ICS
LEGISLATION
MA SUPPLEMENTAL
LAWTALK
Providers with accounts-receivable related to the closure of Independence Care System should have received revised agreements based on additional funds in the state budget.
HCA’s home healthmental health bill passes Senate; sepsis legislation on active list, primed for Senate vote.
New guidance on Medicare Advantage supplemental benefits covers social determinants of health and other aspects.
This month’s HCA LawTalk column explains the intersection between state and federal laws on privacy protections.
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Your Source for HOME CARE News, Policy and Advocacy
UPCOMING PROGRAMS SupervisionPlus Online Managerial Training Self-paced online training module Registration deadline: May 8, 2019 HCA Annual Conference: Force For the Future May 8-10, 2019 Saratoga Springs, NY WEBINAR: 4-Part ICD-10 Coding Webinar Series Thursdays in May May 4, 9, 16, 23 1-2 p.m. Webinar: The Art of Creating and Facilitating Grief Groups May 15, 2019 1-2:30 p.m.
Vol. 4, Issue 18| May 6, 2019
Two Big PDGM Programs Coming Up on Coding Essentials & Clinical Management HCA knows that the Patient Driven Groupings Model (PDGM) is a major area of focus – and anxiety – throughout home care, especially for certified agencies, so we are thrilled to offer two programs, one in June and another in July, to set you on a path to success. Register for one or both programs at a special rate (https://hca-nys.org/wp-content/uploads/2019/05/ PDGM-Programs-HCA-2019.pdf). You’ll get even further savings if you bring your registration to this week’s HCA Annual Conference! Details are below: PDGM Coding Essentials featuring Trish Tulloch June 12, 2019 (Schenectady, NY) With PDGM coming, your outcomes and financial viability demand precision and accuracy in the capturing and reporting of all clinical data. This includes OASIS-D1 and ICD-10-CM See PDGM p. 2
INSIDE Two Big PDGM Programs Coming Up....................................................................1 New ICS Agreements Sent...................................................................................2 First Meeting of FI Workgroup Scheduled.............................................................3 Influenza No Long Prevalent...............................................................................3 HCA-developed Legislation Advances in the Senate..........................................4 Rule Issued on Medicaid Payments to Third Parties.............................................4 Further Guidance Issued on MA Supplemental Benefits.....................................5 Policy Change for Assessment Submission Timeframe........................................6
Grants Available for Workforce Safety Training..........................................7 Opinion Letters Available from US Department of Labor.............................7 Upcoming Deadlines, Meetings and Due Dates..........................................8 Medicare Trust Fund Report Issued..........................................................9 Emergency Rule Readopted for Congestion Surcharge..............................9 Funding Available for Air Conditioners....................................................10 Many Opportunities to Participate in HEPC Meetings..............................10 LawTalk: NYS Privacy Laws and HIPAA.......................................................11 CMS Announces RAC Changes..................................................................12 Health Resources................................................................................13
The Situation Report: the Home Care Association of New York State PDGM from p. 1 diagnosis coding practices that are essential to quality outcomes and agency reimbursement within the larger construct of new clinical groupings and subgroupings under PDGM. This program will make vital connections across the various coding categories and functions for PDGM readiness. PDGM Bootcamp For Clinical Managers and Quality Staff Featuring Barbara Katz July 11, 2019 Suffern, NY Home Health Care Clinical Managers/Supervisors of Clinical Services, Quality Management staff and Clinical Educators will play a key role in the successful implementation of PDGM. In this interactive session, attendees will learn the four key elements of the PDGM scoring system: admission source and timing, clinical groupings, functional levels and comorbidities.
New ICS Agreements Sent Last week, home care providers who are owed money by Independence Care System (ICS) for services provided to their members were sent revised agreements to sign and return by May 15. The revisions were made due to additional funds appropriated in this year’s final state budget to compensate agencies for their outstanding payments, an action for which HCA had advocated strenuously throughout the legislative session. HCA had notified members in January that the ICS Managed Long Term Care plan was closing on March 31, and enrolled members would be transitioned to VNSNY Choice (unless they selected another plan). Those who transitioned to VNSNY were guaranteed a minimum of one year of the same level of care they previously had with ICS, while those who selected another plan would only be guaranteed continuity of care for 120 days.
Home Care Association of New York State (HCA) 388 Broadway, 4th Floor, Albany, NY 12207 Tele: 518-426-8764; Fax: 518-426-8788; Website www.hcanys.org
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The Situation Report is a weekly publication of the Home Care Association of New York State (HCA). Unless otherwise noted, all articles appearing in The Situation Report are the property of the Home Care Association of New York State. Reuse of any content within this newsletter requires permission from HCA. Al Cardillo President and CEO acardillo@hcanys.org Roger L. Noyes Director of Communications, Editor of The Situation Report rnoyes@hcanys.org Rebecca Fuller Gray Executive V ice President for Clinical and Program Affairs rgray@hcanys.org Patrick Conole Vice President, Finance & Management pconole@hcanys.org Andrew Koski Vice President, Program, Policy & Services akoski@hcanys.org Alyssa Lovelace Director for Policy and Advocacy alovelace@hcanys.org Lauren Ford Director of Program Research, Development and Policy lford@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 & Graphic Design jkerbein@hcanys.org Billi Wilson Manager, Meetings & Events bwilson@hcanys.org Teresa Brown Administrative Assistant tbrown@hcanys.org
The Situation Report: the Home Care Association of New York State
Volume 4, No. 18 May 6, 2019
First Meeting of FI Workgroup Scheduled The state Department of Health (DOH) has announced that the Fiscal Intermediary (FI) Workgroup will hold its first meeting on May 15 in Albany. HCA and some of our members have been selected to serve on the Workgroup, which was created under provisions in the final state budget that addressed FIs and the Consumer Directed Personal Assistance Program (CDPAP). The purpose of the Workgroup is to:
Identify and develop best practices for FIs;
Formulate criteria for DOH to use in selecting and contracting with entities to deliver FI services;
Develop quality reporting requirements; and
Establish transition plans for consumers that need to switch to another FI.
As reported in past communications, the state budget made a series of changes to the FI program including a per-member-per-month payment system for FI administrative services, a new procurement process and the addition of new FI responsibilities, including requirements for FIs that cease to operate. For more information, contact Andrew Koski at akoski@hcanys.org or (518) 810-0662.
Influenza No Long Prevalent Flu mask requirement no longer in effect On May 3, the state Department of Health (DOH) declared that influenza is no longer prevalent in New York State. (The announcement can be found on the Health Commerce System.) This means that the “flu mask” requirement for personnel does not apply. Under this requirement, individuals not vaccinated against influenza must wear a surgical or procedure mask while in areas where patients or residents may reside during the period that influenza is prevalent, as determined by the DOH Commissioner. The Commissioner declared flu prevalent on December 20, 2018. Frequently Asked Questions and other resources are at http://health.ny.gov/FluMaskReg. For more information, contact FluMaskReg@health.ny.gov.
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HCA-developed Legislation Advances in the Senate Last week, a number of HCA-developed bills advanced in the state Senate. Most notably, our legislation that would allow for collaboration between home care and mental health providers, S.3872-A (Carlucci/A.6566-A Gunther), passed the Senate on Wednesday, May 1. The bill would authorize the Commissioners of the Office of Mental Health and Department of Health to waive rules and regulations of their respective offices to address existing barriers to collaboration between mental health and home care providers within the Geriatric Service Demonstration Program. HCA’s Director for Public Policy and Advocacy, Alyssa Lovelace, and Director of Program Research, Development and Policy, Lauren Ford, further discussed the bill with legislative fiscal and program staff to advance the bill prior to the end of the legislative session in the Assembly. Additionally, S.1816 (G. Rivera/A.3836 J. McDonald) was sent to the Senate Finance Committee on April 30. This legislation would allow for the integration of home care into the state’s public health and prevention efforts. S.1817 (G. Rivera)/A.3839 (j. McDonald), HCA’s sepsis-related legislation, has been placed on today’s Senate Active List for debate. From there, it is expected to pass. For questions related to HCA’s priority legislation, or to learn more about the Association’s legislative agenda, please contact Alyssa Lovelace at alovelace@hcanys.org or call (518) 810-0658.
Rule Issued on Medicaid Payments to Third Parties On May 2, the U.S. Centers for Medicare & Medicaid Services (CMS) released the Medicaid Provider Reassignment Regulation final rule “removing a state’s ability to direct portions of Medicaid provider payments to third parties outside of the scope of what the statute allows.” The final rule is at https://www.govinfo.gov/content/pkg/FR-2019-05-06/pdf/2019-09118.pdf. The Federal Register announcement states that this final rule removes the regulatory text allowing a state to make Medicaid payments to third parties on behalf of an individual provider for benefits such as health insurance, skills training, and other benefits customary for employees. According to CMS’s press release, Section 1902(a)(32) of the Social Security Act generally prohibits states from making payments for Medicaid services to anyone but the provider. The statute provides only a few specific exceptions to this requirement, such as allowing payment to be made in certain circumstances pursuant to an employment relationship, to medical facilities and billing agents, and under court-ordered wage garnishments. In 2014, CMS provided for a regulatory exception to enable a state to make Medicaid payments directly to third parties on behalf of certain providers, including such redirected payments in connection with the services provided by independent in-home personal care workers. Continued on next page
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Continued from previous page CMS has now determined that its 2014 exception is contrary to federal law and may have resulted in the diversion of payments the law requires to be made directly to providers. Therefore, CMS is finalizing the rule to remove this impermissible exception. CMS notes that this final rule will not impact a state’s ability to perform Financial Management Services (FMS) or secure FMS through a vendor arrangement. FMS are services and functions that assist the Medicaid beneficiary or his/her family to: 1) manage and direct the disbursement of funds contained in the participant-directed budget; 2) facilitate the employment of staff by the family or participant, by performing as the participant’s agent for such employer responsibilities as processing payroll, withholding federal, state, and local tax, and making tax payments to appropriate tax authorities; and 3) performing fiscal accounting and making expenditure reports to the Medicaid beneficiary or family and state authorities. HCA’s counsel is reviewing the rule to determine how, if at all, it affects home care providers.
Further Guidance Issued on MA Supplemental Benefits The U.S. Centers for Medicare and Medicaid Services (CMS) has issued further guidance on “supplemental benefits” that can be offered by Medicare Advantage (MA) managed care plans. This new information is at https://www.cms.gov/Medicare/Health-Plans/HealthPlansGenInfo/Downloads/ Supplemental_Benefits_Chronically_Ill_HPMS_042419.pdf. It addresses how plans may address social determinants of health, provides additional information on potential supplement benefits, and gives some marketing guidance. The April 8 edition of The Situation Report outlined CMS’s 2020 MA Call Letter in which CMS also provided clarification regarding “supplemental benefits.” Beginning in 2019, CMS expanded its interpretation of the criterion that supplemental benefits be “primarily health related.” This expanded criterion considers an item or service as primarily health related if it is used to diagnose, compensate for physical impairments, acts to ameliorate the functional/psychological impact of injuries or health conditions, or reduces avoidable emergency and health care utilization. Separately, the Bipartisan Budget Act of 2018 further expanded the types of supplemental benefits that may be offered by MA plans to “chronically ill” enrollees. These benefits, referred to as Special Supplemental Benefits for the Chronically Ill (SSBCI), include supplemental benefits that are not primarily health related and may be offered non-uniformly to eligible chronically ill enrollees. Under this law, a chronically ill enrollee (authorized to receive expanded benefits) is defined as an individual who: 1) has one or more comorbid and medically complex chronic condition(s) that is life threatening or significantly limits the overall health or function of the enrollee; 2) has a high risk of hospitalization or other adverse health outcomes; and 3) requires intensive care coordination. For 2020, CMS will consider chronically ill enrollees to be those with a chronic condition listed in section 20.1/2 of chapter 16b of the Medicare Managed Care manual (https://www.cms.gov/Regulations-and-
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Guidance/Guidance/Manuals/Downloads/mc86c16b.pdf section 20.1.2). This includes: cardiovascular disorders; chronic heart failure; dementia; diabetes mellitus; autoimmune disorders; and more. In addition, the law requires that the specific SSBCI item or service have a reasonable expectation of improving or maintaining the health or overall function of the enrollee as it relates to the chronic condition or illness. In the April 24 guidance, CMS clarifies the treatment of benefits that address social determinants of health by stating: MA plans can provide non-primarily health related supplemental benefits that address chronically ill enrollees’ social determinants of health so long as the benefits maintain or improve the health or function of that chronically ill enrollee. MA plans may consider social determinants of health as a factor to help identify chronically ill enrollees whose health could be improved or maintained with SSBCI and they may use social determinants to further limit SSBCI eligibility. However, they may not use social determinants of health as the sole basis for determining eligibility for SSBCI. CMS also provides further guidance on the following non-primarily health related supplemental benefits that can be offered: meals; food and produce; transportation for non-medical needs; pest control; indoor air quality equipment and services; social needs benefit; “complementary” therapies; services supporting selfdirection; structural home modifications; and general supports for living. While the added supplemental services create new opportunities for home care and hospice to partner with MA plans, they also pose important and potentially concerning questions. The federal guidance is not particularly clear on whether and which services require delivery through licensed home care providers and hospices, versus allowing these services to be provided through non-home care entities or directly by the MA plan itself. Cases of articles 36 and 40 overreach are already a serious concern in New York state, either as explicit violations by non-home care entities or in such organizations’ desire to cross jurisdictional lines. Home care agencies should actively partner with MA plans to be collaborating providers for these services. HCA will be further exploring these opportunities and recommended strategies.
Policy Change for Assessment Submission Timeframe Impacts Hospice and Home Health Providers The U.S. Centers for Medicare and Medicaid Services (CMS) recently announced an upcoming change in policy regarding the timeframe for submission of “assessments” that are part of the quality reporting program. Current policy allows providers to submit records for up to 36 months from the assessment target date. Beginning October 1, 2019, the policy will be changed to 24 months from the assessment target date. The change applies to new, modified, and inactivated records. This policy change applies to the Outcome and Assessment Information Set (OASIS) for home health providers and the Hospice Item Set (HIS) for hospice providers. Even though CMS stresses that the HIS is not an assessment tool (but a data extraction tool), it is still part of the quality record submission process that falls under this rule.
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Grants Available for Workforce Safety Training The Occupational Safety and Health Administration (OSHA) has announced $10.5 million in Susan Harwood Training Grants for certain nonprofit organizations to provide training and education programs for employers and workers on the recognition, avoidance, and prevention of safety and health hazards in their workplaces. The Harwood Training Grant program (https://www.osha.gov/dte/sharwood/index.html) supports in-person, hands-on training for workers and employers in small businesses; industries with high injury, illness and fatality rates; and vulnerable workers, who are underserved, have limited English proficiency or are temporary workers. Grants are available in three areas: Targeted Topic Training, Training and Educational Materials Development, and Capacity Building.
Targeted Topic Training grants support educational programs that address identifying and preventing workplace hazards. These grants require applicants to conduct training on OSHA-designated workplace safety and health hazards.
Training and Educational Materials Development grants support the development of quality classroom-ready training and educational materials that focus on identifying and preventing workplace hazards.
Capacity Building grants support organizations in developing new capacity for conducting workplace safety and health training programs, and must provide training and education based on identified needs of a specific audience or a set of related topics.
Details on the grants and how to apply are available at Grants.gov. Harwood applications must be submitted online no later than July 2, 2019. Applicants must possess a “D-U-N-S” number and have an active System of Award Management (SAM) registration (https://sam.gov/SAM/). A D-U-N-S number may be obtained free-ofcharge from Dun & Bradstreet (http://fedgov.dnb.com/webform/ displayHomePage.do;jsessionid=81407B1F03F2BDB123DD47D19158B75F).
Opinion Letters Available from US Department of Labor The U.S. Department of Labor (DOL) Wage and Hour Division now offers a function allowing users to search opinion letters by key word, year, topic, and a variety of other filters. The search function is at https://www.dol.gov/whd/opinion/search/fullsearch.htm. An opinion letter is an official, written opinion on how a particular law applies in specific circumstances described by the person or entity requesting the letter. The public can submit requests for opinion letters. To learn about this process or determine whether an existing guidance addresses a question, see: https://www.dol.gov/whd/opinion/search/fullsearch.htm. Opinion requests are not permitted by a party under Wage and Hour Law Division investigation, its representative, or any third party acting on its behalf, or for use in any previously initiated litigation.
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The Situation Report: the Home Care Association of New York State
Upcoming Deadlines, Meetings and Due Dates Requirement/Change/Meeting
Effective/Due Date
More Information
Capital District Health Emergency Preparedness Coalition (HEPC) meeting
May 7, 2019, 10 a.m. to 4 p.m.
Maureen.casaleͲreidt@health.ny.gov
Coalition Surge Test Exercise for Lower Hudson Valley
Sometime between April 29 and May 10, 2019
Andrew Koski at akoski@hcanys.org or (518) 810Ͳ 0662
Interoperable Communications/Medical Countermeasures exercise – Lower Hudson Valley
May 9, 2019
Gyongyi.McQueston@health.ny.gov
State Department of Health and Office for May 13, 2019 (Albany) the Aging Long Term Care Planning Project
https://www.eventbrite.com/e/evidenceͲbasedͲ programsͲandͲinnovativeͲmodelsͲinͲagingͲandͲlongͲ termͲcareͲticketsͲ56430626523
Emergency Planners in Inclusive Communities (Oneida County emergency preparedness) meeting
May 14, 2019
dhanley@ocgov.net
Central NY HEPC Meeting
May 15, 2019, 9:30 a.m. to 4 p.m.
judy.homer@health.ny.gov
Fully Integrated Duals Advantage (FIDA) plans closed to new enrollment
May 20, 2019
https://hcaͲnys.org/wpͲ content/uploads/2019/04/IntegratedͲ Care_stakeholder_session2_022819.pdf
NYC Health Care Coalition Leadership Council Meeting (emergency preparedness)
May 30, 2019
https://www.programinfosite.com/oepr/nychccͲ registration/
Quarterly Wage Parity Certification forms due from LHCSAs and Fiscal Intermediaries June 1, 2019 who operate in NYC, Long Island and Westchester
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https://www.health.ny.gov/health_care/medicaid/re design/2016/2016Ͳ02Ͳ17_wage_parity_alert.htm
Lower Hudson Valley HEPC meeting
June 5, 2019, 9 a.m. to 12:30 p.m.
Gyongyi.McQueston@health.ny.gov
Long Island HEPC meeting
June 6, 2019, 9 a.m. to 12:30 p.m.
drew.fried@health.ny.gov
Western Region HEPC All Partners meeting
June 12, 2019, 8:30 a.m. to 4:30 p.m.
https://tinyurl.com/yyk5vr3q
Emergency Preparedness Coalition of Manhattan (EPCOM)
August 7, 2019, 12 to 1:30 p.m.
Caitlin.Flynn@nyulangone.org
Transition Period for Using Health Insurance Claim Number (HICN) or new Medicare Beneficiary Identifier (MBI)
April 1, 2018 to December 31, 2019
https://www.cms.gov/Medicare/NewͲMedicareͲ Card/index.html
Medicare will only accept claims submitted with the Medicare Beneficiary Identifier (MBI)
January 1, 2020
https://www.cms.gov/Medicare/NewͲMedicareͲ Card/index.html
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Medicare Trust Fund Report Issued In late April, the Medicare Board of Trustees released its annual report for Medicare’s two separate trust funds – the Hospital Insurance (HI) Trust Fund, which funds Medicare Part A, and the Supplementary Medical Insurance (SMI) Trust Fund, which funds Medicare Part B and Part D. The report found that the HI Trust Fund will be able to pay full benefits until 2026, the same as last year’s report. The Trustees project that total Medicare costs (including both HI and SMI expenditures) will grow from approximately 3.7 percent of Gross Domestic Product (GDP) in 2018 to 5.9 percent of GDP by 2038. This trend is attributable to faster Medicare population growth and increases in the volume and intensity of health care services. The SMI Trust Fund, which covers Medicare Parts B and D, had $104 billion in assets at the end of 2018. Part B helps pay for physician, outpatient hospital, home health, and other services for the aged and disabled who voluntarily enroll. It is expected to be adequately financed in all years because premium income and general revenue income are reset annually to cover expected costs and ensure a reserve for Part B costs. The report is available at https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-andReports/ReportsTrustFunds/index.html.
Emergency Rule Readopted for Congestion Surcharge On May 1, the state Department of Taxation and Finance posted a notice that it had readopted an emergency rule establishing a surcharge on certain intra-state for-hire transportation that begins in, ends, or passes through part of New York City (south of 96th Street in Manhattan). The rule is at https://www.tax.ny.gov/rulemaker/emerreadopt/sales/emeraresales.htm#om041019 and https://docs.dos.ny.gov/info/register/2019/may1/rulemaking.pdf (page 22). Effective January 1, 2019, the “for-hire” transportation surcharge for a single passenger is $2.75 per trip, and “pool vehicles” (transporting two or more passengers) will be surcharged $0.75 per passenger. This surcharge is applied to Medicaid transportation providers conducting multi-loaded or group rides. It will be applied to Medicaid taxi/livery, green car, black car, and ridesharing/transportation network vehicles (ambulance and ambulette vehicles are exempt from the surcharge). Medicaid transportation providers, like other transporters subject to the surcharge, must file a monthly return with the Commissioner of Taxation and Finance within 20 days after the end of each month that indicates the number of trips and pool passengers. Transportation providers will be reimbursed for the cost of the surcharge through the Medicaid Fee-for-Service (FFS) billing system. Continued on next page
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Continued from previous page According to an article in the November 2018 Medicaid Update, Managed Long Term Care (MLTC) plans will receive a regional adjustment to their capitated rate. Transportation providers will receive payment in accordance with the terms of the contract with the MLTC plan. Last June, the state Department of Health sent MLTC plans a survey to assess their use of transportation vendors and whether or not they transport members through the congestion surcharge area. The survey revealed that plans have the capability to track transports into or through this area.
Funding Available for Air Conditioners $6 million in state funds are available to help New Yorkers purchase an air conditioner or fan if they suffer from serious health issues that are aggravated by extreme heat. The cooling assistance is available through the Home Energy Assistance Program (HEAP) at the county department of social services beginning Wednesday, May 1. To qualify, applicants must meet existing HEAP eligibility criteria and income guidelines and have at least one member of the household that suffers from a documented medical condition exacerbated by extreme heat. Cooling assistance will be provided on a first-come, first-served basis. County departments of social services, listed at http://otda.ny.gov/programs/heap/contacts/, will accept applications through August 30, or until funding runs out.
Many Opportunities to Participate in HEPC Meetings Home care and hospice providers outside of New York City have many opportunities to participate in their local Health Emergency Preparedness Coalitions (HEPCs), which have meetings scheduled for May and June. Last week, HCA participated in the North Country HEPC meeting that covered: recent Coalition Surge Test (CST), Interoperable Communications and Medical Countermeasures drills; upcoming trainings; internal workgroups on mass gatherings and pediatric preparedness; and more. During the discussion on the CST exercise – which involved three hospitals having to discharge a certain number of patients – HCA expressed concern that none of the patients were sent home with home care and we offered to work with the coalition to ensure a meaningful role for home care and hospice providers in future exercises. HEPCs are coalitions of health care providers, local and state emergency management and local public health preparedness officials that develop and coordinate emergency preparedness across the continuum. Participating in your local HEPC will help your agency develop a network of community partners and resources which will assist in your preparation for emergencies. Continued on next page
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Continued from previous page The following are upcoming HEPC meetings; those interested in participating should contact Andrew Koski at akoski@hcanys.org.
Capital District – May 7 Central NY – May 15 Lower Hudson Valley – June 5 Long Island – June 6 Western Region – June 12 The Oneida County Emergency Planners in Inclusive Communities is meeting on May 14
In NYC, there are coalitions that address emergency preparedness in different counties. The next meeting of the Emergency Preparedness Coalition of Manhattan (EPCOM) is August 7. May Aware Prepare Now Available The May 2019 issue of the state’s Aware Prepare Update is now available online at https://hca-nys.org/ wp-content/uploads/2019/05/2019_May_AP.pdf. It contains upcoming preparedness trainings, such as webcasts, webinars and in-person trainings, as well as archived exercises and on-demand e-learning.
LawTalk: NYS Privacy Laws and HIPAA for Home Care, MLTC Organizations By Frank Fanshawe, Principal and Joe de Perio, Law Clerk, Jackson Lewis, PC The Health Insurance Portability and Accountability Act (HIPAA) is well known as the federal law that protects the confidentiality, integrity, and availability of patient health information and records. However, home care agencies, MLTCs and hospices need to be aware of New York’s own privacy laws, which are codified in, among other places, the Public Health Law (PHL). The applicable sections of the PHL not only take precedence over HIPAA in some circumstances, but they prevail when HIPAA is silent on an issue. As a result, it is important that agencies, MLTCs and hospices are aware of – and comply with – both HIPAA and the PHL for patient information privacy. The state Department of Health (DOH) has determined that when the PHL offers greater protection of patient health information, the PHL applies, unless otherwise indicated by the U.S. Department of Health and Human Services, DOH, or the courts. However, agencies, MLTCs and hospices cannot simply apply the PHL in every instance. Rather, the PHL and HIPAA work in conjunction with one another. Where either HIPAA or the PHL are silent on an issue, health care providers should follow whichever other law addresses the issue. When HIPAA and the PHL are in agreement, providers should be aware of and comply with both HIPAA and the PHL. Where HIPAA and the PHL conflict, the law to apply is the one that provides for a greater security of patient health information and better record keeping, or the law that gives an individual greater access and control over their health information. For example, both HIPAA and the PHL grant patients the right to access their medical records which are maintained by agencies, MLTCs and hospices. HIPAA requires agencies, MLTCs and hospices to allow
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patients to see their medical records within 30 days of receipt of a request. The PHL, however, requires agencies, MLTCs and hospices to do so within 10 days of the receipt of request. Under these circumstances, health care providers would be obligated to comply with the shorter PHL timeframe because the PHL timeframe affords patients greater access to their health information than HIPAA’s relatively longer timeframe. Many providers erroneously view HIPAA as the only law that governs patient information. But it is vital, from a compliance perspective, for agencies, MLTCs and hospices to also be aware of and comply with New York State law in those instances where the PHL applies instead of HIPAA. LawTalk is a monthly column by Jackson Lewis, PC, the firm for HCA’s counsel. Please note that HCA LawTalk articles are for general, informational purposes, are not legal “advice,” and do not create an attorney-client relationship. Because each case is unique, the information provided should be considered to be general in nature, and should never be considered a substitution for legal counsel. Readers should not take, or refrain from taking, any action based on information in this article without first seeking legal advice from competent counsel.
CMS Announces RAC Changes Last week, the U.S. Centers for Medicare and Medicaid Services (CMS) announced changes to the Recovery Audit Contractor (RAC) program. The announcement is at https://www.cms.gov/blog/recovery-audits-improvements-protect-taxpayerdollars-and-put-patients-over-paperwork. The changes include:
RACs will be required to maintain a 95 percent accuracy score and an overturn rate of less than 10 percent, or else see a progressive reduction in the number of claims the RAC can review.
RACs will not receive a contingency fee until after the second level of appeal is exhausted. Previously, RACs were paid immediately upon denial and recoupment of the claim. This delay will help assure providers that the RAC’s decision was correct before they are paid.
RACs review fee-for-service (FFS) claims on a post-payment basis to identify and correct overpayments made on claims for health care services provided to beneficiaries, and they also identify underpayments to providers. The RAC that covers New York State is Performant Recovery, Inc. More information on the Medicare FFS Recovery Audit Program can be found at: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFSCompliance-Programs/Recovery-Audit-Program/.
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Health Resources
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“Appeals of Claims Decisions – Revisions,” by the U.S. Centers for Medicare and Medicaid Services https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/ MLNMattersArticles/downloads/MM11042.pdf
“Medicare Overpayments,” by the U.S. Centers for Medicare and Medicaid Services https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNProducts/ MLN-Publications-Items/ CMS1243389.html?DLPage=1&DLEntries=10&DLFilter=medicare%20over&DLSort=0&DLSortDir=descending
“Home Alone Revisited: Family Caregivers Providing Complex Care,” by AARP Public Policy Institute https://www.aarp.org/content/dam/aarp/ppi/2019/04/home-alone-revisited-family-caregiversproviding-complex-care.pdf
“Enrollment of Medicaid Managed Care and Children’s Health Insurance Program Providers,” by the state Department of Health https://www.emedny.org/info/ProviderEnrollment/ManagedCareNetwork/ MMC_Providers_Presentation_-_4-29-2019.pdf
“Convergence in Health Care Spending Across Counties in New York from 2007 through 2016,” by NYS Health Foundation http://journals.plos.org/plosone/article?id=10.1371/journal.pone.0215850
“Key Design Components and Considerations for Establishing a Single-Payer Health Care System,” by Congressional Budget Office https://www.cbo.gov/system/files/2019-05/55150-singlepayer.pdf
“Addressing Social Determinants of Health Needs of Dually Enrolled Beneficiaries in Medicare Advantage Plans: Findings from Interviews and Case Studies,” by Rand Corporation https://www.rand.org/pubs/research_reports/RR2634.html
PDGM
PROGRAMS
Coding Essentials June 12, 2019 Schenectady, New York
Bootcamp for Clinical Managers and Quality Staff July 11, 2019 Suffern, New York
PDGM
DoubleTree by Hilton 100 Nott Terrace Schenectady, NY 12308
CODING ESSENTIALS June 12, 2019
Who Should Participate:
8:30AM
Registration and Continental Breakfast Provider Quality and ICD‐10‐CM Code and Review Staff; Educators; Clinical, Performance Improvement and Compliance Staff and those responsible for the oversight and review of all provider clinical documentation that supports the delivery of care and services in the certified home health care setting.
9:00AM – 4:30PM Program (Lunch is included) Presented by: Trish Tulloch, RN, BSN, MSN, HCS‐D, Senior Consultant, RBC Limited
Program Outcomes in a Nutshell
With PDGM coming, your outcomes and financial viability demand precision and accuracy in the capturing and reporting of all clinical data. This includes OASIS‐D1 and ICD‐ 10‐CM diagnosis coding practices that are essential to quality outcomes and agency reimbursement within the larger construct of new clinical groupings and subgroupings under PDGM.
• Review the nuts and bolts of PDGM; • Detail ICD‐10‐CM Diagnosis Code updates that impact accurate provider reimbursement in PDGM; • Discuss strategies to support PDGM transition processes to successfully prepare for January 1, 2020.
This program will make vital connections across the various coding categories and functions for PDGM readiness, including ICD‐10‐CM Code Updates, Coding Clinic clarifications, and PDGM Diagnosis Codes for each ICD‐10‐CM Chapter, ensuring that coders and reviewers have an in‐ depth understanding of the nuances of PDGM.
About the Presenter Trish Tulloch RN, BSN, MSN, HCS‐D, is a Senior Consultant with RBC Limited with more than thirty years in the health care industry, including twelve years in home health and hospice management and more than twenty years in health care consulting. She currently consults with multiple health care organizations and agencies to meet regulatory and accrediting standards. She has received rave reviews from conference attendees and is a frequent presenter sponsored by professional, state and national organizations. Education topics include clinical and management best practices, OASIS‐D, ICD‐10‐CM Coding, legal documentation, survey and certification issues, quality improvement and Health Care Reform initiatives.
The program will also specifically address multiple complex home health scenarios that challenge providers to accurately represent clinical complexity and comprehensive care planning, with major implications under PDGM. It will also explore an integrated approach to vital agency quality and ICD‐10‐CM diagnosis code audit and review initiatives so that your team can assess your PDGM performance in real time. Upon completion of this program, participants will be able to: 1.
Detail critical elements of PDGM, including both OASIS‐D1 and ICD‐10‐CM Diagnosis Code updates;
2.
Recognize the PDGM clinical groupings and sub‐ groups that impact home health case mix in PDGM;
3.
Discuss and apply ICD‐10‐CM Code Guidelines and Coding Clinic Updates to complex home health case scenarios;
4.
List strategies to support provider PDGM transition work plans.
Hotel Information DoubleTree by Hilton 100 Nott Terrace Schenectady, NY 12308 HCA has reserved a limited number of rooms at the DoubleTree by Hilton in Schenectady, NY for the night of Tuesday, June 11 at a discounted rate of $124 per night. To receive this special rate, please call (518) 393‐4141 prior to May 17, and ask for the Home Care Association (HCA) group rate.
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PDGM
Crown Plaza Suffern – Mahwah 3 Executive Blvd. Suffern, NY 10901
BOOTCAMP FOR CLINICAL MANAGERS AND QUALITY STAFF July 11, 2019
8:30AM Registration & Continental Breakfast: 8:30AM
About the Presenter
9:00AM – 4:30PM Program (Lunch is included)
Barbara Katz is an experienced clinician, manager, trainer and health care consultant. She is a graduate of the Yale School of Nursing, has a Certificate in Training and Development from Fairfield University and a Coaching Certification from the American Talent Development Association. Barbara was the 2013 winner of the Connecticut Association for HealthCare at Home’s Judith A. Hriceniak Award for Excellence in Nursing Leadership. Barbara has been a hospital nurse, an APRN, a training manager, a director of quality improvement and a clinical manager for a group of medical practices. She has also been a marketing director for a home health care agency and has managed operations for a private duty home care agency. She has designed and taught seminars on process improvement, data analysis, management, motivational interviewing and team‐building. Barbara frequently speaks on topics that include the practical use of data to improve outcomes, motivational interviewing, health literacy, collaboration and care transitions and adapting to the new world of health care.
Presented by: Barbara Katz, RN, MSN, President, BK Health Care Consulting Home Health Care Clinical Managers/Supervisors of Clinical Services, Quality Management staff and Clinical Educators will play a key role in the successful implementation of the new Medicare Patient Driven Groupings Model (PDGM). In this interactive session, attendees will learn the four key elements of the PDGM scoring system: admission source and timing, clinical groupings, functional levels and comorbidities. Managers will leave with specific techniques for obtaining accurate information to support coding, scoring and billing, all while using the least amount of resources to produce the best outcomes. Areas covered include: optimizing complex care, episode utilization and case management, interdisciplinary teamwork, care coordination and collaboration. The session will also describe key PDGM measures and monitoring techniques to optimize efficiency, achieve success and prevent pitfalls. At the completion of this session, participants will be able to:
Hotel Information
• Describe key elements of Medicare’s PDGM payment model • Explain the impact of the new regulations on clinical operations and clinical managers • Identify key clinical operations changes that will be required for PDGM success • Create an initial action plan for successful PDGM implementation
HCA has reserved a limited number of rooms at the Crowne Plaza for the night of Wednesday, July 10 at a discounted rate of $115 per night. To receive this special rate, please call 1‐800‐227‐6963 prior to June 19 and ask for the Home Care Association group rate (code: PDG).
Crowne Plaza Suffern – Mahwah 3 Executive Blvd., Suffern, NY 10901
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PDGM Programs June 12th and July 11th Single Program Registration
Registration
June 12, 2019
Name: _______________________________________________
PDGM Coding Essentials with Trish Tulloch Schenectady, NY
Title: ________________________________________________
□ HCA Member $249 □ Non‐Member $399 July 11, 2019 PDGM Bootcamp for Clinical Managers and Quality Staff with Barbara Katz Suffern, NY
□ HCA Member $249 □ Non‐Member $399
Organization:__________________________________________ Mailing Address: _______________________________________ ______________________________________________________ City/State/Zip:__________________________________________ Email:_________________________________________________ (Required for registration) Phone:________________________________________________
Package Rate Registration
Second Registrant (for Package Rate)
The Package Rate includes a discount if you register for both programs (June 12 and July 11). The Package Rate may be shared between two individuals from the same agency. If sharing the Package Rate, please register the second individual.
To be completed with Registration above if sharing the Package Rate. Name: _______________________________________________ Title: ________________________________________________
June 12, 2019 AND July 11, 2019
□ HCA Member $425 □ Non‐Member $748
Registration Deadline May 29th June 12th Program Cancellation Policy: Cancellations received by June 3, 2019 will receive a full refund, less a 25% administrative fee. Cancellations must be received in writing via e‐mail at info@hcanys.org. Cancellations received on June 4th or later will forfeit their registration fee, as will those who register and do not attend. Substitutions are permitted. July 11th Program Cancellation Policy: Cancellations received by July 1, 2019 will receive a full refund, less a 25% administrative fee. Cancellations must be received in writing via e‐mail at info@hcanys.org. Cancellations received on July 2nd or later will forfeit their registration fee, as will those who register and do not attend. Substitutions are permitted.
FAX TO: (518) 426‐8788 For more information, contact HCA at (518) 426‐8764 or info@hcanys.org
Email:_________________________________________________ (Required for registration) Phone:________________________________________________
Payment Information Please check method of payment: ____MasterCard ____VISA ____Am Exp
____Check*
*Make checks payable to: HCA Education & Research and mailed to 388 Broadway, 4th Floor, Albany, NY 12207. Checks must be received in advance of the event. ________________________________________________________ Card Number _____________________________ _______________________ Expiration Date Security Code ________________________________________________________ Billing Address of Card Holder ________________________________________________________ City, State, Zip ________________________________________________________ Name on Card ________________________________________________________ Authorized Signature