CMS Releases its 2015 Home Care Proposed Payment Rule
Includes 2015 Payment Rates, Face-to-Face Physician Encounters Reform and Much More
July 8, 2014 01:24 PM
The Centers for Medicare and Medicaid Services (CMS) issued a proposed rule late Tuesday, July 1, that includes the usual annual payment rate update along with significant and positive changes to the documentation requirements in the face-to-face physician encounter requirements (F2F) and a host of other proposals that range from the mundane to the dramatic.
The CMS proposal on the F2F would eliminate the daunting, if not impossible, requirement that physicians provide a narrative explaining the patient’s homebound status and need for skilled care. Over recent months, a scourge of audits triggered wholesale retroactive claim denials nationwide based on allegations of insufficient narratives. The arbitrary claim denials triggered a lawsuit by the National association for Home Care & Hospice challenging the validity of the CMS requirement and its application to individual claims. While it can be expected that the issuance of a final rule dropping the narrative requirement will be forthcoming, NAHC continues to seek relief from the thousands of retroactive claim denials suffered by home health agencies.
The proposed rule includes:
2015 Home Health Prospective Payment System rates
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
Clarifications of the requirements for imposition of alternative Civil Money Penalty sanctions for CoP violations
Changes to recertification requirements
NAHC will be analyzing each of the proposals in depth over the coming weeks and will provide updated analysis on each matter proposed. Public comments are permitted through August 29 (the 60th day following publication). NAHC will be issuing draft comments to assist members who wish to submit comments. The rule is accessible here.
Below is a summary explanation of the proposed changes.
Face-to-Face Physician Encounter Documentation
CMS proposes to eliminate the requirement of a physician narrative as part of the F2F documentation requirements. In addition, CMS further proposes that the certifying physician must have sufficient documentation within his/her patient record to support his/her determination as to a patient’s eligibility for coverage, i.e homebound status and need for skilled care. Finally, CMS proposes that where a claim is denied because the certification/recertification was not complete or because there was insufficient documentation to establish eligibility, a physician’s claim for certification/recertification payment would also be denied.
CMS displays a detailed review of changes in Medicare home health utilization since the F2F rule took effect and concludes that the F2F requirement may be partially responsible, along with other matters, for a reduction in home health services utilization. Further, CMS outlines the series of concerns voiced by the home health industry over the F2F rule and its implementation, particularly the physician documentation requirements.
“[I]n an effort to simplify the face-to-face encounter regulations, reduce the burden for HHAs and physicians, and to mitigate instances where physicians and HHAs unintentionally fail to comply with certification requirements,” CMS proposes to;
Eliminate the narrative requirement
Focus claims reviews on the medical record for the patient from the certifying physician or acute/post acute care facility from which the patient was admitted to home health
Reject physician claims for payment where the HHA claim is non-covered because incomplete certification/recertification or insufficient documentation to support coverage
This proposal directly eliminates the unmanageable burden of the physician narrative on homebound and skilled care need. However, CMS makes no mention of relief from the past claim denials or any ongoing audits that may trigger additional denials prior to finalizing the rule. NAHC will be maintaining its lawsuit and other advocacy efforts until those matters are positively addressed and remedied.
An area in need of clarification is the proposal that determinations of a patient’s eligibility will be made “only [on] the medical record for the patient from the certifying physician or the acute/post acute care facility (if the patient in that setting was directly admitted to home health) used to support the physician’s certification of patient eligibility.” NAHC does not believe that this proposal shifts the narrative requirement from an F2F form to the physician’s general patient record. Instead, NAHC sees this proposal as necessitating that physician records contain enough information about the patient to support a finding of homebound and skilled care need. This may be problematic as HHAs cannot be assured that the physician has sufficient records any more than they can control the sufficiency of the soon-to-be-departed narrative requirement. NAHC’s position remains that homebound status and skilled care need should be determined based on the patient’s record as a whole, not just that of the certifying physician.
One way that HHAs can deal with this proposed requirement is to ensure that the certifying physician has all of the HHA clinical records in hand prior to the certification. This should include the OASIS and any other patient evaluations. With these records, the physician’s certification would be supported by sufficient documentation.
CMS is attempting to have the doctor take on some risk of noncompliant certifications, by proposing to deny physician claims for payment when the home health claim is rejected on certification/recertification grounds. This should have some affect, albeit minor, as the amount of payment involved is small and the frequency of such billings well below potential.
2015 HHPPS Payment Rates
The proposed changes to home health prospective payment rates are within NAHC’s expectations given the 4-year phase-in of rate rebasing that started in 2014. CMS is capped at reducing the base episode rate by no more than $80.95 which is equal to 3.5% of the 2010 base rates. The proposal imposes such a cut offset by the annual Market Basket Index (MBI) and the annual Productivity Adjustment which starts in 2015. While, the proposal does not reference the 2% sequestration, it is definitely expected that such will continue in 2015.
The proposed MBI is 2.6% offset by the Productivity Adjustment (labeled by CMS as “private nonfarm business multifactor productivity” or MFP) required under the Affordable care Act. In 2015 the adjustment is proposed at 0.4% leaving the update at a net of 2.2%
The proposed base episode rate for 2015 is set out at $2922.76. In contrast, the 2014 base rate is $2869.27. While that looks like a $53.49 increase, the reality is that payment rates are actually decreased as CMS also recalibrates the case mix adjustment weights that effectively reduce those weights in the aggregate by 2.37%. The recalibration is offset in the base rates by increasing that rate by 2.37% to achieve budget neutrality. That budget neutrality adjustment is responsible for making the base rate appear bigger than the 2014 rate.
It should be noted that the recalibration results in some weights increasing while others decrease, primarily therapy related episodes. The combination of the modified case mix weights and the change in base rate brings about the equivalent of about a 3 point reduction in payment levels that would have occurred in the absence of rebasing and about a 1 point reduction in effective payment levels compared to 2014.
The recalibration focuses on therapy episodes. CMS proposes to increase case mix weights by 3.75% for episodes with 0-5 therapy visits; decrease weights by 2.5% for episodes with 14-15 therapy visits; decrease weights by 5% for episodes with 20+ therapy visits; and institute gradual weight adjustments for episodes between those thresholds. CMS sets out a full chart of the recalibration changes in the proposed rule. NAHC will be evaluating the accuracy and validity of these proposed weight changes along with CMS’s calculation of the budget neutrality adjustment.
The added complication in rate comparisons is the proposed institution of a new CBSA designation for application of the area wage index. In 2015, CMS proposes to blend the wage indexes of the present CBSA designations with the new CBSA areas designated by the OMB in 2013. HHAs should evaluate the impact of the overall proposal using base payment rates, agency-specific case mix weight experiences, and the revised wage index.
The rate rebasing also affects LUPA payment rates. Those rates will rise 3.5% through rebasing and an additional 2.2% through the annual inflation update. Non-routine medical supply rates are also downwardly adjusted through the rebasing by a factor of 2.82 percent.
CMS explains that it will not make any adjustment in 2015 for nominal changes in case mix weights, a.k.a. case mix creep. It concludes that such an adjustment would reduce rates by as much as 2 percent. Instead of imposing such an adjustment, CMS intends to continue to monitor case mix changes further. This decision is welcomed by the home health industry that is facing potentially unsustainable rate rebasing cut. It is hoped that CMS maintains it position in the Final Rule.
With respect to outlier payments, CMS propose to keep the same 80% loss ratio and 0.45 Fixed Dollar Loss components to the outlier eligibility evaluation. CMS projects that such standards will result in spending 2.26 of the 2.5% outlier budget in 2015.
The 3% Rural Add-On continues in 2015 along with the 2% rate reduction for HHAs that fail to comply with the quality data submission requirements that involve OASIS and HHCAHPS.
Detailed rate tables are available in the proposed rule.
Several years ago, CMS instituted a requirement that has confused many and complicated the administration of therapy services within home health agencies. That requirement necessitates a professional therapy reassessment on the 13th and 19th visit of any episode that contains therapy services in excess of those levels. HHAs were forced to arrange services around that standard with additional complications in episodes where patients had more than one therapy discipline ordered.
NAHC long opposed the requirement and held to a position that any therapy reassessment should be based on time rather the number of visits. In the proposed rule, CMS would drop the current 13/19th visit standard and institute a requirement for a professional therapist visit/reassessment every 14 days. This approach is more in line with the NAHC standard, but may be more frequent than necessary for high quality care and appropriate care utilization. Nevertheless, we view it as step in the right direction and would hope that further improvements could be made through the Final Rule.
Current requirements tie Medicare payment rates to the submission of quality data. CMS includes OASIS data and HHCAHPS data as part of the quality data submission mandate. If an HHA fails to submit the required OASIS and HHCAHPS data, payment rates are reduced 2% for an entire year.
The level of OASIS submission required under current standards is minimal. If one OASIS submission occurs, the 2% penalty reduction is avoided. Of course, CMS has also tied OASIS submission to the conditions for payment, thereby creating the potential of a claim denial unless OASIS is submitted on all Medicare claims.
CMS proposes a new OASIS data submission requirement, phased in over a 3 year period beginning July 2015 with a 70% compliance standard, rising to 90% at 10 point increments of increase. The so-labeled “Quality Assessment Only” formula is an equation comparing the number of quality assessments to the combined number of quality assessments and non-quality assessments. “Quality Assessments” include most Start of care, Resumption of Care, and End of Care assessments of various kinds, but does not include limited SOC, ROC and EOC assessments and follow-up assessments. Definitely, some clarification around which must be submitted is needed. It is a safe bet that virtually OASIS will be required to be submitted for purposes of this rate impact.
CMS is proposing to increase the level of submissions required to avoid the 2% rate penalty through this proposal. In the first year, 70% of the number of OASIS calculated through formula must be submitted to avoid the rate penalty. In the second year, it rises to 80% and caps out at 90% in the third year. While few HHAs found themselves penalized in the past, the new requirement is likely to have a much greater impact. However, CMS may not have the systems available to accurately check HHA compliance levels. As such, HHAs should be prepared to acquire and maintain the documentation to support their achievement of compliance.
SPEECH-LANGUAGE PATHOLOGIST QUALIFICATIONS
CMS proposes to align the Medicare home health condition of participation regarding the qualifications of a speech-language pathologist (SLP) with the statutory standards under the Medicare law. Specifically, CMS proposes to require that an SLP be an individual who has a Masters or doctoral degree in speech-language pathology, and who is licensed as a SLP by the State in which he or she furnishes such services. If the state does not license SLPs, alternative qualifications exist although there are no states presently without licensure.
VALUE BASED PURCHASING
It has been a long time coming, but CMS has unveiled a potential pilot program on value based purchasing (VBP) in the proposed rule. The VBP model follows a path previously traveled with hospitals, but with some significant variation. Generally, a VBP program establishes a financial bonus pool funded by payment reductions to the provider group involved. Performance and outcome standards are established to determine which providers receive bonus payments. Those that do not meet the standards are left with lower payment revenues. Those that outperform the standards receive financial rewards.
CMS has not determined whether to move forward with VBP or what approach will be used. Instead, CMS has put out information about a possible model that may be implemented in 2016. CMS is inviting comment on how it should proceed.
NAHC has supported the use of VBP reimbursement provided it is based on reliable, risk adjusted measures and does not pose an access or quality of care problem for beneficiaries. As usual, the devil is in the details of the VBP model.
The VBP model put forward by CMS follows these general guidelines. However, the detailed part of the VBP model deserves special attention. First, the CMS model would reduce or increase Medicare payments in a range of 5-8 percent. This is in contrast with the current hospital VBP which puts at risk 1.25 percent rising gradually to 2.0 percent.
The VBP measures would be based on both achievement and improvement in quality outcomes. HHAs that reach a minimal threshold level in quality performance would receive the incentive bonus payments with the amount determined by the level of quality above the threshold. Performance and bonus payment determinations would be made based on an HHAs performance in comparison to other HHAs in the state.
CMS would institute the VBP program in 5-8 states. It would be a mandatory program in all the affected states.
In this proposed rule, CMS is inviting comment on the VBP model including the measures, performance standards, the amount of payment that is to be placed at risk, and the states chosen for the pilot.
At this point, the VBP model outlined by the state has only bare details. The proposed amount of payment at risk, 5-8%, is significantly higher that other VBP experiments. Since some HHAs will lose money with this model as HHAs are compared with others in the respectively chosen states, there is a serious question as to whether a 5-8% makes sense.
In addition, what matters significantly are the measures used. No clue as to the likely measures is offered. It is very difficult to provide helpful comments if the details of the potential system are absent. NAHC will work to get better details. If none are available, we will limit our comments to the bare structure outlined by CMS.
After nearly 50 years of the Medicare home health benefit, CMS has finally decided to develop some guidance on when it is necessary to have a home health nurse provide insulin injections to homebound patients. This may be good or it may be bad, but it is definitely an important coverage issue. Most outlier claims are involving patients who cannot self inject insulin. At the same time, proper management of an insulin-dependent diabetic can avoid countless costly hospitalizations. There have been abuses of the outlier payments in Medicare that le d to fraud investigations, convictions, and the institution of the annual outlier payment cap. At the same time, Medicare program changes should not create barriers for patients truly entitled to coverage of insulin injections and diabetic care.
The proposed rule includes CMS’s evaluation of the state of the art in insulin administration. In addition, CMS offers an analysis of what are the clinical and functional indications of a patient who may need another party to administer the insulin injections. Where is this all going?
First, CMS is not proposing any policy change at this time. Instead, it is inviting comment on its analysis and evaluation. Second, NAHC sees the presentation of the issue as a message that CMS will be doing something on the standards for coverage of home health insulin dependent patients in the near future. That “something’ could range from focused audits to the issuance of revised policy guidance to a formal rulemaking proceeding that would likely mean greater coverage restrictions. As such, NAHC recommends that HHAs ensure that they maintain solid and comprehensive documentation supporting the need for a nurse to provide the injections.
NAHC will be working on analyzing the clinical, operational, and financial issues surrounding the insulin injection concerns voiced by CMS. Any insights from the home health community will be greatly appreciated.
SURVEY and ENFORCEMENT REQUIREMENTS
As of July 1, HHAs are subject to the risk of the imposition of Civil Monetary Penalties (CMPs) for violations of Medicare Conditions of Participation. The CMPs can be as high as $10,000 a day or $10,000 for each instance of noncompliance. Existing rules provide appeal rights to HHAs so penalized.
CMS proposes to revised the appeal rules to limit the authority of Administrative Law Judges, state hearing officers, and other higher administrative review authorities. Under the proposal, if the appeal authority finds noncompliance, the authority cannot set the penalty at zero or reduce it to zero; review an exercise of discretion by CMS or the state in the imposition of the penalty; or consider any factors other than those specified in federal rules.
Home health agencies have no experience with CMPs as this is a new sanction. However, nursing facilities have faced CMPs for years. The proposed rule change is similar to that applying to nursing facilities.
CMS includes two technical changes that are of note.
A revision to the physician certification rule to clarify that if a beneficiary is discharged from home health services with goals met and no expectation of a return, a readmission to the HHA during the 60-day episode is a new start of care and a new certification rather than a recertification. This will affect the OASIS and certification process (including F2F), but it appears that CMS will still apply a PEP (Partial Episode Payment) adjustment.
While this change may seem minor, its impact cannot be understated. In addition to the need for Start of Care OASIS and all other CoP related admission requirements, the proposal would lead to a significant increase in F2F certifications. CMS estimates that an additional 830,287 episodes would require F2F certifications and documentation. NAHC sees no sense in such a change. First, the patient would have been under the active care of a physician as little as a day earlier, but no less than 59 days with an existing window of F2F allowing for encounters 90 days earlier. Second, CMS would be inconsistently treating these episodes as starts of care given the continuation of PEP adjustments that greatly reduce payments to the HHA.
A technical correction removing the “C” from the OASIS-C reference to achieve amore generic reference and uniformity with other regulations.
Overall, the rule is a combination of expected rate proposals, improved F2F requirements with some outstanding issues, slightly improved therapy assessment requirements, other modifications presented with a label of simplification and uniformity that could create greater administrative burdens for HHAs, hidden problems from minor technical changes, and big clues on future changes that are likely to surface such as Value Based Purchasing and restrictions on coverage of insulin injections.
CMS projects the overall financial impact of the payment rate changes to be $58 million in 2015. However, that is an understatement as it compares spending in 2014 to 2015 instead of what would occur in the absence of the proposals. CMS has used this improper impact analysis approach for years in all sectors. NAHC estimates the real impact (the difference between forecast payment and payment amounts in the absence of the rule) to be approximately $500 million in 2015 alone.