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) 1998 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.
The 1999 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 three years. The Blueprint addresses current and anticipated regulations, providing insight into the problems posed, solutions, and their rationale.
Financial survival is of greatest concern to all 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, administrative, coverage, and other. A separate section has been established for 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 home care regulatory priorities appear below.
- Promote development of an equitable PPS with an adequate case-mix adjuster.
- Fully reimburse agencies for the cost of implementing OASIS; schedule OASIS implementation based on PPS data needs.
- Ensure repayment flexibility for home health overpayments: Establish an outlier or exceptions process to IPS payment limits for patients with extensive care needs.
- Abolish payment delays caused by the sequential billing policy.
- Ensure industry participation if defining homebound based on patient status.
- Ensure repayment flexibility for home health overpayments: Grant forgiveness for per beneficiary limit overpayments where care was necessary and costs reasonable.
- Ensure use of statistically valid sampling methodology for post-payment review.
- Ensure repayment flexibility for home health overpayments: Suspend per beneficiary limits under IPS once budget targets are achieved.
- Refine claims review: require RHHIs to make coverage determinations within a reasonable time for claims under prepayment review.
- Abolish payment delays caused by sequential billing: Guarantee appropriate interest payments to agencies where reimbursement delays are caused by HCFA or the RHHI.
R1. PROMOTE DEVELOPMENT OF AN EQUITABLE PPS WITH AN ADEQUATE CASE MIX ADJUSTOR
R2. ABOLISH PAYMENT DELAYS CAUSED BY SEQUENTIAL BILLING POLICY
R3. REIMBURSE HOME HEALTH AGENCIES FOR TELEHEALTH AND PROVIDE FOR REGULATORY FLEXIBILITY
R4. CLARIFY THAT EXCEPTIONS APPLY TO BOTH THE PER VISIT COST LIMITS AND PER BENEFICIARY LIMITS
R5. ENSURE USE OF STATISTICALLY VALID SAMPLING METHODOLOGY FOR POSTPAYMENT REVIEW
R6. ENSURE NORMATIVE STANDARDS BASED ON ADEQUATE DATA TO PROMOTE APPROPRIATE UTILIZATION
R7. ENSURE REPAYMENT FLEXIBILITY FOR HOME HEALTH OVERPAYMENTS
R8. ENSURE HOME CARE SERVICES UNDER MANAGED CARE
R9. ENSURE APPROPRIATE COST FINDING METHODOLOGY
R10. ONLY PRORATE THE PER BENEFICIARY LIMITS WHEN PATIENTS ARE SERVED BY MORE THAN ONE AGENCY TO CIRCUMVENT THE LIMITS
R11. ENSURE ACCESS TO MEDICAID HOME CARE SERVICES
R12. DELETE THE APPLICATION OF EXTENDING SAVINGS FROM THE FREEZE TO THE PER BENEFICIARY LIMIT
R13. FULLY REIMBURSE HOME HEALTH AGENCIES FOR COSTS OF IMPLEMENTING OASIS; SCHEDULE OASIS IMPLEMENTATION BASED ON PPS DATA NEEDS
R14. ASSIGN THE MEDIAN OF THE COST LIMITS FOR THE CENSUS DIVISION FOR NEW PROVIDERS
R15. APPLY LIMITS IN THE AGGREGATE ACROSS WAGE INDEX AREAS
R16. CLARIFY THE "95% RULE" FOR HOSPICE PATIENTS IN NURSING FACILITIES
R17. DEVELOP NATIONAL STANDARDS FOR MEDICARE PAYMENT CRITERIA
R18. CHANGE OWNER & EXECUTIVE COMPENSATION SCREENS
R19. ENSURE ACCESS TO REVIEW OF MEDICARE REIMBURSEMENT DECISIONS
R20. ENCOURAGE ACCOUNTABILITY FOR HOSPICE UTILIZATION
R21. PROMOTE MEDICARE-MEDICAID COORDINATION
R22. CONTROL FRAUD AND ABUSE
R23. PUBLISH ACCURATE COST LIMITS ON A TIMELY BASIS AND ADJUST FOR NEW REQUIREMENTS
R24. ELIMINATE THE LESSER-OF-COSTS-OR-CHARGES PRINCIPLE
R25. REVISE MEDICARE SECONDARY PAYOR RULES
R26. ENSURE APPLICATION OF PROFESSIONAL AUDITING AND ACCOUNTING STANDARDS
R27. ENSURE YEAR 2000 PROTECTIONS FOR HHAs
R28. ESTABLISH "PROVIDER-BASED" AGENCY REQUIREMENTS THAT ARE RELATED TO THE STEP-DOWN ALLOCATION
R29. ENSURE HOSPICE INDUSTRY PARTICIPATION IN THE DEVELOPMENT AND IMPLEMENTATION OF A HOSPICE COST REPORT
R30. STUDY HOSPICE REIMBURSEMENT FOR DUALLY ELIGIBLE PATIENTS RESIDING IN NURSING FACILITIES
R31. INCREASE TRAINING FOR HOME HEALTH AND HOSPICE SURVEYORS
R32. ABOLISH PRESCRIPTIVE AND BURDENSOME PROCEDURAL REQUIREMENTS RELATED TO VERBAL ORDERS
R33. MAKE PERSONNEL QUALIFICATIONS CONSISTENT AND REQUIRE CRIMINAL BACKGROUND CHECKS
R34. SUPPORT REQUIRED QUALITY IMPROVEMENT PROGRAM
R35. SUPPORT PROPOSED QUALITY ASSESSMENT/PERFORMANCE IMPROVEMENT PROGRAM FOR HOSPICE
R36. CLARIFY SEPARATE ENTITY
R37. CONTINUE TO ALLOW HHAs TO PROVIDE SERVICES UNDER ARRANGEMENTS
R38. CONTINUE FLEXIBILITY IN REQUIRED COVERED SERVICES PROVIDED BY HHAs
R39. INCREASE FLEXIBILITY IN THE APPLICATION OF THE CONDITIONS OF PARTICIPATION
R40. ESTABLISH BRANCH OFFICE AND SERVICE AREA REQUIREMENTS THAT REFLECT QUALITY MEASURES
R41. FOCUS AIDE SUPERVISION ON INDIVIDUAL AIDES RATHER THAN EACH PATIENT
R42. IMPROVE AIDE QUALIFICATIONS TO PROTECT CONSUMERS
R43. REQUIRE REGION OFFICE REVIEW OF CHALLENGES TO DEFICIENCIES
R44. DEVELOP APPROPRIATE REGULATION FOR EQUITABLE IMPLEMENTATION OF OBRA-87 SANCTIONS
R45. MODIFY HOSPICE REGULATIONS FOR INPATIENT RESPITE CARE
R46. BASE SURVEY FREQUENCY FOR MEDICARE HOSPICE PROVIDERS ON PERFORMANCE
R47. ENCOURAGE PUBLICATION OF PROPOSED HOSPICE CONDITIONS OF PARTICIPATION (CoP) BY THE END OF 1999
R48. ENSURE INDUSTRY PARTICIPATION IN DEFINING HOMEBOUND BASED ON PATIENT STATUS
R49. ENSURE PROVIDER RIGHTS
R50. ENSURE REASONABLE APPLICATION AND IMPLEMENTATION OF HOME HEALTH SURETY BOND REQUIREMENT
R51. REFINE CLAIMS REVIEW
R52. ESTABLISH REFERRAL STANDARDS AND DISCHARGE PLANNING REGULATIONS THAT ENSURE PATIENT CHOICE AND EQUAL ADVANTAGE TO ALL PROVIDERS
R53. CONTROL PAPERWORK BY REQUIRING HCFA TO FOLLOW THE PAPERWORK REDUCTION ACT
R54. MODIFY PAYMENT TO PHYSICIANS FOR CARE PLAN OVERSIGHT
R55. CLARIFY THE ROLE OF PHYSICIANS
R56. REFRAIN FROM IMPOSING MANDATORY MEDICAL DIRECTOR REQUIREMENTS UNTIL THE NEED AND IMPACT ARE STUDIED
R57. PROVIDE ACCURATE INFORMATION TO CONSUMERS AND PHYSICIANS
R58. CLASSIFY CLAIMS CURRENTLY SUBJECT TO TECHNICAL DENIALS AS "INCOMPLETE CLAIMS"
R59. STUDY THE FEASIBILITY OF TREATMENT CODES
R60. INCREASE INFORMATION AND REQUIREMENTS FOR NEW AGENCIES
R61. STRENGTHEN REQUIREMENTS FOR PUBLICATION OF POLICY CHANGES BY HCFA
R62. ENSURE APPROPRIATE ACCESS TO HOSPICE SERVICES FOR PATIENTS WITH "PALLIATIVE CARE" DRGs
R63. ENSURE TIMELY UPDATE OF LOCAL MEDICAL REVIEW POLICIES FOR HOSPICE
R64. ENSURE REASONABLE PARTICIPATION REQUIREMENTS FOR HOME HEALTH AGENCIES
R65. DEVELOP A MODEL HOSPICE COMPLIANCE PLAN IN COOPERATION WITH THE DEPARTMENT OF HEALTH AND HUMAN SERVICES OFFICE OF THE INSPECTOR GENERAL (OIG)
R66. PROMOTE CONSISTENT APPLICATION OF HIM-11 COVERAGE RULES
R67. ELIMINATE 485 DOCUMENTATION OF THE END POINT FOR DAILY SERVICE
R68. ENSURE DELIVERY OF NEEDED SERVICES TO MEDICARE BENEFICIARIES RESIDING IN ASSISTED LIVING FACILITIES
R69. CLARIFY HMO HOSPICE SERVICES TO MEDICARE BENEFICIARIES
R70. ENSURE TIMELY UPDATE OF LOCAL MEDICAL REVIEW POLICIES FOR HOSPICE
R71. PROMOTE PROVIDER RIGHTS & OPPORTUNITIES TO COMPETE THROUGH EFFECTIVE ENFORCEMENT OF ANTITRUST LAWS
R72. PROMOTE CONSISTENT RULES FOR DISPENSING OF DRUGS
R73. SUPPORT EFFORTS THAT FACILITATE APPROVAL AND PROMOTE COST EFFECTIVENESS OF CLIA WAIVED TESTS
R74. DEVELOP QUALITY OF CARE STANDARDS FOR CONSUMER-DIRECTED CARE
R75. INFLUENCE OSHA REGULATIONS AND ENFORCEMENT AS APPROPRIATE TO THE HOME CARE AND HOSPICE SETTING
R76. MAXIMIZE USE OF HHAs IN CASE MANAGEMENT
R77. ENSURE ACCESS TO DRUGS NECESSARY FOR PAIN CONTROL
R78. AUTHORIZE THE USE OF ELECTRONIC SIGNATURES AND ENCOURAGE COMPUTER RECORD-KEEPING
R79. PROTECT HOME OXYGEN SERVICES
R80. MAINTAIN INDUSTRY INPUT IN DETERMINING MEDICARE REIMBURSEMENT LEVELS FOR HME
R81. LIMIT HME COMPETITIVE BIDDING DEMONSTRATION SITES
R82. ANALYZE CONSOLIDATED BILLING FOR HME
R83. ALLOW FAXED CERTIFICATES OF MEDICAL NECESSITY FOR HME
R84. ENSURE APPROPRIATE HME SURETY BOND REQUIREMENT