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News Roundup: September 2, 2016

Home Health Agencies Prepare for Pre-Claim Review Chaos

Published by The National Law Review
By Bob Morgan
September 2, 2016

Government is predictable. It is even more so when it comes to federal healthcare agencies. For example, when one segment of healthcare enjoys surges in profits, the Centers for Medicare and Medicaid Services will intervene to adjust reimbursement. When one type of healthcare delivery system experiences outlier levels of fraud or noncompliance, the U.S. Department of Health & Human Services’ (HHS) Office of Inspector General (OIG) will ramp up enforcement mechanisms.

History is now repeating itself, as home health agencies (HHAs) are again coming under increased fire by HHS and their enforcers, Medicare administrative contractors (MACs). On June 8, 2016, and again on June 24, 2016, HHS gave notice about a “Pre-Claim Review Determination in five states” beginning in Illinois on August 1, 2016. This pre-claim review looks to be brutal. A review of the events that put HHAs in the crosshairs of the HHS enforcement apparatus can help providers prepare for the coming storm.

A Short History of Home Health Agency Regulation
HHAs are ubiquitous in the U.S. healthcare system and have been included in our current regulatory model since the dawn of Medicare (a.k.a. the passage of the Older Americans Act of 1965). There is no dispute that as the country’s population ages, the need for HHA services grows. As the needs grow, so do the program costs and the resulting impact on overall healthcare spending.

Over time, ever-increasing home health agency program costs drew regulatory attention. HHS began requiring supporting documentation to justify the need for homecare-based services. With the passage of the Affordable Care Act in 2010, a face-to-face (F2F) evaluation by a physician became a requirement for payment of services delivered to HHA-admitted patients. Although this requirement is easily understood and justifiable, the documentation has proven to be a moving target and has caused a significant amount of lost reimbursement and tension on the part of providers over the last five years.

HHA Admission Requirements Evolve
In general, Medicare Home Health Care Program participation requires that the patient:

1. Be temporarily or permanently homebound;

2. Have a need for skilled services;

3. Be under the care of a physician;

4. Receive services under a plan of care established and reviewed by a physician; and

5. Have a face-to-face encounter with a physician or allowed non-physician practitioner.

Predictably, each of these five requirements further establishes a number of additional conditions that HHAs must satisfy before CMS approves payment. Most recently, the challenge for HHAs has involved documentation: what must be documented, and by whom? The Affordable Care Act has further complicated this problem, and findings by the OIG in 2014, that 32 percent of F2F encounters were not documented sufficiently to prove compliance with Medicare standards, resulted in increased scrutiny of HHA billing.

Enter a Physician Narrative Requirement
From 2011 through the 2014 OIG investigative report, HHS required F2F documentation to include a physician narrative that provided “an explanation of why the clinical findings of such encounter support that the patient is homebound and in need of either intermittent skilled nursing services or therapy services.” (See 42 C.F.R. Sec. 424.22.) It should surprise no one that this generic request for a “physician narrative” justifying hundreds of millions of federal Medicare dollars would cause problems. CMS has used the narrative requirement to deny payments, and pressured HHAs to rally around template narrative language that increased the likelihood of reimbursement. This outcome benefited neither HHAs nor HHS and failed to help detect outright fraud or abuse.

Recent Changes: Simplification, or Exacerbating the Problem?
Beginning in 2015, HHS removed the physician narrative requirements, and instead developed a new standard. HHAs must now authenticate F2F evaluations through preexisting physician documentation such as progress notes, discharge summaries, and the like. Presumably, HHS increasingly viewed narratives as generating inauthentic clinical evaluations designed to substantiate home health services. HHS appears to have concluded that doctors would already have medical records that include the necessary substantiation. The government apparently saw the use of documentation that already exists as the fix for a problem that it had created in the first place. This is where Isaac Newton becomes our guide.

Newton’s Third Law
Newton’s brilliant observation — for every action there is an equal and opposite reaction — is proven true every day, particularly when it comes to government intervention. Actions by the government often create an equal and opposite reaction, especially in the healthcare industry. The cycle has become all-too familiar:

1. Government creates a new requirement for reimbursement.

2. Government creates a standard for verification of the requirement (expecting a sophisticated, diverse, highly regulated industry to adjust and comply).

3. Chaos ensues.

4. Industry reacts and attempts compliance by relying on the plain language of the regulations and guidelines, consulting with peers and industry groups, and working to educate and ensure compliance by staff and medical professionals.

5. In an effort to comply with the standards, providers start providing template language to their medical staff; in this case, for use in the F2F narrative.

6. Government becomes concerned about costs and isolated incidents of abuse, and begins to artificially restrict and recover government payments.

7. New regulations are introduced to streamline the previously problematic narrative requirements.

8. More ambiguity and confusion jeopardizes provider reimbursement and government compliance.

9. Chaos continues.

Lather. Rinse. Repeat.

Pre-Claim Review: A Pandora’s Box or an Actual Solution?
There is no doubt that this five-state pre-claim review will cause serious problems, as unanswered questions remain about the types of documentation and procedures that will satisfy HHS requirements. For example: How soon must HHAs authenticate supporting documentation after an F2F encounter? How may a provider ensure that non-employed physicians properly document the F2F encounter? Exactly how can a non-treating physician provide addenda to the medical record to satisfy a treating physician’s F2F encounter documentation requirements?

We have tried to contact government representatives and Medicare administrative contractors for assistance and clarification. True to form, the government staff believed that existing guidance was clear and that no further clarification was necessary.

All HHAs should be prepared for this new pre-claim review period. Consult with legal counsel, prepare your staff and physicians, and get ready for a bumpy ride.

Who Will Care For Us As We Age? New Research Raises Big Questions

Published by The Huffington Post
By Robert Espinoza
September 2, 2016

They help with dressing, bathing and eating, assisting older people and people with disabilities in their homes and in nursing homes—yet many live in poverty and without health insurance.

Who is this population? What are their economic realities? And will the supply of these workers meet growing demand as millions of Americans grow older in the decades that follow?

New research from PHI, the nation’s authority on the direct-care workforce, sheds light on this critical segment of the U.S. workforce. Released in conjunction with Labor Day, which commemorates the contributions of the American worker, this new data illuminates the realities of direct-care workers.

According to PHI, home care workers and nursing assistants in nursing homes fit a profile: the typical worker in these sectors is a woman, a person of color, and in her late 30s to mid-40s. Roughly a quarter of these workers are born outside of the United States and half lack formal education beyond high school.

While the number of nursing assistants has remained intact over the past 10 years, at a little over 600,000, the home care workforce has more than doubled to 2.2 million people in that time period, reflective of the demand spurred by the “greying of America” and the current older generation’s desire to age at home.

With growth comes profits. Home health care reaps $71 billion a year, while nursing homes generate $116 billion in annual revenue, most of which is covered by programs such as Medicare and Medicaid.

Unfortunately, these industries’ profits don’t trickle down. Twenty-four percent of home care workers and 17 percent of nursing assistants live in poverty. To survive, more than half of home care workers and nearly 40 percent of nursing assistants rely on some form of public assistance.

Wages are a major contributing factor to poverty: home care workers earned $10.11 an hour in 2015 and about $13,400 a year, as a result of working part-time hours and in some cases only part of the year. Similarly, nursing assistants earned $11.46 an hour and brought home an annual income of $19,000 in 2015.

Are these wages enough? Probably not. A housing report from May of this year found that a worker would need to earn $20.30 an hour to afford a decent two-bedroom apartment and not devote more than 30 percent of their income on housing costs.

In addition to low wages, about one in four home care workers and one in five nursing assistants are uninsured, though the Affordable Care Act (ACA) improved health coverage for many of these workers. (Among nursing assistants, health insurance rates increased by 11 percent between 2010 and 2014, largely as a result of expanded coverage made possible by the ACA. Similarly, health insurance rates went up 14 percent for home care workers.)

These job characteristics have repercussions for all of us: poor job quality turns away workers when we need it most. From 2014 to 2024, home care will add 633,000 new jobs, more than any other occupation. Unfortunately, labor force participation among women ages 25 to 64, who make up 73 percent of the home care workforce, will increase by only 2 million—a much smaller pool than the previous decade. Most alarming is that industry reports continually show high turnover rates among direct-care workers, often within a year, leaving for jobs with higher pay and better benefits.

We’re getting older as a country; people age 65 and older are expected to double from 48 million to 88 million between now and 2050. But who will care for us as we age? Where are all the workers going? These are the questions this new research raises. We need answers now.

Supporting home care

Published by Public Opinion
By Melanie Furlong
September 2, 2016

It is critically important for people – particularly decision-makers in Washington and Harrisburg – to recognize how home care services address the needs of our seniors and people with disabilities by enabling them to receive care, whether it is medical, personal or end-of-life care, in the comfort of their own homes.

That is why SpiriTrust Lutheran Home Care & Hospice is joining together with the Pennsylvania Homecare Association (PHA) and home care agencies across the state and country to participate in Bring the Vote Home, a national initiative designed to help seniors and people with disabilities register to vote or apply for an absentee ballot.

Bring the Vote Home will enable us to speak up this political campaign season and tell lawmakers what the home care community supports, such as efforts to reduce hospitalizations and increase funding for home and community-based services and chronic care management, and more importantly what we don’t, like cuts and inadequate reimbursement rates that limit access to Medicaid in-home care and co-pays for Medicare home health.

Pennsylvania’s home care community brings care and services into the homes of more than 575,000 seniors and people with disabilities – a number that is growing each year as people live longer. Home care is a lifeline, providing everything from medical care to assistance with activities of daily living like bathing and grooming. And now, home care will provide a voice to these patients and consumers, who have a lot to say!

As part of Bring the Vote Home, monthly public opinion polls are being conducted of registered voters age 65 and older. These polls measure senior sentiment on key political and policy issues. According to recent polling data, six in 10 seniors (59%) say they are more likely to support a candidate who opposes cuts to home health. The same number say they oppose co-payments on home health.

Home care has the ability to play a tremendous role in reducing care spending by caring for more people in a cost-effective manner at a fraction of the cost of other institutional settings. On behalf of the millions of our nation’s elderly who are thriving thanks to home care, I hope our lawmakers will safeguard these vital services as they make important decisions in Washington and Harrisburg.

Speaking for the clients we serve in their homes, I strongly urge our lawmakers to hear our voices and consider the unique value home care provides to beneficiaries – as well as the extensive savings it allows for the Medicare and Medicaid programs – and to support the home care population and the highly-trained professional care-giving teams like ours who are dedicated to treating our nation’s seniors in the security of their own homes.

Consider homecare, not a nursing home, for your aging loved ones

Published by Penn Live
By Vicki Hoak
September 2, 2016

Recently, there has been a lot of coverage in the Patriot-News and on about how nursing homes are "Failing the Frail"

While there are some instances when a nursing home is a viable option, in most cases people can receive care right in the comfort of their own homes.

Our parents and aging loved ones were and still are the pillars of our families and, as time inevitably marches on, they will turn to us for help with the very things they have given us: a safe place to live, three meals a day and basic care for personal well-being.

Many of us already face the challenge of trying to provide for our own family while taking care of our parents or grandparents.

It is a national dilemma more and more families are facing: Can my parents live at home safely? Is the only option left to move them into a nursing home? The answer is no.

Homecare providers can allow people to live safely at home. Home health agencies help people recover from surgery, recuperate from an illness or manage a chronic disease.

Homecare agencies help people who may need a little bit of help with basic daily tasks, such as bathing, dressing or cooking.

And hospices provide end-of-life care managed by an interdisciplinary team of physicians, nurses, aides, social workers and counselors...again in the privacy and comfort of one's own home.

The work that these in-home caregivers do is extremely personal.

They come into people's homes, in many cases where they started their lives or raised their children. They bathe and dress them alongside photos of their children and grandchildren.

They cover them with an afghan that has been passed down for generations in their family. They become part of a consumer's family. It takes a kind and devoted heart to be a caregiver in the home.

All of these organizations are licensed by the Department of Health and are surveyed by the state frequently, including outreach to consumers for their feedback and input.

Data shows that the number of substantiated complaints are significantly lower for care provided in the home than in nursing homes.

Only 13 of the 46 complaints made against Pennsylvania's approximately 500 home health agencies were substantiated; only 9 of the 24 complaints made against hospices were substantiated, and, perhaps most notably, only 20 of the 60 complaints made against Pennsylvania's 1,500 homecare agencies were substantiated.

As with any healthcare decision, families seeking homecare providers are, of course, encouraged to do their due diligence and research an agency before hiring them. Make sure they are licensed.

Ask for references. Learn about how they supervise and train their caregivers. And make sure the caregiver is a good fit for a parent or loved one. In-home caregivers provide such a lifeline, not only to the client but also to the client's family.

The Pennsylvania Homecare Association has resources available to give families a list of questions to ask a prospective agency. Our group also offers an online tool where people can search for quality caregivers near them.

By 2050, nearly 27 million people will require long-term care, and the majority will choose to receive care in their own homes. Not only does homecare provide solid results in the physical health of patients, it also promotes dignity and independence and enhances a patient's quality of life.

In Pennsylvania, we are lucky to have several options for caring for our older family members. Whenever possible, the first choice should be home.

Industry Groups Critique Home Health Reimbursement Changes

Published by Home Health Care News
By Amy Baxter
September 2, 2016

More home health payment cuts are coming, and home health care groups are fighting back against further proposals to change reimbursement measures. Most recently, industry groups shot back against the Home Health Prospective Payment System Rate Update for calendar year 2017, which had an open public comment period that ended August 26.

In conjunction with the recently-released payment proposal to lower home health payments by $180 million in 2017, the Medicare Payment Advisory Commission (MedPAC) proposed an overhaul of the current payment system for post-acute care settings, which would affect how much providers are paid each year from the Centers for Medicare & Medicaid Centers (CMS).

Much of the proposed new system aims to meet goals outlined in the IMPACT Act of 2014, including reducing health care costs, improving care management and shifting toward value-based purchasing. At the same time, MedPAC has recommended deeper cuts for home health reimbursements, citing that Medicare has overpaid for home health care since the prospective payment system was created in 2000.

Home health care groups have made their voices known that many of the proposed changes could have numerous negative impacts on home health beneficiaries and agencies.

The Case for No Cuts

The American Hospital Association (AHA), a group that includes approximately 1,100 hospital-based home health agencies, offered comments against some of the proposed changes that could take place in the next few years, including the outlier payment changes, which would require home health agencies to report services in 15-minutes units, rather than the total cost per visit.

AHA is concerned this change would give “equal weight to each 15-minute increment of care,” the group wrote in its comments. This could result in shorter visits receiving substantially less payment and leave out other costs associated to the care, including travel time.

“As such, we encourage CMS to refine the proposed policy to give greater weight to the initial 15-minute units to ensure such fixed costs are accurately reimbursed,” the AHA wrote.

The group also urged CMS to consider full reimbursement for partial 15-minute units to avoid a “reporting cliff,” where agencies would be incentivized to not provide care outside of 15-minute reporting intervals.

The AHA also expressed concern over performance-related Medicare cuts within the home health value-based purchasing demonstration, which places up to 8% of a home health agency’s payment at risk.

“The AHA believes placing up to 8% of home health agency payment at risk for performance is too much, too fast, especially in light of the significant Medicare payment reductions home health agencies have endured in recent years,” the AHA wrote.

The group is not the only one within the industry to believe the payment risks are too high, within the value-based purchasing demonstration and in other proposed changes.

The Alliance for Home Health Quality and Innovation, a membership-based non-profit organization comprised of not-for-profit and proprietary home health care providers, also recently commented on the proposed payment cuts for 2017, which they say threaten some of the most vulnerable Medicare patients, who may also tend to be minority populations.

“The rebasing and case mix adjustments that will result in home health payment rate reductions jeopardize access to quality care for patients who are in greatest need of protection,” The Alliance wrote in its comments. “Moreover, the rate reductions threaten the ability of home health providers to make necessary investments to provide better care for patients and the entire health care system.”

The group recommended that CMS rethink the impact that cuts could have on its home health population.

New Program Burdens

The Alliance also took aim with CMS’ recent pre-claim demonstration, which began in Illinois earlier this month. The group wrote that the new reimbursement model creates significant administrative burdens and hinders access to home health care, when care should be expanded instead.

“The pre-claim review demonstration, which CMS announced in June of this year, compounds the already complex process of delivering home health care and severely threatens patient access to care in the identified states (Illinois, Florida, Texas, Michigan, and Massachusetts),” The Alliance wrote. “The pre-claim review demonstration is a major concern for a growing population of Medicare beneficiaries who rely on home health care to provide high-quality care in their preferred home setting.”

Numerous industry groups stood up against the pre-claim demonstration, urging CMS to drop the measure over numerous concerns related to physician requirements and more.

The open comment period for home health agencies to submit comments on the prospective payment system changes closed on August 26. CMS has not yet released a final rule on home health reimbursement changes.

Campaigning to help make voting easier for patients

Published by Democrat & Chronicle
By Elizabeth Zicari
September 2, 2016

During this year’s presidential election season, we hear a lot about voter turnout, polls, and voter registration issues, but one important constituency demands attention: the 400,000 elderly, chronically ill, and persons with disabilities in New York state who receive home care services.

Many of these individuals are homebound, meaning they have difficulty getting to the polls on Election Day. Others have life-limiting illnesses or disabilities that hinder their access to election sites because of transportation issues or the incredibly taxing effort it takes to leave home — access issues that many of us take for granted.

But caregivers around New York are stepping in to help, including HCR Home Care. Our agency and colleagues are engaging in a new nationwide campaign called Bring The Vote Home. This campaign is delivering voter registration and ballot materials to thousands of home care patients as part of an outreach initiative designed to reach this unique and especially vulnerable population.

The premise is simple. Home care providers already deliver a range of medical, assistive and social services to patients in their own homes. HCR Home Care nurses, aides, social workers and other staff have daily contact with individuals in the community to administer medication, provide therapeutic support, monitor and treat chronic illnesses, and keep patients out of the hospital.

With the assistance and organizing work of our state’s home care association – which is handling the New York component of this national campaign — HCR Home Care is instructing our staff to deliver voter registration and absentee ballot forms to these patients, so they can vote from home during this year’s election rather than have to travel to the polls.

Medicare home health eligibility requirements state that a patient must be homebound, which means his or her ability to leave home is extremely restricted. Such is the case for many other home care patients, as well, including Medicaid enrollees or others receiving home care who may have a life-limiting disability and need this kind of support for their voice in the electoral process.

The Home Care Association of New York State has mailed over 10,000 voter packets to organizations like ours for this effort, and many other home care providers are printing and preparing their own packets to deliver to patients. This effort is just one additional way we can help the community. Home care providers already do the work of ensuring that a patient’s environment is safe (from the risk of falls or other dangers) and that patients have their nutritional, medical and social needs met. We also maintain a critical line of communication with patients’ families. These are among the countless tasks which come with the territory of helping patients at home.

If you have a friend or relative who has difficulty reaching the polls on Election Day, you can help too. Visit to find materials to assist a loved one, so they can vote from home and have a voice.