CMS Updates Program Integrity Manual

CMS has issued change request (CR) 9065 that incorporates provisions in the final rule (CMS-6045-F) entitled “Medicare Program; Requirements of the Medicare Incentive Reward Program and Provider Enrollment” into chapter 15 of the Medicare Program Integrity Manual. CR 9065 also addresses several minor provider enrollment policy issues. The CR incorporates provisions that strengthen enrollment policies related to denials and revocations. CMS also includes several factors to be considered when determining if uncollected debt poses an undue risk of fraud, waste, or abuse. One key provision of the rule expands the reason for revocations related to abuse of billing privileges. If a provider or supplier show a pattern or practice of submitting claims that fail to meet Medicare requirements, their billing privileges could be revoked.

Click here to see CR 9065.

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CMS Releases Change Request Outlining Penalties For Hospice Agencies That Do Not Submit Required Quality Data

CMS has issued change request (CR) 9091, which addresses payment to hospice agencies that do not submit required quality data and outlines the penalties for failure to report. For fiscal year 2014, and each subsequent year, if a hospice agency does not submit required quality data, their payment rates for the year will be reduced by 2% for that fiscal year. The 2% reduction may result in an update that is less than 0.0 for a fiscal year and in payment rates for a fiscal year being less than such payment rates for the preceding fiscal year. Additionally, reporting-based reductions to the market basket increase factor will not be cumulative and will only apply for the fiscal year involved.

“For calendar year 2014, CMS considers Hospice Item Set data submitted by the hospices to CMS for reporting periods beginning on or after July 1, 2014, through December 31, 2014, as meeting the reporting requirements. For calendar year 2015 and subsequent years, CMS considers Hospice Item Set data submitted by the hospices to CMS for reporting periods beginning on or after January 1 through December 31 as meeting the reporting requirements for that year. Hospices that receive notification of Medicare certification on or after November 1 of the preceding year involved are excluded from any payment penalty for quality reporting purposes for the following fiscal year.” 

Click here to see CR 9091.

Click here for more information from NAHC.

New CBO Report Lowers Its Projection For ACA Implementation Cost

Once again, the Congressional Budget Office (CBO) has lowered its projection for the cost of implementing the Affordable Care Act (ACA). In a new report, the CBO estimates the cost of health insurance subsidies, Medicaid and Children’s Health Insurance Program (CHIP) outlays and small-employer tax credits at $648 billion for 2015 to 2019. However, once the number is subtracted from the $142 billion in payments to the government due to the individual mandate, employer mandate, and Cadillac tax, the cost of ACA implementation over the same time period comes to $506 billion – a 30 percent drop from the CBO’s initial projection of $710 billion.

The report cites three key factors for the lower estimate:

• Private insurers selling policies in the state and federal insurance exchanges that are charging lower premiums than expected.
• A projected decrease of 2 million in the expected number of Medicaid and CHIP enrollees by 2025.
• The historic low rate of healthcare spending growth.

Click here to see the report.

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New ACO Model May Have Positive Post-Acute Impact

Earlier today, we informed you about CMS’ new Next Generation ACO Model. According to CMS officials, the new model may be beneficial for those trying to offer the best post-acute setting for seniors, specifically for reducing hospital admissions. CMS officials say the model could have a very positive effect on the post-acute arena because it incentivizes providers to keep the person from being readmitted to the hospital. Instead, the model encourages providers to keep people in the skilled nursing facility until they are ready to go home. Furthermore, the program would let beneficiaries “enter skilled nursing care without prior hospitalization” and includes modifications “to expand the coverage of telehealth and post-discharge home services to support coordinated care at home.” These new rules would prevent beneficiaries from potentially falling into the observation stay trap, and avoid returning to the hospital after being discharged from a SNF.

Click here to read more.

CMS Announces “Next Generation” ACO Model

Yesterday, CMS  launched a new Accountable Care Organization (ACO) initiative known as the Next Generation ACO Model. The new model “builds on the successes of earlier ACO models, such as the Pioneer ACO Model, and further enables innovation by providers to improve care for patients.” The Next Generation ACO offers new opportunities in accountable care, setting more predictable financial targets, and gives providers and beneficiaries more opportunities to coordinate care. The Next Generation ACO Model will take on greater financial risk than those in current Medicare ACO initiatives, while also potentially sharing in a greater portion of savings. Additionally, the new model encourages greater coordination and closer care relationships between ACO providers/suppliers and beneficiaries by enhancing services that beneficiaries can receive from participating ACOs.

For more information on the Next Generation ACO Model, click here.

Click here to read more from CMS.

Senior Housing Prices Soared In 2014

In 2014, average per-unit prices in the assisted living market increased by 25 percent. Assisted living average unit prices hit a record $188,700 per unit and average per bed prices for nursing homes jumped 4 percent to $75,500, setting records in the industry for the second straight year. The average price for independent living communities also set a new record of $246,800 per unit, 28 percent higher than in 2013. The new prices came in a year that also saw record levels of mergers and acquisitions. In 2014, close to 300 mergers and acquisitions, representing approximately $26 billion, were announced in the senior housing market. As prices increased, cap rates, or the ratio of net operating income to property asset value, plunged last year, providing more cash flow for investments. Rates for assisted living and nursing homes also decreased.

Click here to read more.

Tiptastic Tuesday: 4 Ways To Tackle Healthcare Disparities

Significant care quality disparities due to race, income, gender, and sexual orientation continue to trouble the American healthcare system. For providers, the biggest challenge is pinpointing what to do about it. However, the Affordable Care Act, along with creative solutions at the community level have expanded coverage and care efforts. Experts offer four practices that can help in eliminating these disparities:

1. Develop health education tools that cater to different segments of the population.
2. Invest in translation and interpretation services for bilingual patients.
3. Use electronic health records (EHRs) to track and measure the health outcomes of patients, and use this information to design better treatments.
4. Partner with the community to foster outreach and care care.

Click here to read more.

CMS Extends Deadline For Long-Term & Post-Acute Care Health IT Survey

CMS is extending the deadline for its long-term and post-acute care (LTPAC) health IT survey. The survey applies to home health and hospice providers, and offers an opportunity to share the challenges and opportunities associated with health IT implementation. They survey period for the voluntary LTPAC EHR survey has been extended to April 3, 2015.

Click here to participate in the survey.

Click here to read more from NAHC.

Monday Morning Recap

The HMS Healthcare Management Solutions Monday Morning Recap reviews some of the top stories and healthcare highlights you may have missed last week.

• Home Health Care Planning and Improvement Act Reintroduced
• CMS Posts Proposed Revisions To The Hospice Cost Report For Hospital-Based Agencies
• CMS Report: Healthcare Industry Makes “Clear Progress” In Triple Aim Measures
• Attention Hospices: CMS Releases Spreadsheet, Instructions For Self-Calculation Of Aggregate Cap
• Study: Behavioral Therapy More Beneficial To Dementia Patients Than Drugs

Study: Behavioral Therapy More Beneficial To Dementia Patients Than Drugs

For caregivers serving those suffering from Alzheimer’s disease or other dementias, the biggest challenge is often coping with other behaviors common in dementia. Antipsychotic drugs to treat these symptoms has become increasingly common with approximately 1 in 3 dementia patients in nursing homes being prescribed them. Outside of nursing homes, 1 in 7 dementia patients are prescribed these drugs – all despite a warning from the Food and Drug Administration saying that antipsychotics increase the risk of death for people with dementia.

According to a recent study published in the British Medical Journal, antipsychotics are much less effective than non-drug treatments in controlling the symptoms of dementia. Researchers say the treatments that show the best results were ones that trained caregivers on how to communicate calmly and clearly, and those that introduced hobbies and other activities to the patient. Researchers believe caregiver interventions work because they train caregivers to look for the triggers of the symptoms. When a caregiver sees the triggers of the symptoms, they train patients on how to manage them.

Healthcare providers typically use antipsychotics because they have not been trained to use non-drug approaches and when they do know how to use them, they are rarely reimbursed for doing so by Medicare or private insurance.

Click here to read more.