2/13/15& HOME HEALTH HOT TOPICS HOME HEALTH MARKET BASKET UPDATE HOME HEALTH PROSPECTIVE PAYMENT SYSTEM CY 2015 (FINAL RULE)

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1 HOME HEALTH HOT TOPICS APTA COMBINED SECTIONS MEETING INDIANA, INDIANAPOLIS Roshunda Drummond-Dye APTA Cindy Krafft Home Health Section HOME HEALTH PROSPECTIVE PAYMENT SYSTEM CY 2015 (FINAL RULE) Home health payment update Potential Impacts of rebasing and face to face requirement Changes to therapy reassessment timeframes Changes to face to face requirement documentation Recalibration of HH PPS case-mix weights Home health quality reporting and value-based purchasing HOME HEALTH MARKET BASKET UPDATE! Reductions in payment of $60 million or 0.3 percent! Includes 2.1 percent payment update and second year of home health rebasing! National 60-day per episode payment rate is $ (May be reduced by 2 additional percentages for failure to comply with HH QRP) 1&

2 CHANGES TO THERAPY REASSESSMENT TIMEFRAMES! Current policy: 13 th and 19 th therapy visits for each therapy discipline and/or every 30 calendar days! New policy: reassessment be conducted at least once every 30 calendar days (PT, OT and SLP).! Therapist must perform the necessary treatment during the visit and assess the patient, measure progress and document objectives and goals.! All other requirements remain unchanged (e.g. documenting objective measurement and done by qualified therapist) ENSURING COMPLIANCE Timing Content EFFECTIVENESS OF THERAPY Objective Measures Determine Next Steps Data Analysis Evaluate Care Plan Functional Relevance 2&

3 DOCUMENTATION FOR FACE TO! Final policy: FACE REQUIREMENT! Eliminate narrative requirement, evaluation must be completed by physician or NPP with documented date of encounter! For eligibility for HH start of care, CMS will review medical record from certifying or PAC physician! Physician claims for certification or recertification of eligibility will not be covered if HHA claim itself is denied for lack of sufficient documentation THINK ABOUT IT How did the person get to the F2F visit?! Self Care! Medications! Mobility! Accessing Office! Return Trip! Rest of the Day HOME HEALTH QUALITY REPORTING! Submission OASIS data to capture Quality Assessments Only! Will transition in with 70% in 2015 and 90% by &

4 ARE YOU CURRENTLY PROVIDING MAINTENANCE THERAPY?? DOES THIS LOOK FAMILIAR?! Therapy evaluation completed! Expectation of improvement! Plan created! Visits made! Goals achieved! Patient discharged R E S T O R A T I V E! Therapy evaluation completed! At optimal level! Possibility of decline! Plan created! Visits made! Goals achieved! Patient discharged M A I N T E N A N C E A BRAVE NEW WORLD! 4&

5 IMPROVEMENT STANDARD LAWSUIT Glenda Jimmo, et. al vs. Kathleen Sebelius Case was filed on January 18, 2011 Proposed settlement agreement filed in federal District Court on October 16, 2012 Preliminary Order to Approve Settlement filed November 20, 2012 (Contingent upon fairness hearing) Fairness hearing held January 24, 2013 and final approval was given on that date 13 ISSUE SYNOPSIS! Contractors interpretation: "Improvement Standard" provider must show a material improvement in patient s condition over a determined period in order to establish medical necessity! Upheld right of patients to continue to receive reasonable and necessary care to maintain condition or prevent or slow decline! Determinant factor is not whether the Medicare beneficiary will improve! Decision covers nursing and therapy services provided under both inpatient and outpatient settings MEDICARE STATUTE! Basis of medical necessity under the Medicare program! Social Security Act 1862(1) states in part, payment may not be made under [Medicare] part A or part B for any expenses incurred for items or services which are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member. 15 5&

6 REASONABLE AND NECESSARY CRITERIA SUMMARY Services must be:! Safe, effective, not experimental! Appropriate in duration and frequency;! Furnished in accordance with accepted standards of medical practice for the condition;! In an appropriate setting! Ordered and furnished by qualified personnel! Appropriate to meet the need, but does not exceed the need! Potential for improvement in response to therapy 16 MANUAL REVISIONS! Transmittal 179! Clarifications contained in the Medicare Claims Processing and Benefits Policy Manual (chapters applicable to home health, IRF, SNF and outpatient therapy)! No rule of thumb application care depends on whether skilled care is required (reasonable and necessary criteria), not restoration potential! Inclusion of examples and documentation guidelines for each setting HOME HEALTH MANUAL PROVISIONS Coverage of maintenance therapy is not solely based potential for improvement rather need for skilled care Covered when demonstrated that the skills, knowledge and specialized judgment of the qualified therapist is needed Based on individual condition of the patient and complexity Services must be provided by the PT (not PTA) 6&

7 ACCOUNTABILITY! Re-review of previous denials! Retroactive January 2011! Appeal rights lie with beneficiary! Medicare/appealsand-Grievances/ OrgMedFFSAppeals /index.html! Claims review through established protocol of sampling of QIC claims! Bi- annual meeting with plaintiffs counsel on claims review findings! Expedited review and resolution of errors and denials WHAT HAPPENS WHEN SERVICES ARE NO LONGER MEDICALLY NECESSARY? Rights of the patient! Periodically meet with your health care providers (i.e. therapist, physician, SNF) to understand treatment options! Can continue to receive services and pay out of pocket! Seek aid through local assistance programs (national Elder Locator program )! Right to appeal denied Medicare claims Rights of the provider! Furnish patient with an ABN! Establish a maintenance program to be carried out by non-skilled individuals! Can continue to collect payment out of pocket! Coordination of services with physician and other health care providers to ensure a consistent message to the patient! Right to appeal Medicare denied claims MEDICARE APPEALS PROCESS! Redetermination (contractor)! Reconsideration (qualified independent contractor QIC)! Administrative law Judge (ALJ) Hearing! Medicare Appeals Council (MAC) Review! Federal Court 7&

8 MEDICARE RESOURCES! Medicare Therapy Services webpage: index.html! Medicare Benefits Policy Manual Guidance/Manuals/Internet-Only-Manuals-IOMs- Items/CMS html? DLPage=1&DLSort=0&DLSortDir=ascending! Medicare Coverage Database overview-and-quick-search.aspx 22 APTA RESOURCES! APTA Medicare Coverage Page Technical briefs on lawsuit and settlement! Summary of manual provisions! Tips and highlights for physical therapists! Podcasts: overview of manual provisions and documentation! To come: setting specific tools and clinical application resources PASSAGE OF IMPACT LEGISLATION 8&

9 IMPACT STAGES OF IMPLEMENTATION Data collection, reporting and analysis Congression al Reports Feedback reports Public Reporting DATA COLLECTION, REPORTING AND ANALYSIS! PAC providers (HH, IRF, SNF and LTCH) must collect and report standardized and interoperable patient assessment data, quality and resource use measures! Separate but uniform assessment instruments that can be compared across settings 9&

10 REPORTING PATIENT ASSESSMENT DATA! PAC providers must report:! Functional status! Cognitive function and mental status! Special services, treatments and interventions required! Medical conditions! Impairments " Claims data will be matched to assessment data for assessing prior service and current service use " Information cannot be used for payment eligibility at a specific PAC setting PENALIZATIONS FOR FAILURE TO REPORT PAC providers who fail to report quality and resource use measures subject to a two percentage point reduction under respective market basket CONGRESSIONAL REPORTING First MedPAC report on alternative payment models for PACs by June 30, 2016 HHS report with recommendations on technical prototype of PAC PPS (after two years of data collection on quality measures) Second MedPAC report on protype based on HHS report by june 30 th following HHS report Study on impact of SES factors (two years after enactment) 10&

11 CHANGES TO HOSPICE SURVEY AND MEDICAL REVIEW " More frequent surveys (every 36 months from April 2015 to September 2025) " Trigger of medical review for certain treatment cases (large percentage of cases with stays over 180 days) " Payment cap aligned to common inflationary index CHANGES OUTLINED BY IMPACT LTCH CARE IRF-PAI MDS OASIS Post Acute Care IMPACT Standardized Patient Assessment Data (October 1, 2018, for SNF, IRF and LTCH and January 1, 2019 for HHA) 32 MEDICARE QUALITY MEASURES: POST-ACUTE CARE Measure LTC H IRF SNF (A) HH Hospice Urinary Catheter-Associated Urinary Tract Infections Central Line Catheter-Associated Bloodstream Infection X X X X Pressure Ulcers measures X X X X 30-day Comprehensive All-Cause Risk- Standardized Readmission Measure Emergency Department Use without Hospitalization CAHPS X X* X** Pain management measures X X X Falls risk ADL information X X X X * In development. **Rehospitalization during the first 30 days of HH. 33 X X X 11&

12 ADDITIONAL QUALITY MEASURES IN IMPACT Timeline for New Resource Use Measures Measures Date Medicare spending per beneficiary 10/1/2016 Discharge to community 10/1/2016 Hospitalization rates of potentially preventable readmissions 10/1/2016 PROPOSED REVISIONS TO CONDITIONS OF PARTICIPATION! Released in Fall of 2014 (final comments January 7, 2015)! 4 guiding principles:! Develop integrated care process across all home health services! Use a patient-centered, interdisciplinary approach that recognizes the contributions of various skilled professionals! Eliminate the focus on administrative process! Safeguard patient rights pdf ARE WE AN INTERDISCIPLINARY TEAM? 12&

13 INDICATORS OF ISSUES # Going to the patient s home and finding out he has been in the hospital for the last 2 days. # Not knowing that the last visit you made 2 weeks ago was actually supposed to be an agency discharge. # Having to write off the last 3 aide visits because the discharging clinician forgot the service was still providing care. # Not knowing who the nurse / therapist / aide is caring for your patient. # Covering a visit for anther clinician and having little to no idea why the visit needs to be made. # Multiple services on the same day without a plan to do so. WHAT ARE THE KEY ELEMENTS A CHF PATIENT NEEDS TO FOCUS ON TO PREVENT RE- HOSPITALIZATION? REPORT TO CONGRESS: AN INVESTIGATION ON ACCESS TO CARE AND PAYMENT FOR VULNERABLE PATIENT POPULATIONS! Surveyed 1,075 Medicare-certified HHAs and 510 physicians to examine factors associated with potential care access issues! More than 80% of HHAs and 90% of physicians reported that access to home health services for Medicare beneficiaries in their local area was excellent or good.! Common obstacle - patients did not qualify for the Medicare home health benefit.! Contributing factors to inability to admit or place patients in home health related to insufficient reimbursements. Health-Agency-HHA-Center.html 13&

14 THERAPY IN HOME HEALTH CONTACT INFORMATION! Roshunda Drummond-Dye! Cindy Krafft! 14&

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