2000 NAHC Regulatory Blueprint for Action

INTRODUCTION

The Regulatory Blueprint for Action identifies important regulatory issues for home care, hospice and home medical equipment providers. It provides a summary of each issue, including background information, recommendations, and rationale for the recommendations. This document provides a guide to the home care industry's position on the issues addressed. The National Association for Home Care's (NAHC) 2000 Regulatory Blueprint for Action has been reviewed by the Regulatory Affairs Subcommittee and the Forum of State Association's Regulatory Affairs Advisory Committee and approved by the Board of Directors.

In order to identify the regulatory issues that are of importance to home care, hospice and home medical equipment providers throughout the country, NAHC engages in a variety of activities. Member comments gathered from telephone calls, letters, and personal contact are analyzed. The current industry trends and government actions are evaluated. Opinions are solicited through NAHC Report's Question of the Week. NAHC committees, the Forum of State Associations' Regulatory Affairs Advisory Committee, and the Board of Directors participate in development of positions for the annual Regulatory Blueprint for Action. NAHC publishes a list of major issues in NAHC Report annually and asks members to score each issue from the least to most important. The results are tabulated and industry priorities identified.

The Blueprint serves as NAHC's regulatory plan for action for the upcoming year. Issues that are identified as most important by members become the priorities in the plan for action. However, NAHC recognizes that priorities may shift during the course of any year as a result of Federal regulatory action or policy changes.

EXECUTIVE SUMMARY

The 2000 Regulatory Blueprint for Action and the priorities established by the membership reflect the impact of the major legislative and regulatory changes that have swept the home care community over the past several years. The Blueprint addresses current and anticipated regulations, providing insight into each problem and offering a proposed solution and rationale.

Financial survival is the greatest concern to home care providers today. Therefore, home health and hospice reimbursement issues are addressed in the first section of the Blueprint. This section is followed by sections on: survey and certification, administration, coverage and other. Separate sections have been created for hospice and home medical equipment issues.

Regulatory priorities were determined through a survey of NAHC members. Members were asked to score current issues from "least important" to "most important." The results were tabulated and ranked according to the highest average score. The top twenty home care regulatory priorities for 2000 appear below:

1. PPS: Ensure appropriate case-mix adjuster for PPS
   
   
2. PPS: Provide for appropriate timing of payment to ensure adequate cash flow.
   
   
3. PPS: Ensure equitable national standardized payment rate for PPS.
   
   
4. Fully reimburse agencies for the costs of implementing OASIS and for ongoing data reporting.
   
   
5. Support a definition of homebound that focuses on clinical and functional status and opposes timekeeping requirements.
   
   
6. Allow rebilling of claims denied for technical reasons, in lieu of formal appeals.
   
   
7. Require FIs to make coverage determinations within a reasonable time for claims under prepayment review.
   
   
8. Ensure that provider rights are upheld in fraud and abuse investigations of home health agencies.
   
   
9. Promote consistent application of Medicare coverage rules throughout the country.
   
   
10. Establish minimum training requirements for surveyors and FI reviewers.
    
    
11. Limit medical review to 4% of claims submitted, except in cases of demonstrated cause.
    
    
12. Ensure fairness in implementation of HCFA guidelines for home health and hospice focused medical review.
    
    
13. Ensure statistically valid sampling methodology for post-payment review and overpayment projections.
    
    
14. Increase flexibility in the application of the CoP for non-Medicare patients (e.g., plan of care, OASIS).
    
    
15. Ensure Medicaid access through appropriate home care reimbursement rates.
    
    
16. Guarantee appropriate interest payment to agencies where reimbursement delays are caused by HCFA or the FI.
    
    
17. Modify the definition of a "visit" under the Medicare home health benefit to encourage appropriate use of technological advances in the delivery of home care services (such as telehomecare).
    
    
18. IPS: Grant forgiveness for per-beneficiary limit overpayments where care was necessary and costs reasonable and allow repayment flexibility for home health overpayments.
    
    
19. Promote Medicare-Medicaid coordination for dually eligible patients.
    
    
20. Require reasonable regulations for surety bond requirements (home health) and 117 (HME).
    
    

TABLE OF CONTENTS

1. REIMBURSEMENT REFORM
   
   PROSPECTIVE PAYMENT SYSTEM (PPS)
   
   
   1. PROMOTE USE OF AN EQUITABLE PPS WITH AN ADEQUATE CASE-MIX ADJUSTER
   2. ELIMINATE LOW UTILIZATION PAYMENT ADJUSTMENT FROM PPS SYSTEM
   3. MODIFY OUTLIER PAYMENT METHODOLOGY UNDER PPS
   4. ENSURE ADEQUATE CASH FLOW UNDER PPS
   5. ADDRESS POST-PPS COST REPORTING TRANSITION PLAN
      
      
   INTERIM PAYMENT SYSTEM (IPS)
   
   
   6. CLARIFY THAT EXCEPTIONS APPLY TO BOTH THE PER VISIT COST LIMITS PER-BENEFICIARY LIMITS
   7. ENSURE REPAYMENT FLEXIBILITY FOR HOME HEALTH OVERPAYMENTS
   8. ONLY PRORATE THE PER BENEFICIARY LIMITS WHEN PATIENTS ARE SERVED BY MORE THAN ONE AGENCY TO CIRCUMVENT THE LIMITS
   9. DELETE THE APPLICATION OF EXTENDING SAVINGS FROM THE FREEZE THE PER-BENEFICIARY LIMIT
      
      
   OTHER
   
   
   10. REIMBURSE HOME HEALTH AGENCIES FOR TELEHEALTH AND PROVIDE FOR REGULATORY FLEXIBILITY
   11. ENSURE USE OF STATISTICALLY VALID SAMPLING METHODOLOGY FOR POSTPAYMENT REVIEW *
   12. ENSURE NORMATIVE STANDARDS BASED ON ADEQUATE DATA TO PROMOTE APPROPRIATE UTILIZATION
   13. ENSURE HOME CARE SERVICES UNDER MANAGED CARE
   14. ENSURE APPROPRIATE COST FINDING METHODOLOGY
   15. ENSURE ACCESS TO MEDICAID HOME CARE SERVICES *
   16. FULLY REIMBURSE HOME HEALTH AGENCIES FOR COSTS OF IMPLEMENTING OASIS; LIMIT OASIS COLLECTION AND REPORTING REQUIREMENTS
   17. DEVELOP NATIONAL STANDARDS FOR MEDICARE PAYMENT CRITERIA *
   18. CHANGE OWNER & EXECUTIVE COMPENSATION SCREENS
   19. ENSURE ACCESS TO REVIEW OF MEDICARE REIMBURSEMENT DECISIONS *
   20. PROMOTE MEDICARE-MEDICAID COORDINATION *
   21. ELIMINATE THE LESSER-OF-COSTS-OR-CHARGES PRINCIPLE
   22. CONTROL FRAUD AND ABUSE *
   23. REVISE MEDICARE SECONDARY PAYER RULES *
   24. ENSURE APPLICATION OF PROFESSIONAL AUDITING AND ACCOUNTING STANDARDS
   25. ENSURE YEAR 2000 PROTECTIONS FOR HHAS
   26. ESTABLISH "PROVIDER-BASED" AGENCY REQUIREMENTS THAT ARE RELATED TO THE STEP-DOWN ALLOCATION
       
       
2. SURVEY AND CERTIFICATION
   
   
   1. INCREASE TRAINING FOR HOME HEALTH AND HOSPICE SURVEYORS *
   2. ABOLISH PRESCRIPTIVE AND BURDENSOME PROCEDURAL REQUIREMENTS RELATED TO VERBAL ORDERS *
   3. MAKE PERSONNEL QUALIFICATIONS CONSISTENT AND REQUIRE CRIMINAL BACKGROUND CHECKS *
   4. SUPPORT REQUIRED QUALITY IMPROVEMENT PROGRAM
   5. CLARIFY SEPARATE ENTITY *
   6. CONTINUE TO ALLOW HHAS TO PROVIDE SERVICES UNDER ARRANGEMENTS
   7. CONTINUE FLEXIBILITY IN REQUIRED COVERED SERVICES PROVIDED BY HHAS
   8. INCREASE FLEXIBILITY IN THE APPLICATION OF THE CONDITIONS OF PARTICIPATION
   9. ESTABLISH BRANCH OFFICE AND SERVICE AREA REQUIREMENTS THAT REFLECT QUALITY MEASURES
   10. FOCUS AIDE SUPERVISION ON INDIVIDUAL AIDES RATHER THAN EACH PATIENT *
   11. IMPROVE AIDE QUALIFICATIONS TO PROTECT CONSUMERS *
   12. REQUIRE REGION OFFICE REVIEW OF CHALLENGES TO DEFICIENCIES *
   13. DEVELOP APPROPRIATE REGULATION FOR EQUITABLE IMPLEMENTATION OF OBRA-87 SANCTIONS *
       
       
3. ADMINISTRATION
   
   
   1. ENSURE INDUSTRY PARTICIPATION IN DEFINING HOMEBOUND BASED ON PATIENT STATUS
   2. ENSURE PROVIDER RIGHTS *
   3. ENSURE REASONABLE APPLICATION AND IMPLEMENTATION OF HOME HEALTH SURETY BOND REQUIREMENT
   4. REFINE CLAIMS REVIEW *
   5. ESTABLISH REFERRAL STANDARDS AND DISCHARGE PLANNING REGULATIONS THAT ENSURE PATIENT CHOICE AND EQUAL ADVANTAGE TO ALL PROVIDERS
   6. CONTROL PAPERWORK BY REQUIRING HCFA TO FOLLOW THE PAPERWORK REDUCTION ACT *
   7. MODIFY PAYMENT TO PHYSICIANS FOR CARE PLAN OVERSIGHT *
   8. CLARIFY THE ROLE OF PHYSICIANS
   9. REFRAIN FROM IMPOSING MANDATORY MEDICAL DIRECTOR REQUIREMENTS UNTIL THE NEED AND IMPACT ARE STUDIED
   10. PROVIDE ACCURATE INFORMATION TO CONSUMERS AND PHYSICIANS
   11. CLASSIFY CLAIMS CURRENTLY SUBJECT TO TECHNICAL DENIALS AS "INCOMPLETE CLAIMS"
   12. STUDY THE FEASIBILITY OF TREATMENT CODES
   13. INCREASE INFORMATION AND REQUIREMENTS FOR NEW AGENCIES *
   14. STRENGTHEN REQUIREMENTS FOR PUBLICATION OF POLICY CHANGES BY HCFA *
   15. ENSURE REASONABLE PARTICIPATION REQUIREMENTS FOR HOME HEALTH AGENCIES
       
       
4. COVERAGE OF SERVICE
   
   
   1. PROMOTE CONSISTENT APPLICATION OF HIM-11 COVERAGE RULES
   2. ELIMINATE 485 DOCUMENTATION OF THE END POINT FOR DAILY SERVICE
   3. ENSURE DELIVERY OF NEEDED SERVICES TO MEDICARE BENEFICIARIES RESIDING IN ASSISTED LIVING FACILITIES
      
      
5. OTHER
   
   
   1. PROMOTE PROVIDER RIGHTS & OPPORTUNITIES TO COMPETE THROUGH EFFECTIVEENFORCEMENT OF ANTITRUST LAWS *
   2. PROMOTE CONSISTENT RULES FOR DISPENSING OF DRUGS *
   3. SUPPORT EFFORTS THAT FACILITATE APPROVAL AND PROMOTE COST EFFECTIVENESS OF CLIA WAIVED TESTS *
   4. DEVELOP QUALITY OF CARE STANDARDS FOR CONSUMER-DIRECTED CARE
   5. IMPLEMENT A COMPREHENSIVE HOME CARE BENEFIT IN THE MILITARY HEALTH SERVICES SYSTEM
   6. MONITOR STATE AND DEPARTMENT OF EDUCATION REGULATIONS FOR THE INDIVIDUALSWITH DISABILITIES EDUCATION ACT (IDEA)
   7. INFLUENCE OSHA REGULATIONS AND ENFORCEMENT AS APPROPRIATE TO THE HOME CARE AND HOSPICE SETTING *
   8. MAXIMIZE USE OF HHAS IN CASE MANAGEMENT
   9. AUTHORIZE THE USE OF ELECTRONIC SIGNATURES AND ENCOURAGE COMPUTER RECORD-KEEPING *
      
      
6. HOSPICE
   
   
   1. ABOLISH PAYMENT DELAYS CAUSED BY SEQUENTIAL BILLING POLICY FOR HOSPICE
   2. CLARIFY THE "95% RULE" FOR HOSPICE PATIENTS IN NURSING FACILITIES
   3. ENCOURAGE ACCOUNTABILITY FOR HOSPICE UTILIZATION
   4. STUDY HOSPICE REIMBURSEMENT FOR DUALLY ELIGIBLE PATIENTS RESIDING IN NURSING FACILITIES
   5. SUPPORT PROPOSED QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT PROGRAM FOR HOSPICE
   6. ESTABLISH HOSPICE MULTIPLE LOCATION AND SERVICE AREA REQUIREMENTS THAT REFLECT QUALITY MEASURES
   7. OPPOSE EFFORTS TO REQUIRE PHYSICIAN CERTIFICATION FORMS TO INCLUDE A FALSE CLAIMS WARNING
   8. MODIFY HOSPICE REGULATIONS FOR INPATIENT RESPITE CARE
   9. BASE SURVEY FREQUENCY FOR MEDICARE HOSPICE PROVIDERS ON PERFORMANCE
   10. ENCOURAGE PUBLICATION OF PROPOSED HOSPICE CONDITIONS OF PARTICIPATION (COP) BY THE END OF 2000
   11. ENSURE TIMELY UPDATE OF HOSPICE LOCAL MEDICAL REVIEW POLICIES
   12. CLARIFY HMO HOSPICE SERVICES TO MEDICARE BENEFICIARIES
   13. ENSURE ACCESS TO DRUGS NECESSARY FOR PAIN CONTROL
       
       
7. HOME MEDICAL EQUIPMENT
   
   
   1. PROTECT HOME OXYGEN SERVICES
   2. INCORPORATE HME COMMUNITY INPUT IN HCFA'S INHERENT REASONABLENESS AUTHORITY
   3. LIMIT HME COMPETITIVE BIDDING DEMONSTRATION SITES
   4. ALLOW FAXED CERTIFICATES OF MEDICAL NECESSITY FOR HME AND STREAMLINE THE CMN PROCESS FOR HHAS THAT PROVIDE HME SUPPLIES
   5. ENSURE APPROPRIATE HME SURETY BOND REQUIREMENT
      
      

* Applies to both home health and hospice.

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