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News Roundup: October 14, 2016

Home Health Agencies Prep for Hurricane Matthew and Its Aftermath

Published by Home Health Care News
By Amy Baxter
October 14, 2016

In the wake of a final rule issuance on emergency preparedness from the Centers for Medicare & Medicaid Services (CMS), home health care companies were tested Friday as Hurricane Matthew barreled down on the United States.

The storm, which reached a Category 3 hurricane designation before weakening to category two, approached Central Florida on the Atlantic coast Friday, and was expected to impact nearly the entire East Coast of the country. Mandatory evacuations were reported in Florida, Georgia, North Carolina and South Carolina as winds topped 100 miles per hour and more than 1 million people lost power in Florida on Friday, according to the Weather Channel.

Several of the nation’s home health care companies were on alert as the storm approached, including Baton Rouge, Louisiana-based Amedisys Inc. (Nasdaq: AMED), which was recently impacted in Louisiana after torrential rain caused devastating flooding that took the life of the company’s founder and former CEO in August.

On Alert

Amedisys began getting ready for the hurricane earlier this week, beginning with daily preparedness calls with its leadership in Florida, Georgia and the Carolinas, Kendra Kimmons, managing director of marketing and communications, tells Home Health Care News. The nation’s second-largest home health care provider closed approximately 30 care centers in those three states.

“Amedisys has a very robust emergency preparedness plan,” Kimmons tells HHCN. “Each new hire is required to take disaster recovery training and then all employees take a required annual training on natural disasters. We also have a corporate emergency preparedness and recovery committee that works directly with regional and local leadership to implement our plans.”

Prior to the storm, the company began to follow plans to prepare and ensure patients and employees were ready.

“This includes making sure each care center reaches out to all of their patients to review and record specific hurricane/evacuation plans; patient education regarding medication needs; and [ensuring] that they have an adequate food and water supply, medical supplies and battery back-ups for medical devices. We also ensure the care centers have patients’ emergency contact information,” Kimmons says.

Once the hurricane reached the United States, Amedisys’ emergency preparedness and recovery committee started meeting twice per day, including through the weekend, to stay updated and begin recovery efforts, Kimmons says.

Similarly, another home health care giant, Lafayette, Louisiana-baed LHC Group Inc. (Nasdaq: LHCG) has closed offices in Ocala, Titusville and Cocoa Beach, Florida, and the company is monitoring the storm for further closures that might become necessary. The company is also ensuring it has contact with its patients and staff in affected areas.

“We have activated our emergency protocol and contacted all of our patients to make sure they have a way to evacuate—or have family members who can help them do so,” Chris Stagg, LHC Group’s division vice president, coastal division, tells HHCN. “We are making sure our patients have extra medications, oxygen tanks and anything else they might need. We are utilizing our mass notification system to stay in connect with staff in affected areas. We also made sure that all agencies had contact information for the emergency services and authorities in their area.”

Preparation is Key

Being ready to communicate with patients, knowing who to care for and knowing where patients are during an emergency are essential for home health care agencies.

“[The most important steps] are to ensure patients are covered, that agencies know how to communicate with patients, get patients evacuated or make arrangements for them with other health care providers,” Mary Carr, associate director for regulatory affairs at the National Association for Home Care & Hospice (NAHC), tells HHCN. “They also really need to go local with their preparedness to local organizations and leadership.”

Amedisys stayed in contact with its patients prior to and during the storm by calling them and reaching out with emergency information to ensure their safety and continuity of care. Staying in touch frequently also helps clinicians get to patients quickly once the storm has passed.

“During the storm, care centers call patients daily through the emergency contact information gathered before the storm to check on them,” Kimmons says of the procedure to stay in communication. “Immediately following the storm, once it is safe for our clinicians, the care centers go out to each patient’s home or evacuation point to check on them.”

At this point, Amedisys isn’t sure what steps it will take in terms of recovery, but is prepared to send fuel trucks so clinicians can get fuel without waiting in long lines to see patients. The company has also sourced hotel rooms for anyone who needs housing, as well as prepared to give financial assistance to any impacted employees and will send other supplies, including food and water, as needs arise, Kimmons says.

LHC Group has tapped into its technology to aid its communication and preparation.

“With the help of our IT department, we’ve implemented an emergency communication plan we call ‘office in a box,’” Stagg says. “This setup includes equipment that allows us to maintain connections with our patients and support staff. Each affected office receives a complete kit. This is shipped overnight and, if needed, we have someone in Pensacola who can drive the equipment to where it needs to be.”

The plan includes a fleet service to help staff get fuel after the storm; to locate all patients after the storm and ensure their safety; and working to restore full service capabilities as soon as its safe to do so, including working with neighboring agencies, Stagg says.

The hurricane underscores the importance of having emergency plans in place and knowing what to do to be prepared. Once CMS passes its final rule, home health care agencies will have to ensure they meet the new requirements, though they may already be familiar with many of the preparedness procedures.

“I think the rule will be hard work for agencies, but it’s necessary,” says Carr. “This brings the rule home. It’s not just a rule that’s meant to be a pain.”

Agencies Slam ‘Misleading’ Data on Illinois Pre-Claim

Published by Home Health Care News
By Amy Baxter
October 14, 2016

While providers in Illinois have been reporting numerous problems and sky-high non-affirmation rates for claims submitted under the Pre-Claim Review Demonstration, the Centers for Medicare & Medicaid Services (CMS) recently released data that appears to characterize the program as proceeding smoothly.

In fact, the data seem so optimistic, it’s hard for many to believe it tells the whole story of how the demonstration is rolling out in the Prairie State, and others called it flat out “misleading.” The data comes after the agency delayed implementing the demonstration in four other states—Florida, Texas, Massachusetts and Michigan—and lawmakers have attempted to delay the program by a year. PCRD has been ongoing in Illinois since August 3.

A Rosy Picture

Illinois home health agencies have reported high rejection rates for their submissions in addition to inconsistent reasons for non-affirmations. However, over the eight weeks that the demonstration has been ongoing in Illinois, 66% of pre-claim review requests were either provisionally afforded or partially affirmed, according to CMS.

The agency also said that the time it takes to submit documents dropped during the timeframe, from 12 minutes to 9 minutes, on average. Others disagree.

“The CMS data is highly misleading,” a review of the data from the National Association for Home Care & Hospice (NAHC) reads. “It does not include the extensive time needed to collect the documentation for submission, nor does it include the time is takes to review all that documentation for compliance. While CMS is correct in stating that HHAs have the responsibility to collect this documentation, its assemblage, review and submission is a new requirement under the demonstration project.”

Other reports, including a video of a HHA going through the process online, reveal submitting claims can take up to one hour rather than a few minutes. One Michigan-based home health care provider with a presence in Illinois, Residential Home Health, says submissions take roughly 45 minutes to hour.

“That’s a gross misrepresentation of all the pre-work that has to happen to organize everything in the documentation,” David Curtis, president of Residential Home Health, told Home Health Care News, speaking of the CMS data. “It’s like saying it only took two minutes to sign a tax return and put a stamp on it. But how long did it take to prepare the filing?”

CMS officials say the data shows an average, and the numbers may not represent what some home health agencies are experiencing.

“Because this is summary or average data, it will not reflect the experience of all home health agencies,” a CMS official told HHCN via email. “For example, an HHA that is having trouble complying with Medicare’s coverage and billing rules may experience much higher non-affirm rate.”

CMS also noted in the data that 99% of claims are returned with a response within the required timeframe. What the data doesn’t account for is the number of claims that home health agencies are holding back in order “to determine the outcome of a sample of their claims,” according to NAHC. In other words, the estimated 50,000 submitted pre-claims submitted to CMS thus far is only a fraction of what home health agencies will submit.

“That means that CMS has yet to come close to seeing the workload level that actually exists,” NAHC’s response reads.

Similarly, Residential Home Health has only submitted about 25% of its claims, according to Curtis.

“And I hear that is productive compared to my colleagues,” he said.

Another Illinois-based home health care agency, Better Care Home Health, has also withheld submitting all its pre-claims.

“We home health agencies have only submitted a fraction of our pre-claims,” Marvin Javallana, CEO and founder of the company, told HHCN. “We’re trying to learn, too. We’ve definitely submitted just a fraction of it.”

A Barrier to Care

Furthermore, NAHC disagrees with the affirmation rate CMS noted—66%—because this figure includes partial affirmations. In those cases, agencies will still have to resubmit the documentation for a full affirmation, which means the rejection rate is likely higher than 34%. Partial affirmations also increase administrative work and costs for agencies.

“The rejection rate is also higher than the reported 34%,” according to NAHC. “…A ‘partial affirmation’ is a partial denial. The financial impact of partial affirmations can be significant.”

Another industry group, the Illinois HomeCare & Hospice Council, agrees that the data may be misleading, or at least differ from what home health agencies are experiencing.

“We are in total agreement with NAHC’s response,” Sara Ratcliffe, executive director of the council, told HHCN. “We had reported to our Congressional delegation that what we were hearing was that the non-affirmation rate was between 60% and 80%. CMS looks at the number in a different way—they were taking into consideration partial affirmation as affirmations. But, if something is partially affirmed, it is partially non-affirmed. We count those as non-affirmations.”

While CMS points out that this 34% rejection rate is much lower than the national improper payment rate reported in 2015—59%—it’s too costly not to reimburse 34% of care, NAHC argues. Patients may be the ones to pay the price as home health agencies wait for their pre-claims to be affirmed or resubmitted.

“Medicare beneficiaries cannot withstand a 34% rejection rate,” the NAHC response says. “PCR is a direct barrier to care access.”

What’s worse is that the comparison to the national improper payment rate may not even be appropriate, like comparing the “proverbial apples to oranges,” according to NAHC.

And even if the pre-claim rejection rate were true, that still means many patients could be harmed in the delayed process.

“Even if the numbers are true, 34% rejection rate is still not good,” Ratcliffe said. “That’s one-third of business being denied. That’s not sustainable. What I would hope is that they delay this.”

Overall, the CMS data release is adding to the mounting frustration that providers are feeling with regard to pre-claim.

“It’s not in touch with reality,” Curtis said. “The most frustrating thing is that I don’t see how applying this financial and operational burden, and by applying the regulations to all providers, reduces fraud. It’s diverting resources that would otherwise go to patient care. If it needs to be put off in the other four states, what’s so special about Illinois to continue this burdensome regulation and cut off patient access to home care services?”

Reasons for Non-Affirmation

In addition to affirmation and non-affirmation rates, CMS provided data on the top four reasons for non-affirmation.

“There no consistency to non-affirmed reasons, and they give you compounded reasons,” Curtis told HHCN. “They aren’t consistent. This review process, particularly with face-to-face, is so subjective. The inter-rater reliability is not high.”

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The “compounded reasons” refers to the fact that many claims have more than one reason for non-affirmation—and sometimes all four reasons are listed. As a result, the data on reasons for non-affirmation may be less than helpful to home health agencies.

Furthermore, the data is not consistent with reports that “insufficient documentation” has resulted in a 94.8% error rate, according to NAHC.

“There’s a lot of confusion out there,” Ratcliffe said of the inconsistency. “I think the Palmetto reviewers are confused and what they are saying to providers is confusing.”

However, over the eight weeks the demonstration has been underway, Curtis says the responsiveness of CMS and the Medicare Administrative Contractors (MACs) has improved. Yet, they are not perfect by any stretch.

One issue has to do with the ability of MAC auditors to cite specific regulations in educational calls with providers, according to one administrator.

“When questioned specifically about the language within the CMS policies as to why a certain physician encounter or signed Plan of Care does not meet the requirements, several of the reviewers are unable to reference the exact policy and have quoted responses such as ‘based on how we were trained’ or ‘that is not my understanding,’ instead of a discussion and reference about the specific written regulations within Medicare policies,” said Nate Johnson, an administrator with Health Resource Solutions, an Illinois-based nursing and therapy agency.

CMS has said the agency is working with MACs to improve responsiveness, even proactively talking with agencies in Illinois that are experiencing especially high non-affirmation rates.

“CMS has directed the MACs to provide additional outreach and education to HHAs, including special outreach to HHAs with particularly low affirmation rates,” a CMS official said in an email. “This outreach includes proactive phone calls to the HHAs to walk through individual cases and help them understand why a particular case was non-affirmed and what they can do to get it affirmed.”

Several agencies have expressed that the physician signature requirement is one of the biggest challenges of the PCRD, and some agencies feel physicians should be more involved.

“The homebound rejection and the face-to-face rejection could significantly be reduced if we educate the physicians or the physicians have skin in the game,” Javellana said. “It doesn’t affect them. I feel that that’s a big factor. Why is the burden all on us at this moment?”

While CMS has pledged to better educate all health care providers about their responsibilities in the demonstration, only home health agencies will be penalized at this point.

“[CMS] has sent the physician’s letters, and that’s the extent of their education,” Javellana said. “We’re going out there now to try to educate the physicians. We’re taking that challenge ourselves.”

Residential Home Health’s Curtis is sympathetic to the huge task faced by the auditors, but thinks there are fundamental problems with some of the expectations related to pre-claim, particularly the physician signature hurdle.

“Everyone is trying to be more responsive and live up to the expectations of CMS,” Curtis said. “But the challenge is that in order to get paid by Medicare, Palmetto is asking us to submit the OASIS admission visit and therapy evals with all that paperwork signed by the certifying physician. That’s absolutely a new requirement. It’s out of the regs. It’s the biggest head scratcher I’ve seen in 15 years in the industry.”

As more data comes in, CMS plans to make it available.

“CMS is always looking for new and better ways to display the data and welcomes all suggestions,” CMS said. “Interested parties that wish to submit a suggested data format may do so by sending an email to”

Kindred, NAHC Say to Hit the Brakes on Bundled Payments

Published by Home Health Care News
By Tim Mullaney
October 14, 2016

The Centers for Medicare & Medicaid Services (CMS) is moving too quickly on bundled payments, according to some of the nation’s largest home health providers and industry associations.

In April 2016, the mandatory Comprehensive Care for Joint Replacement (CJR) demonstration got underway. Under this program, hospitals in selected geographic areas would be responsible for controlling costs for orthopedic patients from the time of surgery to 90 days after hospital discharge; the hospital would have to pay Medicare for costs exceeding a certain benchmark, but would receive an incentive payment for keeping costs below that threshold.

The model incentivizes hospitals to coordinate with home health agencies and potentially share financial rewards, and should theoretically help control costs while improving care. For these reasons, the move to bundled payments generally has garnered support from the home health industry. However, CMS’ move to expand mandatory bundled payments to heart conditions and femur fractures—announced through a proposed rule issued in July—is too aggressive, many stakeholders argue.

CMS should take more time to evaluate the CJR demonstration before implementing mandatory bundled payments for other conditions, according to public comments on the July proposed rule that were submitted last week by various organizations, including the National Association for Home Care & Hospice (NAHC), Kindred Healthcare (NYSE: KND), and the Alliance for Home Health Quality & Innovation (AHHQI).

“Although bundled payment models may work to create efficiencies in health care delivery they can also encourage negative behaviors by the entity(s) that bears the financial risk, such as stinting on care; a delicate balance that CMS has expressed concern over in both this proposed rule and with the initiation of the CJR model,” NAHC stated. “Therefore, it is perplexing why CMS would go forward with plans to create and test three new episode payment models that will impact a significant number of Medicare beneficiaries and health care providers without clear evidence of the effectiveness of these models.”

As part of this effort, CMS should implement a more robust compliance monitoring program that looks at claims data, cost reports, quality measures for all Medicare Part A and Part B providers, beneficiary complaints, and has a schedule for medical record audits, NAHC urged.

CMS has implemented various other bundled payment models and analyzed their results, but these models were not mandatory for providers to participate in, NAHC noted. This is a crucial distinction that supports the argument for a CJR-specific evaluation period, the association stated.

More Flexibility Needed

A similar message came from Louisville-based Kindred, the nation’s largest home health provider.

“As CMS continues to test new models and create new quality, payment, and regulatory changes across the health care spectrum, it is necessary that the agency ensure that the goals, timing, and incentives are harmonized to make sure they are not in conflict with other programs and achieve the objectives of higher quality and reduced spending,” wrote Kindred Executive Vice President of Strategy, Policy & Integrated Care Bill Altman.

In addition to delaying expansion of the mandatory bundled payment program, Kindred urged CMS be more flexible and risk-adjust target prices for bundles, improve data sharing and transparency to help with care coordination, and expand quality metrics and regulatory waivers so that patients can be seen in the most clinically appropriate and cost-effective setting.

Further echoing these sentiments, AHHQI expressed concern that not enough evidence has yet been collected on CJR to justify expanding mandatory bundles.

CMS also should consider waiving the requirement that patients be homebound in certain bundled payment scenarios, AHHQI wrote in its comments. For instance, if a beneficiary meets eligibility requirements at the start of a 60-day episode, but then improves to the point of no longer being homebound.

“For beneficiaries who have already received at least 5 episodes, if a patient is discharged prior to the 60 days, Medicare pays the full 60-day episode rate,” AHHQI Executive Director Teresa Lee wrote. “This waiver would simply enable the HHA to continue to provide services during the remainder of the 60-day episode to non-homebound beneficiaries so that care is not interrupted.”

Waiving the homebound requirement in circumstances such as these would help control costs while improving outcomes, such as by reducing the likelihood of hospital readmission, Lee wrote.

CMS received the message to hit the brakes not only in home health organizations’ comments but from groups across the continuum, including the American Hospital Association (AHA) and the American Health Care Association (AHCA).