CMS Proposes New Face-to-Face Encounter Requirement

Good Morning MFS Bloggers, The following excerpt was taken directly from CMS's recently published proposed rule on the POC face-to-face physician encounter requirement:

"On March 23, 2010, the Patient Protection and Affordable Care Act (The Affordable Care Act) of 2010 (Pub. L., 111-148) was enacted. Section 6407 (a) (amended by section 10605) of The Affordable Care Act amends the requirements for physician certification of home health services contained in Sections 1814 (a)(2)(c) and 1835 (a)(2)(A) by requiring that, prior to making such certifications, the physician must document that the physician himself or herself or specified non-physician practitioner has had a face-to-face encounter (including through the use of telehealth, subject to the requirements in section 1834(m) of the Act), with the patient incident to the services involved.
Therefore, we propose revising §424.22 (a)(1)(v) such that for initial certifications, prior to a physician signing that certification and thus certifying a patient’s eligibility for the Medicare home health benefit, the physician responsible for certifying the patient for home health services must document that a face-to-face patient encounter (including through the use of telehealth if appropriate) has occurred no more than 30 days prior to the home health start of care date by himself or herself, or by an authorized non-physician practitioner (as specified in sections 1814(a)(2)(c) and 1835(a)(2)(A) of the Act) working in collaboration with or under the supervision of the certifying physician as described above.
Similarly, we prose to revise §424.22(a)(1)(v)(B) to reflect that if a home health patient has not seen the certifying physician or one of the specified non-physician practitioners as described above, in the 30 days prior to the home health episode start of care, the certifying physician or non-physician practitioner, would be required to have a face-to-face encounter (including the use of telehealth, subject to the requirements in section 1834(m) of the Act and subject to the list of Medicare telehealth services established in the most recent year’s physician fee schedule regulations) with the patient within two weeks after the start of the home health episode to comply with the requirements for payment under the Medicare program.
We propose implementing the above face-to-face patient encounters provisions as they relate to home health episodes beginning 01/01/2011 and later."

CMS PROPOSES PAYMENT CHANGES TO MEDICARE HOME

Good Morning MFS Bloggers, On Friday, July 16, 2010, the Centers for Medicare & Medicaid Services (CMS)announced a number of proposed changes to Medicare home health payments for 2011.

The proposed rule, on display in the Federal Register, represents a 4.75 percent decrease in Medicare payments to home health agencies (HHAs) for calendar year (CY) 2011. This is an estimated net decrease of $900 million compared to payments HHA’s received in CY 2010. It includes the combined effects of a market basket update, a wage index update, reductions to the home health prospective payment system (HH PPS) rates to account for increases in aggregate case-mix that are unrelated to underlying changes in patients' health status, and other provisions mandated by the Affordable Care Act (ACA) of 2010.

The ACA mandates that CMS apply a 1 percentage point reduction to the CY 2011 home health market basket amount, which equates to a proposed 1.4 percent update for HHA’s in CY 2011. CMS also proposes to further reduce HH PPS rates in CY 2011 to account for additional growth in aggregate case-mix that is unrelated to changes in patients' health status. Based on updated data analysis, instead of the planned 2.71 percent reduction for CY 2011, CMS proposes to reduce HH PPS rates by 3.79 percent in CY 2011 and an additional 3.79 percent in CY 2012.

The ACA also changes the existing home health outlier policy through a 5 percent reduction to HH PPS rates, with total outlier payments not to exceed 2.5 percent of the total payments estimated for a given year. HHAs are also permanently subject to a 10 percent agency-level cap on outlier payments.

2010 Office of Inspector General Work Plan: Home Health Agencies

Good Morning MFS Bloggers, I thought you would be interested in reading the areas of home health enforcement the Office of Inspector General will be taking a closer look at in the next year. I highly recommend each of you review your compliance programs to ensure these areas are addressed during your audits. The following text is taken directly from the OIG 2010 WorkPlan.

Part B Payments for Home Health Beneficiaries
We will review Part B payments for services and medical supplies provided to beneficiaries in home health episodes. Most services and nonroutine medical supplies furnished to Medicare beneficiaries during home health episodes are included in the HHA prospective payments. The Social Security Act, §§ 1832(a)(1) and 1842(b)(6)(F), require that in the case of home health services furnished under a plan of care of an HHA, payment for those services be made to the HHA, including payment for services and supplies provided under arrangements by outside suppliers. We will identify Part B payments made to outside suppliers for services and medical supplies that are included in the HHA prospective payment and examine the adequacy of controls established to prevent inappropriate Part B payments for services and medical supplies.

Home Health Agencies: Accurately Coding Claims for Medicare Home Health Resource Groups
We will review Medicare claims submitted by HHAs to determine the extent to which the billing codes for home health resource groups (HHRG) are used in determining whether payments to HHAs are accurate and supported by documentation in the medical record. The Social Security Act, § 1895, governs the payment basis and reimbursement for claims submitted by HHAs, including a case-mix adjustment using HHRGs. Medicare pays for home health episodes based on a PPS that categorizes beneficiaries into groups, referred to as HHRGs. Each HHRG has an assigned weight that affects the payment rate. We will assess the accuracy of HHRG assignment and identify patterns of miscoded HHRGs.

Medicare Home Health Payments for Insulin Injections
We will review the incidence of Medicare home health services outlier payments for insulin injections. Insulin is customarily self-injected by a patient or is injected by a family member. However, CMS’s “Medicare Benefit Policy Manual,” Pub. No. 100-02, ch. 7, § 40.1.2.4.A.2, states that when a patient is either physically or mentally unable to self-inject insulin and no other person is able and willing to inject the patient, the injections would be considered a reasonable and necessary skilled nursing service under the Medicare home health benefit. The unit of payment under the home health PPS is a national 60-day episode rate with applicable adjustments. The law requires the 60-day episode to include all covered home health services, including medical supplies. When beneficiaries experience an unusually high level of services in a 60-day period, Medicare systems will provide additional “outlier” payments to the episode payment. Outlier payments can result from medically necessary high utilization of home health services. CMS makes outlier payments when the cost of care exceeds a threshold dollar amount. We will also examine billing patterns in geographic areas with high rates of home health visits for insulin injections.

Home Health Agency Outlier Payments
We will review CMS’s methodology for calculating outlier payments to HHAs to determine whether the methodology reimburses HHAs as intended for high cost episodes. Pursuant to the Social Security Act, § 1895(b)(5), the HHS Secretary may provide outlier payments for episodes of care that incur unusually high costs. In recent years, outlier payments have significantly increased.

Home Health Prospective Payment System Controls
We will review compliance with various aspects of the home health PPS, including billings for the appropriate location of the services provided. Pursuant to the Social Security Act, § 1895, the home health PPS was implemented in October 2000. Since that time, total payments to HHAs have substantially increased from $8.5 billion in 2000 to $16.4 billion in 2008. We will also analyze various trends in HHA activities, including the number of claims submitted to Medicare, the number of visits provided to beneficiaries, arrangements with other facilities, and ownership information.

Home Health Agency Profitability
We will review cost report data to analyze HHA profitability trends under the home health PPS to determine whether the payment methodology should be adjusted. The Social Security Act, § 1895, added by the Balanced Budget Act of 1997 (BBA), § 4603, requires a PPS for home health services. Since the PPS was implemented in October 2000, HHA expenditures have significantly increased. We will examine various trends, including profitability trends in Medicare and the overall profitability trends for freestanding and hospital-based HHAs.

Medicare Home Health Payments for Diabetes Self-Management Training Services
We will review Medicare home health payments for diabetes self-management training services. Medicare covers diabetes self-management training services (DSMT) to educate beneficiaries in the successful self-management of diabetes. The Social Security Act, §§ 1861(s)(2)(S) and (qq), permits Medicare coverage of DSMT when these services are furnished by a certified provider who meets certain quality standards. Other conditions for coverage of DSMT are included in 42 CFR pt. 410, subpart H, which includes requirements for plans of care and physician certification. Services include instructions in self-monitoring of blood glucose, diet and exercise education, an insulin treatment plan, and motivation for patients to use the skills for self-management. We will examine billing patterns in geographic areas with high utilization of diabetes self-management training services.

Oversight of Home Health Agency Outcome and Assessment Information Set Data
We will review CMS’s oversight of Outcome and Assessment Information Set (OASIS) data submitted by Medicare-certified HHAs. Federal regulations at 42 CFR § 484.55 require HHAs to conduct accurate comprehensive patient assessments that include OASIS data items and submit the data to CMS. OASIS data reflect HHAs’ performance in assisting patients to regain or maintain their ability to function and perform activities of daily living. OASIS data also include measures of physical status and use of services, such as hospitalization or emergent care. CMS has used OASIS data for its HHA PPS since 2000; began posting OASIS-based quality performance information on its Home Health Compare Web site in fall 2003; and started a home health pay-for-performance demonstration based on OASIS data on January 1, 2008. We will review CMS’s process for ensuring that HHAs submit accurate and complete OASIS data.