NATIONAL UPDATE: The Washington Scene 2014

Transcription

1 NATIONAL UPDATE: The Washington Scene 2014 NAHC Financial Management Conference July 13, 2014 William A. Dombi Vice President for Law National Association for Home Care & Hospice 2014: The Home Care is in the Forefront New delivery models underway h Chronic care management Transitions in care Accountable Care Organizations Post acute care bundling Community based care is the focus Avoiding hospitalizations and institutional LTC Avoiding hospitalizations and institutional LTC Medicaid home care expansions Medicare demonstration programs 1

2 PROGRAM FOCUS Private Pay Home Care Department of Labor FLSA Companionship pservices rule ACA employer mandate Medicaid home care Expanded HCBS Managed LTSS Medicare Home health Services Hospice Care 2014 Home Care Legislative/Regulatory Priorities Block HHPPS cuts through rebasing Stop Copays Stop Copays Delay ACA provision on individual mandate and employer responsibilities/penalties Seek exemption or protection from employer penalties for home care and hospice employers Reverse changes to FLSA companionship exemption Improve Medicare F2F rules Manage MLTSS Nurse practitioner certification authorization Telehealth pilot program Program integrity changes Toughened participation standards Establish reasonable hospice payment model reforms 2

3 Private Pay Home Care: Companionship Services FLSA Exemption DoL rule effectively eliminates minimum wage and overtime exemption /pdf/ pdf gov/fdsys/pkg/fr 10 01/pdf/ pdf Eliminates exemption for 3 rd party employment on companionship services and live in domestic services Changes definition of companionship services Excludes 3 rd party employers from live in exemption Medicaid and disability rights advocates opposition HCAOA, et al v Perez Case No. 1:14 cv (D.DC) filed Challenges validity of rule Increased private litigation on W&H issues Validity of claimed FLSA exemption status hours worked Break time rights IMPACT DoL sees limited impact Transfer of dollars from employer/payer at $232M annually p y /p y $ y Industry sees greater impact Increased staff recruiting Higher staff turnover Shift to part time workers Limited Medicaid rate support NAMD requests DoL delay Gov. Brown (CA) limits MediCal worker hours Lower customer satisfaction 3

4 ACA Employer Mandate: Home Care Impact On January 1, 2015, employers of 100 or more FTEs must offer a qualified health plan FTEs delayed until 2016 Less than 50 FTE exempt Many, but not all Medicare HHA/hospices have or offer comprehensive health insurance $3000 per non insured penalty a risk Most Medicaid home care providers do not have health insurance for employees $2000 per FTE penalty a risk Private pay home care companies rarely have employee health insurance $2000 per FTE penalty a virtual certainty Employer Mandate: Advocacy Efforts Delay the implementation date Eliminate the employer mandate Change the law E.g., Redefine full time to 40 hours per week (30 is current standard) Employer options Stay below 50 FTEs and/or 30 full time employees Limit the number of employees at 30 hours or more per week Offer bare bones, qualified health plan Seek higher Medicaid rates (good luck!) Raise charges to clients (tough sell) 4

5 Medicaid Home Care Rebalancing of LTC spending continues Just less than 50% of Medicaid LTC spending now in home care States balance bl in spending wide ranging ACA incents home care Higher federal match to low balance states (BIP) New HCBS option benefit /medicaidprogram state plan home and community based services 5 year period forwaivers provider States increasing Medicaid home care audits and oversight Big focus on caregiver qualifications by OIG Documentation weaknesses on care plans ad authorizations Major movement to managed care Medicaid LTSS Duals Medicaid Managed Care Nationwide shift to managed Medicaid Long Term Services and Supports (MLTSS) CMS supports move with some caution Dual eligible demo programs are the big wave Managed care programs flying blind? Great opportunities for some, impossible challenges for others Expanded home care? Lower rates; restricted utilization; limited networks? Need comprehensive standards for both providers and beneficiaries 5

6 MEDICARE HOSPICE Proposed Rule CMS Issued the FY2015 proposed rule: /medicare program fy 2015 hospice wage index andpayment rate update hospice quality reporting No new payment model proposed CMS indicates that it wants to evaluate not yet available data from new cost reports and claims submissions; focus on program integrity for now MEDICARE HOSPICE Proposed Rule 1.3% rate increase proposed 2.7% MBI (0.3%) ACA reduction (0.4%) productivity adjustment (0.7%) BNAF wage index reduction Add in 2% sequestration 6

7 MEDICARE HOSPICE Proposed Rule Solicitation it ti of comment terminal illness definition related condition definition Hospice cap calculation (speed up) Attending MD on election form Quality data reporting Medicare Part D coordination (codify existing guidance already underway) Prior authorization; hospice or prescriber must document unrelatedness to terminal condition(s) MEDICARE HOSPICE: Drug Liability Who pays for drugs: Part D or the hospice? National coalition addressing CMS policy Potential solutions under consideration Long term risk to hospices? 7

8 Medicare Hospice: Regulatory Challenges Collection of additional data on claims Hospice face to face rule Terminal illness documentation Quality reporting Hospice Item Set (July 2014); Hospice Experience of Care Survey (Jan. 2015) New Cost report 2015 MedPAC Hospice Recommendations No inflation update Accelerate new payment model U Shaped reimbursement Provide hospice within MA Plans 8

9 Home Health Regulatory Issues HHPPS 2015 proposed rule Rate rebasing Face to Face Therapy assessments More. PECOS Medicare improvement standard New Medicare CoP sanctions (and potential new CoPs) Moratorium on new HHAs 2015 Medicare Home Health Rate Final Rule CMS Proposed Rule (July 2, 2013) _PI.pdf. Continued rebasing payment rates Full cut (3.5%) allowed under law (14 points total) Recalibrated case mix weights Focus on therapy episodes Budget neutrality adjustment Outlier eligibility remains same despite low spending MBI: 2.6% New Productivity Adjustment ( 0.4%) 04%)net MBI at 22% 2.2% Remember 2% payment sequestration (February 1 and later payments) New wage index blend of CBSAs 9

10 2014 Medicare Home Health Rate Proposal: Assessment CMS continues 4 year phase in from 2014 CMS chose unfavorable calculation method Used proxies for episode revenue and costs Formula guarantees aggregate payments less than average cost Better alternatives available Ignored cost increases and costs not on cost report Telehealth F2F; therapy assessment Siloed rebasing rather than aggregation Failed to include capital needs Proposed HHPPS Rates 2015 Case mix weights recalibrated unevenly 0 5 therapy visits + increase weights 3.75% therapy visits decrease weights by 2.5% 20+ therapy visits decrease weights by 5% Budget neutrality adjustment of Base rate in 2014 $ Base rate in 2015 $ This is a decrease because of case mix weight recalibration 1.45% effective decrease in base rate Add in 2.0% Sequestration 10

11 2015 MedPAC Home Health Recommendations Repeat 2014 recommendations Accelerate rebasing No inflation update Add copay on community admission episodes Institute a hospital readmission penalty Establish a common PAC patient assessment Supports PAC bundling PRPOSED RULE: Other Regulatory Developments Affecting Home Health Services Face to Face Physician Encounter rule modifications Face to Face Physician Encounter rule modifications Significant change to the requirement for professional therapy reassessments A new standard for the submission of OASIS to avoid payment rate reductions Modifications of the standards for qualification of speech language pathologists under the CoPs The introduction of possible new coverage standards on the administration of insulin injections The unveiling of a likely model for Value Based Purchasing The unveiling of a likely model for Value Based Purchasing Clarifications of the requirements for imposition of alternative Civil Money Penalty sanctions for CoP violations Changes to recertification requirements 11

12 Face to Face Physician Encounter Proposed Changes Eliminate physician narrative requirement Require certifying physician to have sufficient records to support certification Reject physician payment claims for certification/recertification when home health claim denied for noncompliant certification/recertification Face to Face Physician Encounter Lawsuit itfiled NAHC v. Sebelius/Burwell 1:14 cv (filed ) US District Court for the District of Columbia Alleges excess documentation required in relation to ACA requirements failure to provide adequate and clear guidance on acceptable documentation Failure to review whole record Lawsuit will continue to address past claims denials and continuing audits 12

13 Medicaid F2F Proposed rule July 2011 Unified Agenda October 2014 Some States have a F2F requirement CMS permits, but does not encourage Proposed Rule Changes Therapy Assessments Drop 13 th /19 th visit requirement p / q Substitute a professional therapy visit/assessment every 14 th day OASIS submission Require 70/80/90% submissions over 3 year phase in Noncompliance leads to 2% rate penalty Speech Language Pathologist qualifications modified to require state licensure and educational levels Clarification of Start of Care certifications/oasis Readmission w/in episode where discharged with goals met Would require another F2F 13

14 New CMS Ideas Insulin injection standards Request for input on standards Signals likely oversight on insulin injection outlier episodes Value based Purchasing Request for input CMS possible VBP model 5 8 selected states Mandatory application of VBP 5 8% of payment at risk Sliding scale of bonuses and penalties Based on performance and improvement in performance PECOS: Physician enrollment as a HH Condition of Payment ACA and regulation requires all home health certifying and ordering physicians be enrolled in Medicare 42 CFR (b) Medicare requires an approved enrollment record in PECOS HHAs only have access to ordering and referring file Physician name and NPI as they appear in PECOS on the claim Edit effective with SOCJanuary 6, 2014 Edit currently on certifying MD only Watch for expanded enrollment focus in claims reviews Problems: VA physicians and MD re enrollment procrastinators 14

15 PECOS Full Implementation of Edits starting January 6, and Education/Medicare Learning Network MLN/MLNMattersArticles/Downloads/SE1305.pdf See also 8441 : Home Health Agency Reporting Requirements for the Certifying Physician and the Physician Who Signs the Plan of Care Effective July and Guidance/Guidance/Transmittals/Downloads/R2789CP.pdf 8356:Handling of Incomplete or Invalid Claims once the Phase 2 Ordering and Referring Edits are Implemented and Guidance/Guidance/Transmittals/Downloads/R2767CP.pdf MEDICARE HOME HEALTH: Alternative Sanctions Applies to condition level deficiencies Sanctions include: Directed corrective action Temporary management Payment suspension Civil monetary penalties $500 $10,000 Per diem/per instance Termination Informal dispute resolution possible Informal dispute resolution possible CMPs and payment suspension no earlier than 7/1/14, Appeal rights w/o penalty suspension In the 2015 NPRM CMS proposes to limit ALJ power to reduce CMPs 15

16 COMPLIANCE: FOCUS ON HOME CARE ZPICs and RACS looking at home care Homebound status Medical necessity Technical compliance incl. F2F High level fraud/false Claims Act investigations E.g., $375M physician directed fraud allegation OIG continues home care efforts New report alleges widespread fraud and abuse Report is weak on facts and methodology, strong on hyperbole Medicaid home care new on the agenda Personal care is the main focus Staff credentials including health screening a target NEW Medicare coverage guidelines Jimmo v Sebelius settlement content/uploads/2012/12/jimmo Settlement Agreement pdf. Focused on illegal improvement standard CMS is clarifying existing guidelines; provider education will follow Permit coverage of skilled maintenance therapy Permit coverage of chronic care/terminal patients Existing guidelines recognize such coverage but MACs changed the rules CMS clarified guidelines with specific prohibition of an improvement standard (w/in 6 months) Education/Medicare Learning Network MLN/MLNMattersArticles/Downloads/MM8458.pdf 16

17 Medicare Home Health Target Areas Homebound Absences documented or reported by patient Conflicting documentation Medical Necessity Therapy is a big target Improper improvement standard Documentation weakness on skilled nature of care Coding diagnoses Face to Face Encounter Therapy Assessments Moratorium on New HHAs / /medicare medicaid and childrens 02166/medicare medicaid and childrens health insurance programs announcement of newand extended temporary. Miami Dade counties in Florida Cook County (Chicago area) in Illinois Dallas, Houston, Detroit, Ft. Lauderdale New providers CHOWS allowed Relocation w/in area permitted New Branches included in moratoria 17

18 CONCLUSION Home Care and Hospice is diverse and in the midst of a revolution/evolution Opportunities/Challenges abound Range of legal/regulatory issues is endless Significant regulatory energy directed towards home care and hospice Compliance issues/concerns Center of innovation in care is home care; change triggers action 18