quality reporting system, that promote higher quality and value in the system.

The Institute of Medicine, in its 2014 report “Dying in America,” included ACP payment as one of its top five recommendations, stating: “payers and health care delivery organizations should adopt these standards and their supporting processes, and integrate them into assessments, care plans and the reporting of health care quality.”

CMS is expected to release its CY 2016 physician payment rule in the coming weeks. NAHC Report will continue to provide updates regarding this issue.

Originally published by NAHC on June 25, 2015

The U.S. Supreme Court issued a 6-3 decision today in King v. Burwell that upheld the legality of subsidies under the Affordable Care Act (ACA) for individuals who purchase health insurance through a federal exchange. Congress, the White House, and all of America had been anxiously awaiting the ruling over the last several months. The case involved a challenge to an Internal Revenue Service rule permitting health insurance subsidies under the ACA to individuals who acquire health insurance through a state, federal, or joint state-federal health insurance exchange. The central issue was whether the language of the law permits the subsidies to individuals only if they obtain the insurance through a state exchange. Presently, 34 states do not operate a state exchange.

In a 6-3 decision written by Chief Justice Roberts, the Court held that the overall context and structure of the ACA law compelled the conclusion that the tax credit subsidy was available whether through a state or federal exchange. The Court found that Congress intended to improve access to health insurance, not make it more difficult. The Court further concluded that rejecting subsidies through federal exchanges would have had a calamitous result, the opposite of what Congress sought with the law. Chief Justice Roberts was joined by Justices Kennedy, Ginsburg, Breyer, Sotamayer, and Kagan in the majority decision.

Val J. Halamandaris, President and CEO of the National Association for Home Care & Hospice (NAHC), released the following statement on the ruling:

“Today’s ruling is the best possible result we could have reasonably expected. Any other result would have led to wholesale chaos for the health care system with people across the country being denied their benefits. The Court’s ruling essentially amounts to a ceasefire in the repeal effort.

“To be sure there are serious problems with the law that need to be addressed, with a particular focus on long-term care and more emphasis on improving chronic care management. Chronic care amounts to about 93 percent of all Medicare spending. Congress has the time and opportunity to make the necessary changes, including softening the blow of the employer mandate, which will hit many small employers hard. We will continue to urge Congress to change the employer mandate to exempt home care providers, amend the definition of full-time to 40 hours per week, provide subsidies to home care agencies, and provide tax credits to home care clients to cover the increased cost of care triggered by the employer mandate. Congress should also help states provide low-wage home care workers with health insurance through Medicaid.”  

The loss of the subsidies would have affected over 6 million individuals across 34 states without a state exchange. For several months, Republican leaders in Congress have grappled with the question of what they would do if the Court ruled that the subsidies were illegal. Many wanted to take no action as the loss of subsidies could lead to the wholesale dismantling of the ACA. Others sought a means to protect the insured individuals for a transitional period of time. In recent days, there have been indications that a consensus was developing among Republicans to tie continued, but temporary, financial support to currently insured individuals while repealing the individual and employer mandates. Congressional Democrats and the Obama Administration had offered no suggestions on what should happen if they lost the case before the Court, arguing that the Court should uphold the legality of the subsidies.

Several states have recently received approval to begin operating a state exchange that relies on the federal healthcare.gov infrastructure. This type of hybrid state exchange would be controlled by the state but operate in a fashion very similar to a federal exchange.  With the ruling today, states will not need to institute quick changes in their operation in order to continue the subsidies to their citizens.

While the case does not directly impact home care and hospice, its indirect impact is significant. The loss of subsidies in the 34 states would have led to the effective elimination of the employer mandate in those states as the employer responsibility liabilities for penalties are linked to the subsidies. A “large” employer (50 or more FTEs) is subject to a penalty if the employer does not offer affordable and compliant health insurance to full-time employees if just one of those employees qualifies for and receives a health insurance subsidy.

NAHC surveys since 2013 show that there is a high incidence of home care employers that do not offer a qualified health insurance to full-time workers. The survey findings show that nearly 75% of Medicaid-focused home care providers and 90% of private pay, private duty home care companies are at risk of a penalty. Few state Medicaid programs have considered the problem of underfunded payment rates as insufficient to cover the costs increases related to ACA. With private pay companies, the burden of ACA falls on vulnerable elderly and disabled clients. Many of these home care companies have taken steps to avoid the liability of penalties by limiting the number of full-time employees. Less than a third of Medicare home health agencies and hospices face such a risk.

With the ruling, a significant employer penalty is now all but certain in the absence of a change in law. That change is unlikely to occur during the remainder of the Obama presidency as a veto is virtually guaranteed.  Affected home care companies must now turn to alternative measures that include offering a qualified health insurance to full time workers, modifying employment practices to control the number of “full-time” workers, seeking higher Medicaid payment rates to cover the added costs, or other actions that avoid or cope with the cost of insurance or penalty.

You can read the Court’s decision in King v. Burwell here.

Originally published by NAHC on May 12, 2015

The continuing legal challenge to the Medicare home health services physician face-to-face narrative requirement advanced with the filing of NAHC ‘s Motion for Summary Judgment and supporting Memorandum of Law. The Medicare program has until June 26, 2015 to respond followed by a July 24 deadline for the NAHC final brief.

In terms of the legal issues presented in the case, NAHC must establish that the plain language of the law does not permit the physician narrative requirement. If the language of the law is unclear or ambiguous, NAHC must prove that the requirement is unreasonable or arbitrary and capricious.

In its brief, NAHC argues that the plain language of the face-to-face physician encounter law only permits Medicare to require that the physician document that the encounter occurred during the allowable timeframe. The Centers for Medicare and Medicaid Services (CMS) had previously argued in its brief that the narrative was a permitted interpretation of the word “document” that is contained in the law.  CMS’s position is that it has the authority to require that a physician document “why” the physician considers a patient meets the homebound and skilled care requirements.

NAHC’s position on the plain language argument is supported by a review of the entire sentence that includes the word “document.” That full sentence supports NAHC’s reading over the CMS reading that is based on isolating the word “document” in a silo. NAHC also argues that the narrative is a physician’s opinion, not something that fits as a matter to be documented.

Beyond the plain language, NAHC argues that the narrative is not reasonable and results in arbitrary determinations from Medicare. Specifically, NAHC explains in its brief that the narrative requirement leads to claim denials for patients who are truly homebound and in need of skilled care because the review of a physician  narrative ignores the patient’s full clinical record. NAHC argues that the policy is arbitrary and capricious because is allows a partial record review, e.g. the narrative, to control the outcome on Medicare coverage.

NAHC further supports its arguments with evidence of the confusion surrounding the standard for a compliant physician narrative, the high rate of claim denials, and the failure of CMS to provide adequate guidelines on compliance. Also, NHC explains that CMS itself abandoned the requirement when it realized it was virtually impossible to administer it fairly.

While the narrative requirement has been rescinded, NAHC is continuing the lawsuit for purposes of resolving the tens of thousands of claims previously denied for an “insufficient narrative” as well as possible future audits of claims from 2014 and earlier.   NAHC continues to seek overall relief from the face-to-face requirements and hopes to secure a legislative remedy from Congress shortly.

Originally published by NAHC on March 19, 2015

Beginning July 2015, Home Health Agencies (HHAs) will have a *free* new tool available to help them to assess their risk for improper Medicare payments. TMF® Health Quality Institute is developing a new Program for Evaluating Payment Patterns Electronic Report (PEPPER) for HHAs.

PEPPER is an educational tool available to providers to help them proactively monitor their claims and work to prevent improper Medicare payments. PEPPER summarizes an HHA’s Medicare claims data in areas that may be at risk for improper Medicare payments. It compares the HHA’s statistics with aggregate statistics for the nation, Medicare Administrative Contractor (MAC) jurisdiction and the state. If a provider’s statistics are at/above the national 80th percentile the provider is identified as an “outlier” and may be at risk for improper Medicare payments. PEPPER cannot identify the presence of improper payments.

As the regulatory focus on improper Medicare payments becomes more intense for HHAs, this free comparative data report can help providers identify when their billing statistics differ from most other HHAs for these six target areas:

The HHA PEPPER is currently under development. TMF anticipates the reports will be available to providers in July 2015 through the PEPPER Resources Portal.

In June 2015, a HHA PEPPER user’s guide will be made available in the section for Home Health Agencies at the following website: PEPPERresources.org website. TMF will conduct web-based training sessions to help providers understand the report. Join the email list to receive notifications of training opportunities and report distribution.

​

Originally published by NAHC on February 10, 2015

The Centers for Medicare & Medicaid Services (CMS) held its second Open Door Forum (ODF) call for the proposed five star rating system for home health agencies. The presenters reviewed the star rating system, the comments received from the previous an ODF call, the revised methodology for calculation, and the next steps in developing the star rating system.

CMS reviewed their initial plans to implement a five-star rating system for home health agencies (HHAs), similar to the system used for skilled nursing facilities. The plan was officially announced on an ODF call held back in December. During that call, CMS presented ten selected measures and a preliminary methodology to be used for the five-star rating system.  

Many of the comments CMS received from the initial ODF call were related to the selected measures, the methodology for calculating the star rating, and concerns regarding consumer interpretation of the rating system. Several comments addressed the robustness of risk adjustment and the request for CMS to issue changes through the rule making process.

The ten measures originally selected will be used. CMS rejected several requests for the inclusion of stabilization measures and measures from the Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS). According to CMS, the stabilization measures do not meet the criteria for selection. None of these measures are reported on Home Health Compare nor do any have NQF endorsement. Additionally, the scores for these measures do not have enough variation.

CMS revealed plans to apply a separate star rating for the HHCAHPS measures and eventually incorporate these scores into the outcome measure rating system. However, CMS did not have any concrete plans for this initiative.  

During the most recent ODF call, CMS also presented a revised methodology for the rating system. Rather than place agencies in quintiles with ratings from 1-5 stars, agencies would be sectioned into deciles and be rated in half star increments between 1 and 5 stars.

By distributing agencies among deciles the ratings distribution are “flattened”, allowing for less clustering around 3 stars. However, CMS plans to apply the same approach with the calculation as in the previous method. The score for each measure will be adjusted towards a rating of 3 if the score for that measure is not significantly different from the median across all agencies. 

CMS plans to begin publishing the star ratings on Home Health Compare (HHC) in mid-July 2015. The ratings will be based on Outcome and Information Assessment Set (OASIS) data from January through December 2014 and claims data from October 2013 through September 2014. These are the same data that will be published on HHC in April 2015 under the usual schedule. The star ratings will be updated quarterly.

Agencies will be able to review their reports in March and will have several weeks to review and provide feedback on any data errors identified that affect the final star rating.

CMS is accepting another round of comments that are due Friday, February 13, 2015. CMS will also be drafting and testing consumer language, and plans to continue to solicit additional input on the rating system through informal stakeholder group.

The National Association for Care & Hospice (NAHC) has the same concerns with this proposal as it did with CMS’ initial proposal. NAHC has a general concern with using a star rating system framework to communicate to consumers the difference in quality of care among HHAs.

NAHC also maintains that measures other than those selected should be used. Additionally, the revised methodology continues to divide agencies in sections - now ten rather than five - even when performance variation between providers may be slight. This is compounded by ranking agencies on a “curve” that moves agencies towards a 3 star rating. Lastly, CMS will not likely be able to develop language that will effectively communicate to consumers how this star rating system differs from other consumer star rating systems.

The approach CMS has taken to inform stakeholders of their intent to apply a star rating system for HHAs is also of concern. NAHC has requested that CMS use the formal rulemaking process for public notice and comment to communicate this initiative to stakeholders.

A separate web page has been set up for the home health five sat rating system on the Home Health Quality Initiative page. On this page, agencies will find the handouts for the ODF call and the revised methodology for the rating system along with other information on the star rating system.

Originally published by NAHC on March 3, 2015

In its most recent Home Health Chartbook, the Alliance for Home Health Quality and Innovation (AHHQI) found that home health users rehospitalized within 30 days of hospital discharge decreased by nearly two percent - from 19.17 percent to 17.39 percent - between 2011 to 2012 for the top 20 most common diagnosis groups of patients discharged from hospitals to post-acute care. The overall rate across all post-acute care settings for 30-day hospital readmissions remains higher at 18.4 percent. 

AHHQI is a non-profit, national consortium of home health care providers and organizations – including NAHC - that invests in research and education about home health care and its ability to deliver quality, cost-effective, patient-centered care across the care continuum. The organization’s Home Health Chartbook summarizes and analyzes statistics on home health from a range of government sources. 

In addition to declining 30-day hospital readmission rates, the Chartbook reveals that the national averages for home healthcare quality measures improved in 15 distinct areas of care. For example from the year ending March 2013 to the year ending March 2014, there was a three percent increase in patients who improved at walking or moving around while using home health when compared to the same timeframe one year earlier. Other areas of better patient outcomes include improved breathing among home health beneficiaries, improvement at getting in and out of bed and an increased rate of home health professionals checking patients’ risk of falling. 

Home health beneficiaries also continue to reflect an older, sicker and majority female population as compared with the general Medicare population. The number of home health recipients over the age of 85 increased from 24.2 percent in 2011 to 25.3 percent in 2012 and home health users with three or more chronic conditions increased just over two percent from 2011-2012. The proportion of female home health patients (compared to male home health patients) rose by nearly three percent. 

“The improved quality of care reflected in the data from the Chartbook is indicative of the home health community’s effort to prioritize better patient outcomes through coordinated, efficient care executed by teams of interdisciplinary home health professionals,” said Teresa Lee, Executive Director of the Alliance. “
To read the full AHHQI Chartbook, please click here.

Originally published by NAHC on January 14, 2015

The White House Conference on Aging (WHCOA) is launching a series of regional forums to engage with older Americans, their families, caregivers, leaders in the aging field, and others on the key issues affecting older Americans.  Meeting locations include Tampa, FL on February 19th; Phoenix, AZ on March 31st; Seattle, WA on April 9th; Cleveland, OH on April 27th; and Boston, MA on May 28th. 

The forums are designed to help provide input and ideas for the 2015 White House Conference on Aging, which will be held in Washington, DC later this year. 

The regional forums are being co-sponsored with AARP and co-planned with the Leadership Council of Aging Organizations (LCAO), a coalition of more than 70 of the nation’s leading organizations serving older Americans. Participation is by invitation, but the events will be webcast to various locations.

The White House Conference on Aging has been held once a decade, beginning in 1961 and is designed to help chart the course of aging policy.  The 2015 Conference will focus on four areas:  ensuring retirement security; promoting healthy aging; providing long-term services and supports; and protecting older Americans from financial exploitation, abuse, and neglect.

Additional information on Conference activities can be found here. 

Join us at the AAHC Annual Conference being held June 25-26 in Scottsdale featuring a special opening session on the future of home care in Arizona.  Learn More

Originally published by NAHC on October 17, 2014

Home Care and Hospice Preparation for Ebola

Special thanks to Barbara Citarella, MS, RN, RBC, Limited Healthcare & Management, www.rbclimited.com, for writing today's story on "Home Care and Hospice Preparation for Ebola."  If you are attending the NAHC Annual Meeting & Exposition in Phoenix, AZ on October 19 - 22, 2014, Barbara will present two education sessions at the Annual Meeting. The first session will take place on Sunday, Oct. 19, entitled "How to Prevent Infection Control Breaches," and the second session will be held on Tuesday, Oct. 21, entitled "How to Identify Home Care and Hospice’s Triggers and Indicators: Crisis Standards of Care."
 
Earlier this week, Val J. Halamandaris, President of the National Association for Home Care & Hospice (NAHC) wrote to Sylvia Matthews Burwell, Secretary of U.S. Department of Health and Human Services and Tom Frieden, MD, MPH, Director of  Centers for Disease Control and Prevention (CDC) requesting guidance from CDC on appropriate protocols relative to Ebola for home care workers. Officials at CDC indicated they had brought Halamandaris's letter to the Director's attention. NAHC  will continue to monitor and report on activity in this important area and will be announcing additional actions it is taking to ensure the greatest possible safety of the home care and hospice community and the patients they serve.  Watch for updates in the coming days.

As the Ebola outbreak continues to make headlines around the world, much of the focus, guidance and protocol development have been on acute care facilities. But we in home care and hospice need to be prepared also. At this moment in time, chances are slim we will see an acutely ill patient with Ebola, but we cannot rule it out as the situation changes daily. (As of this moment, a second strain of Ebola has been identified in the Congo, which has a 71% mortality rate.) Here are some suggestions that providers can begin implementing now for the current situation. We will update as it changes.

• Agencies should begin a comprehensive infection prevention education program for all staff but especially for field staff. Intensive training in the use of personal protective equipment (ppe) is paramount. Staff need to know how to don and doff ppe without contaminating themselves. This includes gloves, masks (either surgical or N95 respirator masks), gowns, and face shields. Hand washing is included. Agencies should bring staff in for demonstrations and re-demonstrations. An increase in field supervision should follow as a “buddy system” to monitor infection prevention technique.
• Reinforce the proper use of bag technique. According to the World Health Organization, Ebola can be spread by contact with previously contaminated surfaces (October 6, 2014). Home care and hospice providers do not control their environment.
• Reassure staff by giving them the facts on Ebola. Share your mission to keep them safe while they provide patient care. Have a communication plan for your staff and patients.
• Review and update policies such as your pandemic plan, influenza protocols, and monitoring staff that may have been exposed. Don’t forget to include the intake process of new patients. All new patients, and the referral source, should be asked questions following the CDC algorithm. Is the patient symptomatic, if so, what are the symptoms? Then obtain a travel history of the patient, family, and friends. If the answers meet the CRITERIA for possible Ebola, contact the health department. (9-1-1 dispatchers are being trained to handle these possible transports.)
• Check your supplies of ppe. If they are outdated- DO NOT USE. The integrity may be compromised. Order additional supplies including some booties and head coverings. Don’t wait. Remember how quickly health care providers ran out of ppe during the H1N1 pandemic.
• If a possible Ebola patient (meeting the criteria) is identified during a home visit. The staff should immediately don personal protective equipment and place patient in a room by him or herself. It should preferably be one with a door but this is home care and we may not always have that option. Staff should then call the health department and 9-1-1 explaining the situation and wait for guidance. No one should leave the home until clear guidance has been given. That includes staff.
• Research your state health department’s website. They all have the most recent information and may have some specifics for your state. Keep your staff informed daily but be sure the information you share is accurate. People are anxious and inaccurate information can spread easily.

As home care and hospice providers, our role is to prevent and control the spread of the Ebola virus while protecting our staff and patients.

Useful Links:

• General CDC link to INFORMATION FOR HEALTHCARE WORKERS AND SETTINGS

Patient Evaluation:

• Algorithm - Evaluating Returned Travelers for Ebola, US[PDF - 1 page]
• Checklist for Patients Being Evaluated for Ebola in the U.S.[PDF - 1 page]

Protecting Healthcare Workers:

• Sequence for Putting On and Removing Personal Protective Equipment (PPE)[PDF - 3 pages]
• Tools for Protecting Healthcare Personnel

Originally published by NAHC on September 18, 2014

NAHC Lawsuit on Face-to-Face Physician Encounter Rule Advances

The lawsuit challenging the validity of Medicare's requirement that physicians provide a narrative to support their certification of a patient's homebound status and skilled care need is advancing in Federal District Court. The Department of Justice has filed a motion to dismiss with the court arguing that the court does not have the power to hear the case. This motion to dismiss is a typical action in Medicare litigation through which Medicare attempts to avoid the scrutiny of the federal court.

The Medicare Motion to Dismiss argues that NAHC failed to exhaust all administrative remedies prior to filing a lawsuit in federal court. In addition, the government motion claims that the NAHC complaint fails to state a cause of action that the court could hear. Over the past 25 years, the federal courts have restricted what's known as "jurisdiction" on Medicare related matters. Earlier decisions from the US Supreme Court generally require an exhaustion of administrative appeals.

NAHC anticipated this type of response from Medicare attorneys. "This is a "garden variety" type of defense offered in Medicare litigation," stated Bill Dombi, the lead counsel in the lawsuit. "We believe that the exhaustion of administrative appeals is not necessary in this matter for several reasons," he added.

The NAHC lawsuit counters the government's defensive action in its allegations that Medicare has already reached a final decision on the issues presented administratively. NAHC presented all of the lawsuit claims prior filing the case in court to the head administrator of Medicare at the Centers for Medicare and Medicaid Services (CMS). These efforts to resolve the concerns with the face-to-face encounter documentation requirements were rebuffed by CMS, thereby triggering the right to go to court.

The lawsuit also claims that there is a right to judicial review under the Mandamus Act, which gives federal courts a right to review disputes with government actions when the challenged activity is in direct conflict with the laws passed by Congress. With the face-to-face encounter rule, the lawsuit alleges that Congress specifically limited documentation requirements in a way that does not permit the narrative requirement added by CMS. The law itself only requires that physicians document that the encounter occurred.

NAHC has until October 10 to respond to the government's motion. Medicare will have the opportunity to reply to the NAHC response thereafter.

It is expected that CMS will issue a Final Rule on the proposed changes to the face-to-face documentation requirements prior to the close of the briefing in the lawsuit. While it is anticipated that CMS will continue its plan to eliminate the narrative requirement, the lawsuit is continuing with the design of bringing a favorable resolution on the past-denied claims where Medicare contractors rejected physician narratives as "insufficient."

Published on August 25, 2014 by NAHC.

The National Council on Medicaid Home Care Releases Survey Results on Medicaid Managed Care in Home Care

Survey of Council members highlights trends and concerns on the adoption of Medicaid managed care in home care. 

In July and August, NAHC’s affiliate, the National Council on Medicaid Home Care, surveyed its members as to the status of their adoption of Medicaid managed care in home care. The Council conducted two surveys.  The first had 45 respondents, and the second, a modified and more detailed version of the first survey, had 67 respondents, for a total of 112 respondents. The Council discusses the results of these surveys in a new report, available here.

The survey results are based on the responses received from agencies and associations, and are not stratified by state. Therefore, some states may be represented by multiple responses. The survey results represent only a small cross-section of those adopting Medicaid managed care in home care nationally. The total number of states and enrollees adopting Medicaid long-term services and supports (MLTSS) is shown in tables 1 and 2 of the report that is linked above.

Analysis

Affiliation. Most respondents were representatives of home care agencies rather than hospice companies or the Forum of State Associations. Out of both surveys, 81 stated that they represented a home care agency, 16 stated that they represented an agency that provides both home care and hospice, 13 stated they represented a member of the Forum of State Associations, and three stated that they represented a hospice company. Since the first survey did not delineate “hospice” as an independent category, one of the three that represented a hospice company indicated so in the “other” category in the first survey (in addition to responding that he/she represented a home care agency), so these numbers total 113 and not 112.

Current Implementation of Managed Care. Out of the total of those surveyed, 53 stated that their state now has managed care in home care, four stated that they have Medicaid managed care through coordination of dual eligibles, and 51 stated that their state has both Medicaid managed care in home care and through coordination of dual eligibles. Only three of those surveyed stated that their state does not have Medicaid managed care at all.

Services. The most popular services that respondents noted were already in Medicaid managed care in their states were: home health services (94), home and community based waiver services (67), personal care services (46), and hospice (42). The most popular services pending transition were:  home and community based waiver services (11), private duty nursing (10), mental health services (9), and personal care services (9).

Patient populations. The most common patient populations that respondents noted were already in Medicaid managed care in their states were: dual eligibles (73), elderly (68), physically disabled (54), and pediatric (46). The most common patient populations that were pending transition were: dual eligibles (16), intellectual or developmentally disabled (I/DD) (11), and physically disabled (9).

Level of Satisfaction with Managed Care. In both surveys, the Council asked respondents to rank numerous aspects of their transition to managed care on a scale of 1 to 5, with 1 being a very negative experience and 5 being a very positive experience. In both surveys, none of the aspects averaged a score of three (neutral) or higher. All of the responses averaged between a 2 (negative) and 3 (neutral score). This was true both looking at the two surveys independently of each other, as well as aggregating the results.

Conclusion

The survey results reflect a reaction to managed care from home care agencies, joint home care/hospice agencies, and state associations that can be described as lukewarm at best. While the transition to Medicaid managed care is filled with challenges, stakeholders are not powerless or voiceless in the matter. Agencies and associations alike should take opportunities to learn from previous experience. The Council provided key lessons regarding managed care in NAHC’s March on Washington, as well in its recently released toolkit on the transition to Medicaid managed care.

Stakeholders can be very useful in improving a state’s transition to managed care in Medicaid. Likewise, if these stakeholders have outright opposition to using managed care in Medicaid, or otherwise need to navigate their transition to managed care, they should consult with both their state associations and the Council.  Home care providers are encouraged to keep abreast of managed care transitions in their states, advocate on a state level, and to contact the Council with any questions or concerns.

To read the full report, please click here.

The Arizona Association for Home Care is a member of the National Association for Home Care and has republished this article with permission.

Published on  June 2, 2014 by NAHC

The National Association for Home Care & Hospice (NAHC) filed a lawsuit on June 5, 2014, challenging the administration of the physician face-to-face encounter documentation requirements developed and administered by the Centers for Medicare and Medicaid Services.

The NAHC Board of Directors approved the filing of the lawsuit because the regulations have caused a dramatic upsurge in the retroactive denials of patient claims for payment under Medicare.

These denials are based on the allegations not that physicians had failed to see patients or certify them for payment but rather because physicians did not supply sufficient paperwork, i.e. a narrative and explanation for their judgment that patients are homebound or in need of skilled nursing or physical therapy.

“This new regulation, which had the goal of improving the quality of care, has had the opposite effect. It has created a crisis and is denying the infirm elderly the care that they need which is why we had no choice but to take our case to Federal Court,” said Andrea Devoti, Chairman of the NAHC Board of Directors.

The lawsuit was filed in the U.S. district Court in Washington, D.C. NAHC claims that CMS violated Medicare law in three respects:

CMS violated the law that authorized the physician face-to-face encounter by requiring that the physician provide a narrative that explains why a patient is home bound and in need of skilled care. The authorizing statute requires only that the physician document that the encounter occurred.

To the extent that CMS can require the physician narratives, CMS violated The U.S. Constitution and the Medicare Act by failing to provide adequate, reasonable, and clear guidance on the standards for compliance. In other words, CMS must explain what constitutes "sufficient" narratives.

CMS further violated Medicare law by allowing its contractors to deny payment retroactively based solely on the sufficiency of the physician narratives without reviewing the entire patient record to determine whether the patient is, in fact, home bound and in need of skilled care.

“We filed the suit reluctantly only after we tried to make CMS understand that their regulation was redundant, amounted to bureaucratic overkill, created disincentives for physicians to order home care services, and was leading to the loss of care by thousands of Medicare patients who are so sick that they cannot leave home without assistance,” said Val J. Halamandaris, President of NAHC.

NAHC had sought a suspension of retroactive reviews of the physician narratives as an interim action by CMS until such time as CMS revised its rules. CMS informed NAHC that it plans to issue possible revisions in an upcoming proposed rule scheduled for release in late June or early July. Given that home health agencies are experiencing an endless series of claim denials based on the sufficiency of the physician narratives, NAHC determined that is was not in the best interest of the home health community that it take a chance on the possibility of a proposed rule that might provide some undefined change in the requirements which would take effect no earlier than late October when the final rule changes would be issued.

NAHC expects to pursue a preliminary injunction designed to expedite the court's review of the claims presented. Following that effort, NAHC will ask the court for summary judgment on the claim that CMS does not have authorization to require the physician narratives. A trial on the other claims may be needed since there may be disputed factual issues.

While the lawsuit is pending, NAHC will continue to work with members of Congress in hopes of a legislative remedy. Currently, NAHC and its affiliated Forum of State Associations are engaged in an effort to secure relief through the appropriations process underway in the House of Representatives. NAHC has also extended an offer to CMS to reopen the settlement negotiations in hopes of avoiding protracted litigation. NAHC believes that CMS recognizes the need for corrective action on the face-to-face rule.

The lawsuit is being prosecuted by Bill Dombi, NAHC’s Vice President for Law.

Mr. Dombi has a long history of successful litigation against the U.S. Government and health insurance companies on behalf of the home care industry.

NAHC is asking all Medicare patients and provider organizations to join in supporting this litigation.

To access the Compliant filed in federal court, go to this link. Ongoing reports on the progress of the litigation will be published in NAHC Report.

On March 4, President Obama released his budget proposal for the Department of Health and Human Services (HHS) for Fiscal Year 2015.  The National Council on Medicaid Home Care – a NAHC affiliate - reports on the budget’s implications for Medicaid home care.

Overall Medicaid budget. Overall, outlays in Medicaid were expected to rise from $2.7 billion in 2013 to $3.1 billion in 2014 to $3.4 billion in 2015.  The budget also includes a total of $7.3 billion in total savings to the Medicaid program. For details, see pages 14 and 55, here.

Program integrity. Under the President’s budget proposal, FY 2015 Medicaid program integrity expenditures will total $522 million, of which $423 million is the federal share.  To see the breakdown of these costs, see page 72, here. To see total investments and savings in the Medicaid Integrity Program from 2014 through 2024, see page 70, here.  Program integrity legislative proposals would altogether amount to $620 savings over 10 years.  See page 81, here.

MFCU mandate extended into home based care. The budget proposal gives Medicaid Fraud Control Units (MFCUs) the option to get federal matching funds to investigate and prosecute home care abuse and neglect.  This provision thus increases the prosecutorial power of the MFCUs into home care, as it had traditionally been more institution-focused.  This provision is estimated to have no budgetary impact.  For details, see page 73, here.

Medicaid Legislative Proposals

The President’s 2015 budget also highlights several Medicaid legislative proposals, including:

Provide HCBS to children eligible for psychiatric residential treatment facilities.  This proposal allows states to expand to non-institutional options for children’s mental health care.  This would encourage rebalancing of this population that is currently institutionalized or otherwise meet the institutional level of care.  Otherwise, this population would only be able to receive care in an institution.  This provision is inspired by the Community Alternatives to Psychiatric Residential Treatment Facilities Demonstration Grant Program that saw savings of approximately $40,000 per year per participant.  This provision is estimated to cost $1.9 billion over 10 years.  For details, see page 80, here.  

Dual eligible provisions.  These proposals include integrating the appeals process for duals (no budgetary impact), and a pilot to expand the Program of All-Inclusive Care for the Elderly (PACE) to those aged 21 through 55 (no budgetary impact).  PACE is a rebalancing program that provides community based LTSS to duals via an interdisciplinary team.  For details, see pages 81-82, here. 

Expand Money Follows the Person.  This proposal would extend this rebalancing demonstration program through FY 2020.  Currently, eligibility for Money Follows the Person (MFP) is based on institutionalization.  This proposal would allow these funds to prevent people from being institutionalized at all in some instances, reduce the existing institutional requirement to 60 days (from 90 days), and also allow skilled nursing facility stays to count toward this requirement.  The proposal would also allow for transitions to HCBS to those in certain mental health facilities.  For details, see page 91, here. 

Administration for Community Living

The budget proposal allocates $1.2 billion to the Administration for Community Living to assist seniors in independent and community living.  This includes $815 million in nutrition services.  In addition to the $1.2 billion, the budget proposal also includes $348 million for home and community based services for seniors.  For details, see page 121, here.  

Analysis

The Council supports continued efforts at rebalancing, as evidenced in this budget proposal, including proposals to expand PACE, MFP, and to provide HCBS to children eligible for psychiatric residential treatment facilities.  The Council also supports reasonable program integrity measures, and advises home care companies to strengthen their compliance efforts in light of this budget proposal’s financial incentives for MFCU investigations and prosecutions into home care.