CONFERENCE
MLTC UPDATES
PRE-CLAIM REVIEW DELAY
BOOTCAMP
Read up on some HCA Annual Conference features! Have you registered yet? Don’t miss out on HCA’s biggest program of the year.
Managed care advisory meeting provides critical updates on MLTC and managed care budget and policy developments.
While pre-claim review was not scheduled to go into effect in NYS, CMS’s decision to pause the problematic program is welcome news.
HCA is offering a special bootcamp education program to assist LHCSAs in their readiness for value-based payments
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Your Source for HOME CARE News, Policy and Advocacy
Vol. 2, Issue 15 | April 10, 2017
COMING UP Rediscover, Reimagine, Reinvent at HCA’s Annual Conference in Saratoga Saratoga Springs, NY May 3 to 5 Moving Beyond Personal Care to Meet the Challenge & Opportunities of Value-Based Care New York City, NY May 18, 2017 For more information on these and other programs, please visit the education and events section of HCA’s website at http://hca-nys.org/ events-education/ upcoming-events
State Budget Finalized Over the weekend and concluding late last night, the Legislature and Governor negotiated, agreed to and passed the remaining bills for necessary adoption of a final 2017-18 state budget. The budget agreement coalesced late last week and through the weekend. It followed the Legislature’s passage of “bare-bones” extender bills last week. This extender legislation was enacted as a stop-gap mechanism to keep state operations running See BUDGET p. 6
Learn the Leadership Benefits of “Being Wrong” at HCA’s Annual Conference with Acclaimed New Yorker Writer Kathryn Schulz Self-awareness is a critical part of leadership in home care and in any other area of life. During HCA’s 2017 Annual Conference, less than one month away, New Yorker staff writer Kathryn Schulz will be sharing insights from her acclaimed book on what it means to “be wrong,” and how we can learn from this self-analysis as leaders, by understanding the benefits of being in error. None other than President Bill Clinton has seen the wisdom of Schulz’s book, stating: “If you want to feel better about not being perfect and see the potential upside in your See CONFERENCE p. 2
INSIDE State Budget Finalized.............................................................................1 Learn the Leadership Benefits of “Being Wrong”.............................1 Discover Your Niche in a Value-Based Health Care Marketplace.............2 Monthly MLTC Meeting Developments.................................................3 A Message From HCA Sponsor Sandata.................................................3 CMS Hits Pause Button on Pre-Claim Review Demo........................................8 CMS Post Updated Review and Correct Reports via CASPER Application.........9
Civil Monetary Penalties Increased.............................................................9 Member Hiring Announcement....................................................................9 Bootcamp for LHCSAs on Contract Negotiations, Operational Fine-Tuning....10 DSRIP Report on PPS Job Title Vacancy Rates...............................................10 New OPWDD Article 16 Audit Protocols and Revised ALP Protocols Posted..11 Participants for Accountable Health Communities Announced..................11 NGS Updates........................................................................................12 Resources...........................................................................................13
The Situation Report: the Home Care Association of New York State CONFERENCE from p. 1 errors, read Being Wrong by Kathryn Schulz ... a brilliant book with a sweeping grasp of philosophy and physics and all points in between.” In Being Wrong, Schulz explores why we find it so gratifying to be right and so maddening to be mistaken, and how this attitude toward error corrodes our relationships, whether between family members, colleagues, neighbors, or nations. Schulz will share her view on why error is both a given and a gift that can transform our workplace culture. Don’t miss Kathryn Schulz and the other enlightening sessions at the conference. Register today by visiting the conference website at www.hcaannualconference.com.
Discover Your Niche in a Value-Based Health Care Marketplace and Position Your Agency for Success At HCA’s Annual Conference, national health care expert Karen Butterton will share a powerful step-by-step approach to effectively market your agency’s services and partnership value to payors, health care systems, ACOs and self-insured plans to increase and/or ensure future revenue streams. This information couldn’t be any more important than it is right now! Ms. Butterton, a Lean Six Sigma Greenbelt, has produced extraordinary results leading and guiding organizations. She currently serves as the Chief Operations Officer for Barnes Healthcare Services. She is an expert in the Affordable Care Act and the future changes to the health care industry. Karen has excelled in turning around under-performing organizations and capitalizing on new growth opportunities, driving the development, commercialization, and delivery of new products and programs into the medical marketplace via strong marketing, sales-leadership and operational delivery expertise. She has worked in hospitals, assisted living, specialty infusion services, respiratory services, specialty pharmacy, oncology centers, and the 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. Joanne Cunningham HCA President jcunningham@hcanys.org Roger L. Noyes Director of Communications, Editor of The Situation Report rnoyes@hcanys.org Al Cardillo Executive V ice President acardillo@hcanys.org Patrick Conole V ice President, Finance & Management pconole@hcanys.org Andrew Koski Vice President, Program, Policy & Services akoski@hcanys.org Alexandra Fitz 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 & Special Projects jkerbein@hcanys.org Billi Wilson Manager, Meetings & Events bwilson@hcanys.org Teresa Brown Administrative Assistant tbrown@hcanys.org
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home care arena at such companies as: National Medical Enterprises, Total Pharmaceutical Care, Apria, Alterra, VACO Consulting, Air Liquide Global Healthcare and Liberty Medical. This eye-opening presentation will help you:
Strategically position your company to gain and grow its business in the local marketplace
Align and create a value-based proposition for health care systems to become their “preferred” provider of choice
Present to an ACO why partnering with your company helps them achieve their Triple Aim objectives
Create substantive value and quantitative benefits that reduce spend for the payer
Take advantage of this session and all of the other exciting programs at HCA’s Annual Conference on May 3 to 5, 2017, plus our Annual Awards luncheon, networking sessions, exhibit hall of vendors, “town hall” meeting with the HCA Policy team and more. Reserve your seat today at www.hcaannualconference.com.
Monthly MLTC Meeting Focuses on Budget, Program Developments The April 6 monthly state Department of Health (DOH) meeting for managed care plans and association representatives highlighted key developments affecting managed long term care (MLTC) plans and network providers. Covered items included: a debrief on the adopted areas of the state health and Medicaid budget (see related p. 1 story); rollout of the 2017 MLTC rates and adjustments; developments and milestones on value based payment; new steps in behavioral health integration into managed care; deeper DSRIP-MLTC engagement; a general MLTC/FIDA program update; and other. Budget Report The budget report summarized gubernatorial cuts to MLTCs that were ultimately rejected by the Legislature. Rejected cuts included the MLTC transportation carve-out and limit on MLTC
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A message from HCA sponsor Sandata
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enrollment to nursing home eligibility. The Governor’s cuts that were pushed through (mostly administratively to bypass the Legislature) included a reduction in MLTC Quality Incentive payments, an MLTC marketing ban, and reduced VBP incentive funding. In addition, the Department described plans to evaluate MLTCs for potential “efficiency” cuts that could be accomplished during the rate year, imposed on MLTCs with comparatively “higher utilization and cost” than peers. DOH further spoke of possibly redirecting some of these funds to financially “needy” plans. Officials also described the agreement to expand wage parity requirements to include services provided by personal assistants under the consumer directed personal assistance program (CDPAP), with conflicting information as to whether additional funds to support the mandate will be included in the rates. These and other budget items are described in the slide deck at http:// hca-nys.org/wp-content/uploads/2017/ 04/BudgetAgreementOverview.pdf. Rate Adequacy Side-Letter The Executive agreed to address the Legislature’s MLTC and provider “rate adequacy” proposals but via a “side-letter” with the Legislature rather than in actual budget or legislative language. These items were derived specifically or conceptually from proposals advanced by HCA and
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Unpacking the Home Health CoPs
Last week, news came that changes to the Home Health Conditions of Participation (CoP) are being delayed until January 1 ... but providers nevertheless have a lot to get ready for within a very short period of time. Clinical and operational expert Trish Tulloch, of RBC Limited, provided New York's home care community with a detailed guide through the most relevant CoP changes, along with strategies to prepare for them, during our conference this week on "Unpacking the Home Health CoPs" in Albany.
others, and advocated strenuously by the Legislature, to ensure proper reimbursement of plans and providers. The letter, when drafted, will include content and timetables agreed to by the Executive and Legislative negotiators. While this approach is far from the strength or breadth of the HCA rate adequacy proposals adopted in the Legislature’s onehouse budget bills, the side letter provides new leverage and a live venue to pursue these goals. Rate Rollout DOH announced intentions to finalize the April 2017 rates by the end of the month, including adjustments for moneys owed in the 2016-17 rate year. DOH anticipates a July rate package that will contain further adjustments, including MLTC cuts/ changes in the budget. DOH indicated that it will seek feedback on whether to apply some of the adjustments
The Situation Report: the Home Care Association of New York State prospectively from July forward, or to make adjustments retrospective to April; in either case, DOH stated that budget-driven actions would be retroactive to April. DOH anticipates the July package to be ready by July, with risk adjustments not ready until August. Value Based Payment (VBP) On VBP, DOH reiterated the requirement that, by the end of 2020, 80 percent of plan payments must be VBP. DOH encouraged plans to examine their current “level zero” rate agreements involving bonus payments, and adding performance criteria sufficient to move these to level-one VBP (and thus within the scope of the 80 percent milestone). DOH indicated that prior to April 1, 2018, managed care plans would be surveyed to determine their VBP prevalence; plans failing to meet required milestones face possible sanction, as would providers determined to not be progressing, or creating impasses, to VBP. DOH indicated it will hold a VBP Town Meeting April 12 in Albany and subsequently in Rochester, with a date and time to be determined.
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Other Items DOH also presented managed care plans with snapshots of proposed grids and dashboards intended to actively engage plans in DSRIP/ PPS. The grids and dashboards would include key managed care plan contacts for PPS and PPS performance. Also discussed were a variety of issues related to integration of behavioral health providers into PPSs, managed care and VBP, including $60 million in funding to assist with planning and implementation of behavioral health integration. Managed Care Update at HCA Member Financial Managers Forum DOH confirmed at last week’s HCA Senior and Financial Managers’ Forum that, once approved by the state Division of the Budget, the rates for FIDA, PACE and mainstream Medicaid Managed Care plans should cover the minimum wage increase since January 1, 2017. HCA asked and DOH agreed to release guidance for plans and home care providers once those rates are approved.
General MLTC Program Update General MLTC updates include the following:
Per the state budget agreement, the NHTD/ TBI Waivers transition into managed care has been postponed to January 1, 2019.
Community First Choice Option implementation into managed care remains January 1, 2018.
DOH has approved transition plans for GuildNet to withdraw from serving Westchester, Nassau, and Suffolk Counties; and Elderplan from Suffolk County.
Enrollment stands at 193,344 members, including all types: partial cap, FIDA, PACE, MAP.
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In addition, DOH said that it will soon release additional guidance on the funding for the Fair Labor Standards Act (FLSA) changes. While the notice will include how much monies each plan received for a certain period of time, it will not provide any new information on how much each plan must pass on to its home care providers. DOH’s presentation materials note that $70 million is available for the Quality Incentive Vital Access Provider Pool (QIVAPP) for 2016-17. HCA has asked DOH for more information, but at this time it is not known if the eligibility criteria for the program will be changed from previous years or when the monies will become available.
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BUDGET from p. 1
Infrastructure Funds
while intense negotiations continued on large-scale, complex policy items in the budget, running out the clock on the April 1 deadline for the start of the state fiscal year.
In a significant win, the budget more than doubles last year’s minimum set-aside of infrastructure funds for home and community health providers. The budget authorizes $500 million for Health Care Facility Transformation, which includes a $75 million allocation exclusively for home care and other communitycare providers. It is unclear at this time whether the $500 million includes, or supplements, the $300 million for projects funded under last year’s request for applications (RFA). HCA is working to confirm these specifics as quickly as possible.
The Assembly passed the final, complete budget agreement on Saturday and the Senate passed it on Sunday. Both houses are now scheduled to be adjourned for two weeks, returning on April 24 to resume work during the legislative session. As extensively reported to the membership, several non-health-care provisions had bogged down negotiations in recent weeks, many of which are now reconciled in the final agreement. These include: Workers’ Compensation reform; a program for tuitionfree education at public institutions; raising the age for criminal responsibility in the justice system (from 16 to 18); water infrastructure investments; housing subsidies; tax initiatives; permitting ride-hailing services in upstate New York; and others. HCA will be providing a more detailed summary of the final budget, once we’ve had an opportunity to review the entire agreement and related summary documents. The capacity for HCA and public analysis is made more complex by this year’s final budget process, in which late agreements on many unrelated items were aggregated into final multi-topic bills. Additionally, the Governor intends to pursue a number of his actions administratively, and without specific Legislative endorsement; these items will not be stipulated in the budget bills and thus need to be separately tracked and confirmed. Here is a preliminary analysis related to the outcomes for home care, MLTC, hospice and waiver programs. Minimum wage It is our understanding that the budget includes Medicaid funding for the costs of the minimum wage increase, but those exact figures are not known at this time and will be shared with the membership following our review of the budget and discussions with state officials. HCA advocated strenuously throughout the process for full funding of minimum wage and all labor mandates for providers and health plans.
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The Legislature, particularly the Senate, insisted throughout the budget negotiations that the Department of Health (DOH) disclose the awards for the outstanding $300 million appropriated last year under the Transformation program. Those awards still have yet to be announced. It appears that the final budget requires DOH to announce awards for last year’s RFA by May 1. Last year’s program was funded at $200 million, with a $30 million community-care set-aside. HCA will be seeking further information on the coordination between these two award cycles and how this relates to the overall $500 million/ $75 million allocated in the new budget. Both last year and this year, HCA and coalition partners were instrumental in achieving this community-care allotment, emphasizing the health care system’s increasing reliance on community-based providers for the success of state policy initiatives and outcomes. In that vein, this year, we stressed that the earmark for community-care providers must comprise 25 percent of the total pool, or $125 million, considering the state’s goal of a 25 percent reduction in hospital admissions – a transfer of focus that falls largely within the communitybased sector. Rate adequacy HCA pushed hard both before and during negotiations for MLTC and provider rate
The Situation Report: the Home Care Association of New York State adequacy to effectively meet costs, including critical labor, infrastructure, staffing and operational supports. HCA offered legislative language to this effect, which both houses of the Legislature adopted and sought to advance, but the provisions faced resistance from the Executive. The final budget agreement seeks to address this issue via a so-called “side-letter,” rather than in actual budget or legislative language. The proposals and elements anticipated to be examined in the letter include rate cells for high-need home care and nursing home enrollees in MLTC, as well as a tighter connection between services shown to be needed and covered via the patient assessment and the amount that the state is paying to plans and providers. MLTC Restorations & Cuts HCA had strongly advocated for the rejection of the Governor’s proposed rate cuts, marketing ban, eligibility changes and transportation carve-out for MLTCs. We succeeded in gaining the Legislature’s support, which was reflected in the one-house bills. However, despite the Legislature’s support and intentions, some of these cuts and actions were (and will yet be) pursued directly by the Governor in his implementation of the budget. The budget rejects the Governor’s proposed MLTC eligibility limit as well as the Governor’s proposed transportation carve-out. The Governor would not agree to legislative language precluding his proposed rate cuts and marketing ban, which he argues he can (and now will) impose through DOH administrative action. Wage Parity for CDPAP, FI Requirements The final budget adds personal assistants providing care through the Consumer Directed Personal Assistance Program (CDPAP) to the definition of “home care aide” for purposes of the Wage Parity law in New York City, Long
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Island and Westchester. It seems to include some minimal funding for this new wage parity compliance, but there have been conflicting reports as to whether additional funding will accompany this new requirement. Relatedly, the budget also redefines “fiscal intermediary” (FI) and “FI services”; establishes an authorization process for FIs, requiring all entities performing “fiscal intermediary services” to be authorized to perform such services by the Department of Health; and prohibits Article 44 managed care plans from becoming certified FIs. Regulatory Team, Community Paramedicine, Essential Personnel Set Aside The final budget agreement sets aside the Governor’s proposed Health Care Regulation Modernization Team, which posed both opportunities as well as risks for home care. It is possible that the Executive could pursue this Modernization Team approach administratively (without legislation), or it could take shape as a legislative proposal post-budget. Also excluded is a provision allowing for community paramedicine. HCA worked arduously with coalition partners across various sectors to develop a version of community paramedicine that respected existing jurisdictional boundaries, including Article 36 home care, offering positive opportunities for all stakeholders. While HCA’s efforts brought together wide stakeholder consensus, the Assembly did not want to take up the bill with the budget. Similarly, despite wide support and strong Senate positioning to include HCA’s “Essential Personnel” legislation for home care and hospice in the adopted budget, the Assembly set the language aside for the post-budget deliberation. HCA will be regrouping with our allied partners to address these important areas proactively in the remaining weeks of the state Legislative session. Workers Comp Reform Among the very final items agreed to and passed were Workers’ Compensation reform and College Tuition Assistance. Workers’ Compensation costs and cost increases are significant challenges to providers and MLTCs. Continued on next page
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Continued from previous page HCA has advocated for cost control as well as adequate reimbursement to cover these debilitating costs. Workers’ Compensation reform was one of the major priority issues of the Legislature, particularly the Senate, in this year’s negotiations. HCA will provide members with analysis of the reforms passed last night and the relevance for the field.
More details coming soon These are some of the major provisions included in the budget but there are numerous other technical or long-standing Medicaid rate and payment provisions that HCA will be reporting in our followup communications.
CMS Hits Pause Button on Pre-Claim Review Demo The U.S. Centers for Medicare and Medicaid Services (CMS) has announced a 30-day suspension of the pre-claim review demonstration in Illinois, beginning April 1, and a hold on extending the demo to Florida. The Florida implementation was supposed to go into effect on April 1. Under this demo (not occurring in New York), third-party Medicare Administrative Contractors (MACs) decide whether the claims for care provided by home health agencies should be approved for payment. The MACs are directed to make determinations of whether the care was medically necessary and whether all coverage requirements were met prior to the submission of a claim for billing. By requiring agencies to submit documentation before the claim is submitted, this demo is a sweeping departure from past Medicare integrity efforts, which have largely focused on post-payment audits, targeting those agencies, services or regions which exhibit risk, rather than subjecting all claims to an onerous pre-claim audit regardless of historical accuracy. While New York is not one of the states scheduled to undergo the demo, HCA has taken proactive steps to comment on and warn federal officials of the risks and problems inherent in the model. These problems have borne out in the experiences of Illinois home care providers, already subject to the demo. Reports from Illinois show that claim denials and affirmations are inconsistent, with some agencies submitting claims, getting rejections, and then resubmitting the same claims unchanged, only to have them approved.
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“After March 31, 2017, and continuing throughout the pause, the Medicare Administrative Contractors will not accept any Pre-Claim Review requests,” CMS states on its website. “During the pause, home health claims can be submitted for payment and will be paid under normal claim processing rules. CMS will notify providers at least 30 days in advance … of further developments related to the demonstration.” This announcement, late last week, coincided with CMS’s proposal to delay implementation of changes to the Home Health Conditions of Participation (CoPs), as sought by HCA and partners. New York Rep. John Faso was instrumental in the CoP delay. Please see the press release from his office, quoting HCA, at http://faso.house.gov/news/ documentsingle.aspx?DocumentID=246. CMS’s exact reason for the pre-claim review pause is not known, though home care association representatives nationally and in the affected states had vigorously opposed the program, and word has it that the program may undergo some changes during the suspension period. HCA has included pre-claim review in our target list of several federal rules and regulations. See our position paper at: http://hca-nys.org/wp-content/ uploads/2017/01/ HomeCareRegulationsandMandates.pdf. Our formal comments on pre-claim review are at http://hca-nys.org/wp-content/uploads/2016/07/ Medicarehomehealt-preclaimreviewcommentsJuly202016.pdf
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CMS Post Updated Review and Correct Reports via CASPER Application The U.S. Centers for Medicare and Medicaid Services (CMS) has recently made available the Home Health Review and Correct reports within the CASPER application. Review and Correct reports contain quality measure information at the facility level and are available on demand. These reports provide aggregate performance information for the past four full quarters (when data is available). These reports only contain data submitted prior to the applicable quarterly data submission deadlines and display whether the data correction period for a given quarter is “open” or “closed.” Providers can access their review and correct reports in the CASPER system at https:// web.qiesnet.org/qiestosuccess/ HCA members can find additional Home Health Quality Reporting information on CMS’s website at: https:// www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/ HHQISpotlight.html
Civil Monetary Penalties Increased The U.S. Centers for Medicare and Medicaid Services (CMS) has posted a letter to inform State Survey Agency Directors of a recent final federal rule that adjusts civil monetary penalties (CMPs) for certain violations as of February 3, 2017. The letter is at https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/ Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-17-23.html. The increased amounts are explained in a Federal Register notice on February 3, 2017 at https:// www.gpo.gov/fdsys/pkg/ FR-2017-02-03/pdf/201702300.pdf. The adjusted amounts apply to CMPs assessed on or after February 3, 2017, when the violation occurred after November 2, 2015. If the violation occurred on or prior to November 2, 2015, or if the violation occurred after November 2, 2015, but the CMP was assessed prior to February 3, 2017, the CMP amounts in effect before this adjustment will apply. Continued on next page
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Chief Financial Officer Oneonta, New York Bassett Healthcare Network: At Home Care, Inc. (AHC), a nationally recognized and progressive Medicare Certified Home Health Care agency, seeks to hire an executive level financial leader. Operating across five predominantly rural counties in Central NY, AHC is an integral healthcare network partner. With a data driven integrated financial and clinical leadership approach, the individual will be responsible for planning, oversight and directing all fiscal operations of the organization. Candidate Qualifications x Experienced home health financial leader with McKesson Horizon IS experience, preferred x MS Office and accounting software experience required x A clear and concise communicator, written and oral x Education: bachelor’s degree in accounting or finance required; Masters or CPA, preferred Competitive salary and benefit package offered. For more information, or to submit a CV in confidence, please direct to: Patricia Brown, Director HR; 25 Elm Street, Oneonta NY 13820 Or, E-mail: pbrown@ahcnys.org
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Continued from previous page Some of the penalties listed are for:
Each day a home health agency is not in compliance with statutory requirements
A home health agency’s deficiency or deficiencies that cause immediate jeopardy and result in actual harm
An isolated incident of noncompliance in violation of established home health agency policy
A repeat and/or condition-level deficiency that does not constitute immediate jeopardy and that is related predominately to structure or process-oriented conditions; and others.
Bootcamp for LHCSAs on Contract Negotiation Readiness, Operational Fine-Tuning Moving Beyond Personal Care to Meet the Challenge & Opportunities of Value-Based Care: May 18, 2017 As New York State races toward a system of value-based payment metrics and financial incentives, LHCSAs must deliver on the quality-of-care expectations being driven by their managed care plan contract partners in the evolving landscape. By 2019, 80 percent of managed care payments must be based on some type of value-based arrangement. On May 18 in New York City, HCA is holding a special bootcamp program that will show LHCSA operators how to fine-tune their operations in line with the new reimbursement models governing managed long term care for enhancing LHCSA appeal in contract negotiations and readying LHCSAs to meet the standards of a fundamentally changing system. This program is presented by Andrea Brown, RN, President/CEO, AB Coaching and Consulting, who has more than thirty-two years of experience in health care and has served in roles with responsibility for home care operations, delivery of clinical care, staff education, quality improvement, and compliance. Register today and get further information in the flyer and registration form below.
DSRIP Report on PPS Job Title Vacancy Rates The state Department of Health (DOH) released a new report this week, the “Performing Provider Systems (PPS) Job Title Vacancy Rate Snapshots, Demonstration Year 1 (DY1).” This report provides a high-level summary of job title vacancy rate as they were reported by each PPS in a recent survey. This information may be useful for further planning related to workforce trends, shortages, and planning. This report can be found on the DSRIP website at: http://www.health.ny.gov/health_care/medicaid/redesign/ dsrip/workforce_docs/index.htm Any questions on the report can be directed to DSRIP@health.ny.gov.
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New OPWDD Article 16 Audit Protocols and Revised ALP Protocols Posted The state Office of the Medicaid Inspector General (OMIG) has posted new audit protocols for Office for People with Developmental Disabilities (OPWDD) Articl16 clinic services, and revised audit protocols for Assisted Living Programs (ALPs). Both protocols are at https://www.omig.ny.gov/audit/audit-protocols. Some of the Article 16 protocols, dated April 3, 2017, include:
Missing recipient record
No documentation of clinic service
No initial assessment, annual assessment or annual reassessment
Late physician signature for annual reassessment
Missing elements of the treatment plan
Missing physician order
Incorrect rate code billed
Billing for unauthorized services; and more
The ALP protocols, revised March 10, 2017, include:
Missing documents (i.e., patient record, medical evaluation, service documentation, medical reassessment, plan of care, patient review instrument, certificate of immunization, required health assessment, personnel records)
Incorrect rate code billed
Failure to complete annual performance evaluation
Participants for Accountable Health Communities Announced The U.S. Centers for Medicare and Medicaid Services (CMS) has announced the participants for the Assistance and Alignment Tracks of the Accountable Health Communities (AHC) Model. The AHC Model is a five-year test by CMS’s Innovation Center to learn whether identifying and addressing beneficiaries’ health-related social needs through referral and community navigation services can: improve care delivery; enhance quality of care; and reduce their total cost of care and impatient and outpatient
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health care utilization. The AHC Model aims to identify and address beneficiaries’ health-related social needs in the following core areas:
Housing instability and quality; Food insecurity; Utility needs; Interpersonal violence; and Transportation needs beyond medical transportation.
This model intends to promote clinical-community collaboration through:
Screening of community-dwelling beneficiaries to identify certain unmet health-related social needs;
Referral of community-dwelling beneficiaries to increase awareness of community services;
Provision of navigation services to assist high-risk community-dwelling beneficiaries with accessing community services; and
Encouragement of alignment between clinical and community services to ensure that community services are available and responsive to the needs of community-dwelling beneficiaries.
Two entities in New York State – St. Joseph’s Hospital Health Center in Syracuse and New York Presbyterian Hospital in Manhattan – were selected for the assistance and alignment tracks, respectively. The Assistance and Alignment Tracks of the Accountable Health Communities Model will begin on May 1, 2017 with a five-year performance period. The list, along with other information on the model, is at https://innovation.cms.gov/initiatives/ahcm/.
NGS Updates National Government Services (NGS), New York’s Medicare Administrative Contractor (MAC), has recently posted the following information to its website.
2017 MAC Satisfaction Indicator (MSI) - This ten-minute survey allows you to provide feedback on NGS services. See: https://cfigroup.qualtrics.com/jfe/form/ SV_3WeVjGWpc5NQXOJ?MAC_BRNC=5&MAC=J6%20%E2%80%93%20NGS
Common Working File (CWF) Hosts Dark Day on Saturday May 13 - On Saturday, May 13, 2017, the CWF will be conducting a history archive, resulting in a “dark day” for CWF. It will impact access to beneficiary eligibility and claim overlap information as the CWF will be unavailable.
For further information, contact HCA’s Patrick Conole at (518) 810-0661 or at pconole@hcanys.org.
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Resources
“Special Income Standard for Housing Expenses: If Discharged from Nursing Homes or Adult Homes and Enroll in MLTC Plan,” by the NY Legal Assistance Group http://www.wnylc.com/health/entry/212/
“Strengthening the workforce to Support Community Living and Participation for Older Adults and People with Disabilities: Proceedings of a Workshop,” by the National Academies of Sciences, Engineering and Medicine http://www.nationalacademies.org/hmd/Reports/2016/strengthening-the-workforce-to-supportcommunity-living-proceedings.aspx
“Early Findings on Care Coordination in Capitated Medicare-Medicaid Plans under the Financial Alignment Initiative,” by RTI International (for CMS) https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/ Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/ CareCoordinationIssueBrief508032017.pdf
“Beneficiary Experience: Early Findings from Focus Groups with Enrollees Participating in the Financial Alignment Initiative,” by RTI International (for the U.S. Center for Medicare and Medicaid Services/CMS) https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/ Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/ FocusGroupIssueBrief508032017.pdf
“Issue Brief: Special Populations Enrolled in Demonstrations under the Financial Alignment Initiative,” by RTI International (for CMS) https://www.cms.gov/Medicare-Medicaid-Coordination/Medicare-and-Medicaid-Coordination/ Medicare-Medicaid-Coordination-Office/FinancialAlignmentInitiative/Downloads/ SpecialPopulationsIB508032017.pdf
For more information, contact Andrew Koski at (518) 810-0662 or akoski@hcanys.org
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