Medicare Program Integrity
Accountable Care Organizations
Comprehensive Care for Joint Replacement
Value Based Purchasing
Face-to-face - Centers for Medicaid & Medicare Services
(CMS) issued a rule that requires an in-person consultation between a physician
and a patient no more than 90 days before the first home health services or no
later than 30 days after admission to home health. CMS imposed burdensome, duplicative, costly
and confusing documentation requirements that exceed the intent of the law
passed by Congress. The increased paperwork burden has created a disincentive
for physicians to recommend home health care. Congress should enact legislation
repealing or reforming this rule.
Pre-Claim Review - Centers for Medicaid & Medicare Services (CMS) has proposed a demonstration program for Medicare home health pre-claim review in 5 designated states: Florida, Texas, Illinois, Michigan, and Massachusetts. The proposal as described would implement a demonstration project to develop and test a Medicare pre-claim or prior authorization process for identifying and preventing fraud before home health claims could be submitted and processed. While the industry recognizes the need for intelligent policies to combat fraud, waste, and abuse – we are against policies that simply do not work and harm patients.There is a bill in Congress, the Pre-Claim Undermines Seniors' Health (PUSH) Act, that would impose a one year moratorium on the Pre-Claim Review Demonstration (PCR) and requires CMS to report to Congress on the impact of the project on patients, home health agencies, physicians, and Medicare spending.
HHPPS Rebasing - Under the CMS rate rebasing rule, CMS
concedes that at least 43% percent of home health agencies will be paid less
than their costs by 2017. Congress
should a) postpone implementation and require CMS to reevaluate the rule to
consider all usual and customary business costs, consistent with standards
under the Internal Revenue Code, telehealth services, all disciplines of
caregivers, and usual business operating expenses along with needs for
operating capital and operating margins; b) establish transparent and accurate
processes for modification of PPS payment rates and case-mix adjustments; and
c) ensure full market basket updates to Medicare home health payments.
Department of Labor Repeal of the Companionship Exemption -
In 2011 the Department of Labor issued guidance that reinterpreted and
effectively repealed Congress’ 1974 “companionship exemption” within the Fair
Labor Standards Act (FLSA). For the past
nearly 40 years, the exemption has meant that direct-care workers who met
certain criteria did not have to be subject to the same minimum wage and
overtime in the FLSA as other workers. A lawsuit contesting the DOL rule, led
by the national home care association and others, is pending in federal court.
Medicare Program Integrity - CMS contracts with for-profit
companies called RACs to audit and recoup improper payments from Medicare
providers; and ZPICs to prevent, detect and deter Medicare fraud. CMS and
Congress must undertake comprehensive reform of the audit processes to make it
more accurate, fair and transparent.
RACs and ZPICs frequently utilize questionable tactics, faulty data, and
sloppy processes resulting in a staggering number of recoupments and provider
appeals to the HHS Office of Medicare Hearings and Appeals (OMHA). Inappropriate payment denials leave home
health agencies with no other option but to appeal in order to receive payment
for medically necessary services they delivered to Medicare beneficiaries.
Accountable Care Organizations (ACOs) are groups of doctors,
hospitals, and other health care providers, who come together voluntarily to
give coordinated high quality care to their Medicare patients. TAHC&H works to educate home care
agencies on how to effectively participate in ACOs and does select outreach to
these organizations to promote the use of health care at home.
Comprehensive Care for Joint Replacement Payment Model -
This model tests bundled payment and quality measurement for an episode of care
associated with hip and knee replacements to encourage hospitals, physicians,
and post-acute care providers to work together to improve the quality and
coordination of care from the initial hospitalization through recovery.
TAHC&H submitted detailed comments and is working with our members and CMS
to ensure success for home care providers in this model.
Value Based Purchasing - As Congress considers legislation
to introduce Value Based Purchasing (VBP) in Medicare, lawmakers should work
closely with industry leaders to ensure that these payment reforms support
patient-centered care, access to home care services and utilize an “at-risk”
payment share that is commensurate with other health care industries (e.g. no
greater than 2%). VBP should base
at-risk payments on a small number of true clinical quality measures that
indicate patient health outcomes.