ASAP
A Weekly Publication Of HCA Home Care Association of New York State
Legislative Issues Public Policy
News
Volume 20, No. 39 November 6, 2015
HCA Shares Quotes from Congress for National Home Care Month Social Media Campaign For National Home Care Month, in November, HCA is conducting a social-media campaign where we’ve asked Members of Congress to provide a quote about home care which we are posting to social media as infographics along with pictures. This week we got our first submission: from Rep. Lee Zeldin. (See image at right.) See CAMPAIGN p. 2
HCA Memo Summarizes Final 2016 HHPPS Rule for Home Care HCA this week shared a comprehensive memorandum on the recently finalized home health prospective payment system rule for 2016, issued by the U.S. Centers for Medicare and Medicaid Services (CMS). See MEMO p. 2
Inside ASAP
Court Upholds F2F Rule but Warns About Contractors “Second-Guessing” Physician Documentation A U.S. District Court Judge issued a decision this week on the Medicare Face-to-face (F2F) requirement lawsuit, ruling that the ambiguous nature of the underlying law (the Affordable Care Act) did not preclude the U.S. Centers for
HCA’s National Home Care Month Social Media Campaign...............1
See COURT p. 4
Memo Summarizes Final 2016 HHPPS Rule..........................................1 Court Upholds F2F..............................................................................1 Member Hiring Announcements..........................................................5 Deadlines for 2014 Statistical Reports Released.................................6 Register Now For LTHHCP Forum......................................................6 In Depth: More Details on Discharge Planning Rule............................7 HCA Completes Regional Meet-Ups.................................................8 Are You Ready to Join the Home Health Leadership Go-Team?.........8 Clarification Issued on Fiscal Intermediary Policy................................9 OMIG Posts Webinars on Compliance Elements................................9 FIDA for Intellectual and Developmental Disabilities Population.....10 August Medicaid Cap Report: Spending $4M Under Projections....11 CMS Posts Updates to CAHPS Hospice Survey Website..................11 OIG Releases 2016 Work Plan...........................................................12 NGS Education Programs..................................................................14 DSRIP Update...................................................................................14 Change in Submission of Transfer of Ownership Interest Notices...15
Helping New Yorkers Feel Right At Home
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MEMO from p. 1
CAMPAIGN from p. 1
Our memo provides a detailed narrative about the payment calculations for 2016, along with tables and appendices showing case-mix and wage index changes. It also summarizes several programmatic elements of the rule such as CMS’s value based purchasing pilot program in nine states (not including New York), home health quality reporting requirements, home health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) requirements and procedures, and more.
To make the most of this campaign, we ask that members: 1) visit HCA’s Facebook page, 2) “Like” the infographic (and, of course “Like” our page), and 2) share the infographic on your own social media pages. We are also posting the infographics to Twitter; so, we also ask that you take a moment to retweet the infographics on your personal or organizational Twitter pages as well. We’ll be posting these infographics throughout the month of November as we receive them, so please be sure to follow HCA’s social media pages to see what Members of Congress are saying about home care this month – an important way of connecting with key elected officials on the value of the work that you and your staff do.
HCA strongly urges all home care providers to review the memorandum for budgeting in 2016, if you are a Medicare-certified agency, and to understand the payment landscape for contracting purposes if you are a licensed agency or managed care plan who partners with Medicare-certified providers. You can read the memo on our Policy Memos page; but you must have a member account for HCA’s website to view it at http://hca-nys.org/category/ policy-memos. HCA members can get an account for our website by e-mailing HCA’s Communications Director Roger Noyes at rnoyes@hcanys.org.
Visit HCA’s Facebook page at https:// www.facebook.com/HCANYS/. Visit HCA’s Twitter Page at https:// twitter.com/HCANYS.
ASAP is a weekly publication of the Home Care Association of New York State (HCA). Unless otherwise noted, all articles appearing in ASAP are the property of the Home Care Association of New York State. Reuse of any content within this newsletter requires permission from HCA. President: Editor:
Joanne Cunningham, jcunningham@hcanys.org Roger L. Noyes, Director of Communications, rnoyes@hcanys.org Al Cardillo, Executive Vice President, Policy & Programs, acardillo@hcanys.org Patrick Conole, Vice President, Finance & Management, pconole@hcanys.org Andrew Koski, Vice President, Program Policy and Services, akoski@hcanys.org Alexandra Blais, Director of Public Policy, ablais@hcanys.org Laura Constable, Senior Director, Membership & Operations, lconstable@hcanys.org Celisia Street, Director of Education, cstreet@hcanys.org Mercedes Teague, Finance Manager, mteague@hcanys.org Jenny Kerbein, Director of Governance and Special Projects, jkerbein@hcanys.org Billi Hoen, Manager, Meeting and Events, bhoen@hcanys.org Teresa Brown, Administrative Assistant, tbrown@hcanys.org 388 Broadway, 4th Floor, Albany, NY 12207 Tele: 518-426-8764; Fax: 518-426-8788; Website www.hcanys.org
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COURT from p. 1 Medicare and Medicaid Services (CMS) from interpreting the word “document” as a basis for requiring a physician narrative. At issue in the lawsuit, filed by the National Association for Home Care and Hospice (NAHC), was the appropriateness of the F2F narrative requirement – a requirement which the Court essentially upheld in this week’s summary judgment. (The narrative part of F2F is no longer in effect, but the ruling still has implications for retrospective and/or appealed claims, as described later in this article.) As NAHC reported this week, if the language of the law underlying F2F (in this case, the Affordable Care Act) “is at all ambiguous, [then] the regulation is considered valid, unless the interpretation is unreasonable, arbitrary or capricious.” Judge Christopher R. Cooper found that CMS’s F2F interpretation (requiring a narrative) did not meet this test and, thus, the narrative is a “reasonable way to verify that an appropriate encounter actually took place.” But the judgment did suggest that Medicare cannot go beyond the narrative requirement and “second-guess the medical judgment of the patient’s physician” regarding the narrative’s content. Says NAHC: “That means that if the physician narrative presents patient clinical findings and explains why those findings support the need for home health services, the documentation requirement is met.” The following part of the ruling (as reported by NAHC) provides a potential avenue for agencies to contest claims denials in cases where a medical reviewer on behalf of CMS and the U.S. Department of Health and Human Services (HHS) made interpretations of medical necessity that go beyond the judgment and intent of the physician: Finally, it is important to note that this Court’s analysis would look very different if the rule allowed a Medicare claim reviewer to second-guess the medical judgment of a patient’s physician. For instance, if the rule authorized a reviewer to deny a claim—on the basis of insufficient documentation—simply because she disagreed with the physician’s clinical findings or the physician’s reasoning for why those clinical findings support a need for home-health services, that would go far beyond what the statute allows. HHS’s interpretive authority is limited to determining, within reason, how physicians should document that an appropriate face-to-face encounter actually took place—that is, that an encounter occurred that truly focused on determining whether a patient qualifies for home-health services. In making that determination, HHS chose to require physicians to describe their clinical findings and explain why those findings support the need for home-health services. In the Court’s view, the rule requires only that. To the extent HHS may have veered from that requirement in practice, home-care organizations that have been denied reimbursement on the basis of insufficient documentation are free to contest HHS’s implementation of its rule on a case-by-case basis [emphasis added].
NAHC’s lawsuit takes aim at the F2F narrative requirement which is no longer in effect; nevertheless, ongoing issues with physician narratives could still be the basis for retrospective denials. NAHC also continued to press its arguments against the narrative requirement to provide an avenue for recovery of past claims which were previously denied on the basis of insufficient narratives, in the eyes of medical reviewers deciding claims on behalf of Medicare. Continued on next page 4
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Continued from p. 4 HCA members are urged to consult with their legal counsel about the wording of Judge Cooper’s opinion (available at http://hca-nys.org/wpcontent/uploads/2015/11/ SJDecision.pdf ) to consider any decisions about appeals for claims that may be supported by the language cited on page 4. Meanwhile, NAHC is considering the next steps in its legal strategy and expects the introduction of legislation in Congress on a F2F fix. As reported in last week’s ASAP, HCA and partner associations from the physician and hospital communities have also met to discuss a proposed HCA and member-developed addendum for providers to use when documenting Medicare F2F. The purpose of this effort is to create a single, streamlined, consolidated form for compliance, and it accompanies HCA’s legislative advocacy to reform F2F by allowing for certification of F2F documentation on the 485/plan-of-care. HCA will keep the membership further apprised of advocacy developments in this area.
HIRING Patient Relations Manager Americare, New York’s leader in home health care, seeks a high energy, dynamic, selfstarter for an exciting career opportunity in its patient relations department. The Patient Relations Manager’s primary responsibility will be to develop relationships and educate MDs about home care and the benefits to their patients. The ideal candidate will have 2-3 years home care or pharmaceutical experience. An excellent compensation and benefits package is offered, including: 401K with company match, medical, dental and direct deposit. E-mail résumé to hrrecruiter@americareny.com. www.americareny.com. EOE Jefferson County Public Health Service Director of Patient Services is responsible for the administrative, professional and financial operations of the home health programs. Minimum qualifications include licensed and currently registered nurse with two years of experience as a Supervising Public Health Nurse; or two years of home care nursing experience plus a master’s degree in nursing, public health, business administration or another health related field. Master’s degree preferred. Applications Accepted At: Jefferson County Department of Human Resources, 175 Arsenal Street, Watertown, NY 13601; (315)-785-3147. EOE. http://www.co.jefferson.ny.us
For more information, please contact a member of the HCA Policy staff. 5
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Deadlines for 2014 Statistical Reports Released The state Department of Health (DOH) has posted a Dear Administrator Letter (DAL) to the Health Commerce System (HCS) announcing the schedules for submitting 2014 annual statistical reports for CHHAs, LTHHCPs, and LHCSAs and the Hospice Cost and Utilization Report. Statistical Report
Start Date
Due Date
CHHA/LTHHCP Statistical Report
11/16/15
1/11/16
LHCSA Statistical Report
12/14/15
2/8/16
Hospice Cost and Utilization Report
12/14/15
2/8/16
The DAL includes instructions for finding the surveys on HCS and submitting data to DOH. As was done with the last request for statistical information, a separate statistical report will be used to collect data from LHCSAs exclusively providing services to Assisted Living Program (ALP) residents. Individuals assigned to the Administrator, Director of Patient Services, HCS Coordinator and Data Reporter roles in the HCS Communications Directory may enter data into a statistical report. Only an Administrator may submit data. According to DOH, agencies not submitting all appropriate forms for these required surveys will be cited and subject to enforcement action, and Certificate of Need and licensure applications of delinquent agencies will not be processed. Questions and requests for assistance should be sent to HCStatRpts@health.state.ny.us.
Register Now For LTHHCP Forum One Week From Today HCA’s LTHHCP Forum is coming up one week from today, on November 13 in Albany, and we wanted to make sure LTHHCPs had a chance to register for this members-only program which focuses squarely on the issues affecting you, your program and your staff. The Forum will provide key updates from HCA on our recent meetings with the state Department of Health on the status of the LTHHCP as well as FIDA, MLTC Plus and other managed care policy developments; soon-expected regulatory changes for the time-frame of physician orders; a new federal proposed rule on discharge planning (see related p. 7 story); and results of HCA’s survey of LTHHCP providers. Importantly, we also want to hear from you about your concerns, issues and planning for your LTHHCP, so that HCA can advocate on your behalf. In the afternoon portion of the session, we’ll have representatives from the state’s Divisions of Home and Community Based Services and Long Term Care providing you with program and regulatory updates, and we’ll close the program with a focus on strategic planning for the future and follow-up on behalf of the LTHHCP. Continued on next page 6
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Continued from p. 6 Don’t miss this critical opportunity for engagement. If you are an LTHHCP, you will not want to miss this important program for your organization. Download our Member Forum registration at the link below, select the “LTHHCP Forum,” and send in your registration today! Register for the Forum here: http://hca-nys.org/wp-content/uploads/2015/09/HCA-Combined-ForumRegistration-Form-2015.pdf.
In Depth: More Details on Discharge Planning Rule As reported in last week’s ASAP, the U.S. Centers for Medicare and Medicaid Services (CMS) released a proposed rule on October 29 that would modify the Improving Medicare Post-Acute Care Transformation Act of 2014 (IMPACT Act) and related requirements for discharge planning by various types of hospitals, facilities, and home health agencies (HHAs). The proposed rule would update HHA discharge planning requirements, specifically, by requiring more preparation of patients and caregivers to actively participate in self-care, and by improving transitions from one type of care to another to provide continuity of care. HHAs would need to create and implement a discharge planning process that: effectively engages patients and caregivers in post-discharge care and plans; ensures a successful transition of care; and reduces factors that lead to otherwise preventable readmissions. The proposal would require that the HHA ensure the identification and inclusion of the individual patient’s goals, preferences and needs in each discharge plan. Also, the HHA should regularly reevaluate and update the plan to reflect any changes. It would also require the assessment of the patient’s caregiver/support person status and that individual’s ability to perform any identified care at home, and then the incorporation of that capacity and need in the discharge plan. Additionally, the proposal would require that the physician responsible for the home health plan of care be involved, on an ongoing basis, in the discharge planning process. HHAs would have to utilize and share data about post-acute care providers with patients and caregivers as part of the process when discharging patients to a post-acute setting. The HHA should provide the data on quality and resource use (for example, by using the Nursing Home Compare website until the measures stipulated in the IMPACT Act are finalized) and use that information in discussion with the patient and caregiver as it relates to the patient’s goals and treatment preferences. HCA will be seeking more information on this requirement to learn the extent of the HHA’s responsibilities and liabilities. The proposed rule also includes a timeliness requirement, indicating that HHAs should begin the process early enough so that all appropriate discussions and arrangements are made prior to transfer or discharge; but CMS does not establish specific timeframes for this to be accomplished, leaving it to HHAs to establish them internally. Regarding the discharge/transfer summary content, the HHA would be required to include, minimally, the patient’s demographic information, referring physician contact information, advance directive, course of illness/treatment, procedures, diagnoses, laboratory and other diagnostic test results, consultation results, functional status assessment, psychosocial assessment social supports, behavioral health issues, medication reconciliation, all known allergies, immunizations, smoking status, vital signs, and unique device identifier(s) 7
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for any implantable devices, any guidance for ongoing care, patient’s goals and treatment preferences, current plan of care, and more. In order to comply with the proposed requirements, CMS estimates the startup cost to be $2,816 for each HHA or $34 million for all HHAs. CMS also estimates that each HHA will incur annual costs of $24,000. A future HCA story will focus on changes to the discharge planning process for hospitals that also affect home care providers including a requirement that hospitals provide patients with quality and resource use information to help their patients choose a post-acute provider. HCA continues to review the rule to identify any concerns with protocols or the potential overall cost impacts. For more information, contact Alex Blais at ablais@hcanys.org or (518) 810-0658.
HCA Completes Regional Meet-Ups HCA finished our regional member Meet-Up tour where we came to five areas of Upstate and Downstate New York to discuss with members your issues and concerns about local payment and regulatory issues. The meetings (in Rochester, Utica, Brookhaven, New York City and Tarrytown) also provided an opportunity to hear more about your efforts to work with regional Delivery System Reform Incentive Payment (DSRIP) programs so that we can advocate on your behalf to assure a meaningful seat at the table in these developing regional provider networks. For more information, please contact a member of HCA’s Policy staff.
Are You Ready to Join the Home Health Leadership Go-Team? As a leader in home care, you are charged with piloting uncharted terrain in a rapidly unfolding health care delivery and payment environment. Value-based purchasing, federal star ratings, bundled payments and regulatory changes dot the landscape with potential pitfalls creating what seems like an impossible operation. The 14th Annual Northeast Home Health Leadership Summit in Boston on January 19-21 has gathered intelligence from across the country to offer you the inspiration, strategies, insights and tools you need to make this mission ... POSSIBLE! ‘Mission: Possible’ Agents & Training Highlights •
Sharing insights and lessons learned through her experience as a first-responder at the Boston marathon bombing, Dr. Natalie Stavas, named 2013 Bostonian of the Year by The Boston Globe, will teach you how to flex your leadership muscles by running towards chaos.
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Robert Fazzi, PhD and Tim Ashe, MS, MBA from Fazzi Associates will guide you on successfully navigating the inevitable changes in health care and what these changes mean to every agency in the country. Continued on next page 8
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Continued from p.8 •
Armed with findings of the American Hospital Association’s soon-to-be-released report on the operational and policy changes facing the post-acute care marketplace, Rochelle M. Archuleta, MSHA, MBA will provide attendees with a national road map for acute/post-acute collaboration.
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Grammy-nominated musician Angus Clark of Song Division will lead the final mission on creating a culture of innovation through his interactive session demonstrating how to cultivate group cohesiveness and productivity in your agency to innovate and succeed.
For full mission details, or to sign up and join the home health leadership go-team, visit www.nehomehealthsummit.com. There you can find hotel information, a full brochure, online registration and a list of the conference sponsors. This program is sponsored by a consortium of nine state home care associations, including HCA, which is event coordinator for the Summit. Members of HCA and other partner state associations get a special member discount. There’s also an early registration discount for those who commit by December 18, so please register today.
Clarification Issued on Fiscal Intermediary Policy This week, the state Department of Health (DOH) posted a follow-up to an earlier guidance (MLTC Policy 15.05) to clarify that entities that want to provide fiscal intermediary (FI) services for managed care enrollees don’t need another Medicaid provider number if they already have one. The new instructions are at http://www.health.ny.gov/health_care/medicaid/redesign/docs/mltc_policy_1505a.pdf and the prior guidance is at http://www.health.ny.gov/health_care/medicaid/redesign/ mltc_policy_15-05.htm. HCA thanks DOH for issuing this clarification, as we have been requesting this for some time to address requests from managed care plans to home care agencies that they obtain another distinct Medicaid provider number in order to provide FI services to consumers receiving Consumer Directed Personal Assistance Services (CDPAS). HCA members who want to provide FI services should still review the other applicable requirements in MLTC Policy 15.05, including meeting the requirements in 18 NYCRR 505.28; and signing an Administrative Agreement with the health plan. For more information, contact Andrew Koski at (518) 810-0662 or akoski@hcanys.org.
OMIG Posts Webinars on Compliance Elements This week, the state Office of the Medicaid Inspector General (OMIG) posted a nine-part series on New York’s mandatory compliance program obligation. The first in the series outlines the eight elements required of mandatory compliance programs, identifies who is required to have a compliance program, and details the areas of a Medicaid provider’s operations to which compliance programs must apply. The next eight individual webinars (Webinar Nos. 27 through 34) are each 9
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dedicated to one of the eight elements required of Medicaid providers’ mandatory compliance programs. The webinars identify a specific compliance element’s statutory and regulatory requirements, outline what OMIG’s Bureau of Compliance looks for when it assesses a Medicaid provider’s compliance program, and details compliance-related tools and resources available on OMIG’s website to assist providers in meeting the mandatory compliance obligations. The webinar series is available on OMIG’s website at https://www.omig.ny.gov/resources/webinars. In December, OMIG will publish Frequently Asked Questions (FAQs) raised in reference to the webinar series. Questions submitted to OMIG by November 25, 2015 will be included in the December FAQs. Additional information about the FAQs, including instructions for submitting questions, is included in each webinar material.
FIDA Plan Announced for Individuals with Intellectual and Developmental Disabilities The U.S. Centers for Medicare and Medicaid Services (CMS) and the state Department of Health have announced the roll out of a new Fully Integrated Duals Advantage (FIDA) plan for individuals with intellectual and developmental disabilities (called FIDA-IDD). It will be offered by Partners Health Plan to about 20,000 Medicare/Medicaid enrollees in New York City, Long Island, Rockland and Westchester on a voluntary basis and will begin no sooner than April 1, 2016. Some differences from the existing FIDA program are that there will be no “passive” enrollment under FIDA-IDD and the benefit package will be geared to individuals with intellectual and developmental disabilities. According to CMS, this new demonstration includes care coordination, performance metrics, continuityof-care requirements, and an external evaluation. A Frequently Asked Questions (FAQs) document posted by the state Office for People With Developmental Disabilities (OPWDD) is at http://www.opwdd.ny.gov/node/6241. It describes who can join a FIDA-IDD plan; who is not eligible to enroll; covered services; enrollment and disenrollment periods. More information, including a link to the Memorandum of Understanding between CMS and New York, is at https://www.cms.gov/Newsroom/MediaReleaseDatabase/Press-releases/2015-Press-releasesitems/2015-11-05.html. The announcement of FIDA-IDD comes at the same time that the state’s FIDA plan faces low enrollment and the withdrawal of some plans, and when the state has proposed changes to FIDA to address identified concerns, and to offer the MLTC Plus initiative. This would expand benefit packages for selected MLTC partial capitation plans and enhance provider coordination through targeted incentive payments and new care management protocols.
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August Medicaid Global Cap Report: Spending $4M Under Projections The state Department of Health (DOH) has issued its monthly Medicaid Global Cap report. This latest report, for August, covers the period of April 1 to August 31, 2015. It finds that overall spending for this period was $4 million below Medicaid Global Cap projections, across all sectors, a difference of $7.663 billion in actual spending versus $7.667 billion in estimated spending for the five-month period. The category that includes home care (“Other Long Term Care”) was $24 million over projections, a difference between actual spending of $291 million versus projected spending of $267 million “as a result of more recipients billed than anticipated in personal care, 4.2 percent. This likely reflects a slower than expected transition to Long Term Managed Care,” according to the report. Medicaid Managed Care was $45 million over projections, a difference of $5.114 billion (actual spending) versus $5.069 billion (estimated spending). The report refers to “slightly higher than expected billed claims through August, which appears to be timing related” under Mainstream Managed Care, which was $30 million over projections. The MLTC category was also above projections by $15 million due to higher than expected enrollment in the partial capitation program. The full report is at http://www.health.ny.gov/health_care/medicaid/regulations/global_cap/monthly/ sfy_2015-2016/docs/august_2015_report.pdf. HCA is surveying these reports carefully in an information gathering effort, combined with other data analysis, related to home care’s performance under the Global Cap. The Medicaid Global Cap for the current fiscal year (April 1, 2015 to March 31, 2016) is $17.7 billion for all sectors. For further information, contact Patrick Conole at (518) 810-0661 or pconole@hcanys.org.
CMS Posts Updates to CAHPS Hospice Survey Website The U.S. Centers for Medicare and Medicaid Services (CMS) has recently posted the following updates to the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey website at: http://www.hospicecahpssurvey.org/Content/WhatsNew.aspx CAHPS Hospice Survey Quality Assurance Plans Submission Deadline The deadline for survey vendors to submit their CAHPS Hospice Survey Quality Assurance Plan (QAP) was November 3, 2015. Survey vendors are responsible for meeting this deadline as a condition of approval. CAHPS Hospice Survey Quarter 2 2015 Data Submission Deadline Approaching The deadline for survey vendors to submit CAHPS Hospice Survey Quarter 2 2015 (patient deaths in April, May and June 2015) data is November 11, 2015. Survey vendors are responsible for successfully submitting
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files by 11:59 p.m. on November 11, 2015. As a reminder, the XML File Specification V1.3 must be used for the November 11, 2015 data submission. CAHPS Hospice Survey Quality Assurance Guidelines Version 2.0 Summary of Updates and Emphasis Now Available The CAHPS Hospice Survey Project Team has posted the CAHPS Hospice Survey Quality Assurance Guidelines Version 2.0 Summary of Updates and Emphasis document. This document is a reference tool that highlights the major changes from the CAHPS Hospice Survey Quality Assurance Guidelines Version 1.0 to Version 2.0. Survey Instruments Page Updated The CAHPS Hospice Survey Project Team has released translations of the CAHPS Hospice Survey mail materials in Russian and Portuguese. In addition, updated versions for all existing translations of the CAHPS Hospice Survey mail and telephone materials have been posted. Revisions to survey materials and CATI scripts must be implemented with survey administration beginning January 2016. CAHPS Hospice Survey Fact Sheet Updated The CAHPS Hospice Survey Fact Sheet has been updated to reflect the September 2015 release of the CAHPS Hospice Survey Quality Assurance Guidelines Version 2.0. For further information, contact the HCA Policy staff.
OIG Releases 2016 Work Plan The U.S. Office of Inspector General (OIG) has released its 2016 Work Plan at http://oig.hhs.gov/reports-and-publications/archives/workplan/2016/oig-work-plan-2016.pdf. The report describes OIG audits, evaluations, and certain legal and investigative initiatives that are continuing. This edition also forecasts areas for which OIG anticipates planning and/or beginning work. In fiscal year (FY) 2016 and beyond, OIG will expand its focus on delivery system reform and the effectiveness of alternate payment models, coordinated care programs, and value-based purchasing. Future planning efforts for FY 2016 and beyond will also include: additional oversight of hospice care, including oversight of certification surveys and hospice-worker licensure requirements. The following areas will be reviewed in 2016. Medicare Home Health •
Compliance with various aspects of the home health prospective payment system (HHPPS), including documentation required in support of the claims paid by Medicare. Continued on next page
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The extent and way in which the U.S. Centers for Medicare and Medicaid Services (CMS) and its contractors have implemented enhanced screening procedures for Medicare providers pursuant to the ACA.
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Extent to which providers participating in Accountable Care Organizations (ACOs) use electronic health records (EHRs) to exchange health information to achieve their care coordination goals and assess providers’ use of EHRs to identify best practices and possible challenges to the exchange and use of health data, such as degree of interoperability, financial barriers, or information blocking.
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CMS’s early management of ICD-10 codes in Medicare Parts A and B.
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Medical record documentation to ensure that it supports the diagnoses that Medicare Advantage (MA) organizations submitted to CMS for use in CMS’s risk-score calculations and determine whether the diagnoses submitted complied with federal requirements.
Medicaid Home Health Services and Other Community-Based Care •
Medicaid payments by states for adult day care services to determine whether providers complied with federal and state requirements.
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A determination of whether selected states claimed federal reimbursement for unallowable room-and-board costs for community-based services waiver programs.
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Expenditures the states claimed under the Balancing Incentive Program (BIP) to ensure that they were for eligible services and in accordance with the Affordable Care Act (ACA).
Hospice •
Use of the general inpatient care level of the Medicare hospice benefit, including assessing the appropriateness of hospices’ general inpatient care claims and the content of election statements for hospice beneficiaries who receive general inpatient care; reviewing hospice medical records to address concerns that this level of hospice care is being billed when not medically necessary; and checking beneficiaries’ plans of care to determine whether they meet key requirements.
State Program Integrity Activities •
Determine the extent to which states collect required ownership information for provider entities enrolled in Medicare and Medicaid, as well the extent to which they verify the collected information and whether states and CMS checked exclusions databases for enrolling and enrolled providers.
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Whether states are conducting enhanced screenings that assess risk for fraud, waste, and abuse for moderate- and high-risk enrolling and revalidating Medicaid providers and suppliers.
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Payments to providers with allegations of fraud deemed credible by states and states’ use of payment suspensions.
Other Providers and Areas •
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Outpatient physical therapy services provided by independent therapists to determine compliance with Medicare reimbursement regulations. Medicare payments to physicians for evaluation and management home visits to determine if they were reasonable and made in accordance with Medicare requirements.
Medicaid Managed Care • 13
States’ managed care plan reimbursements to determine whether managed care organizations
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(MCOs) are appropriately and correctly reimbursed for services provided and to ensure that the data used to set rates are reliable and include only costs for services covered under the state plan. •
States’ reimbursements made to MLTC plans to determine whether those reimbursements complied with certain federal and state requirements.
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Determine whether Medicaid MCOs identified and addressed incidents of potential fraud and also describe how states oversee MCOs’ efforts to identify and address fraud and abuse.
NGS Education Programs National Government Services (NGS), New York’s Medicare Administrative Contractor (MAC), has recently posted the following educational webinars. Home Health Billing Basics (Tuesday, November 17, from 2 to 3:30 p.m.) This webinar will provide information on billing the home health request for anticipated payment (RAP) and final episode claim. This is a good opportunity for new billers to become familiar with basic billing practices. Registration is at: https://attendee.gotowebinar.com/register/109838281280932097. Home Health Notices: ABN/HHCCN/NONMC (Tuesday, November 24, from 2 to 3 p.m.) This webinar will discuss the Advance Beneficiary Notice of Noncoverage (ABN), Home Health Change of Care Notice (HHCCN) and Notice of Medicare Non-coverage (NONMC) and when each form should be issued to a home health patient. Attendees will be provided with resources and references and a question and answer period will follow this session. Registration is at: https://attendee.gotowebinar.com/register/ 7892578508407579649. Certifying Home Health Care (Monday, December 7, from 12:30 to 2 p.m.) This webinar is designed to provide a greater understanding of patient/beneficiary eligibility, face-to-face encounters and certification requirements as per the 2015 Medicare home health benefit regulations. Registration is at: https://attendee.gotowebinar.com/register/746323570929656065. For further information, contact Patrick Conole at (518) 810-0661 or pconole@hcanys.org.
DSRIP Update The state Department of Health (DOH) has announced its latest video, “Value Based Payments (VBP): An Introduction.” The video gives an overview of what value based payments are, its important role in the state Medicaid program, and how it will help to improve patient outcomes. The video can be viewed at: https://youtu.be/94X7og_56XM. More information on VBP can be found at http://www.health.ny.gov/health_care/medicaid/redesign/dsrip/vbp_reform.htm. Any questions may be directed to dsrip@health.ny.gov. 14
Volume 20, No. 39 November 6, 2015
ASAP – a publication of the Home Care Association of New York State
Change in Submission of Transfer of Ownership Interest Notices As the state Department of Health (DOH) transitions from paper forms to electronic submission for health care facility and agency licensure applications and notices, the next step is the electronic submission of Transfer of Ownership Interest Notices (also known as 90-Day / 120-Day Notices). Effective November 4, 2015, the Department no longer accepts paper submissions for these notices which must be submitted via the New York State Electronic Certificate of Need (NYSE-CON) system. To do so, you must have a Health Commerce System (HCS) account. For information on obtaining an HCS account, go to http://www.health.ny.gov/facilities/cons/nysecon/ public_authenticated_frequently_asked_questions.htm. Transfer of Ownership Interest Notice submissions will be similar to Certificate of Need application submissions. The required form can be found near the bottom of the following website: http:// www.health.ny.gov/facilities/cons/more_information/#forms_schedules. A guidance document – which is intended to assist in determining when a notice is required (along with training documents) – is also on the website near the Notice form. For technical questions, contact nysecon@health.ny.gov. For questions concerning the Transfer of Ownership Interest Notice form or required documents, contact cons@health.ny.gov.
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