NAHC Submits Formal Comments to CMS on the 2015 Prospective Payment System Rate Update
September 5, 2014 11:17 AM
The National Association for Home Care & Hospice (NAHC) recently submitted formal comments to the Centers for Medicare and Medicaid Services (CMS) on the proposed rule entitled, “Medicare and Medicaid Programs: CY 2015 Home Health Prospective Payment System Rate Update; Home Health Quality Reporting Requirements, and Survey and Enforcement Requirements for Home Health Agencies.” This proposal includes the 2015 Medicare home health payment rates, outlier payment standards, and new CBSA designations for the wage index. It also includes significant regulatory proposals on the physician face-to-face encounter rule, modified requirements for therapy assessments, and new OASIS submission requirements along with a solicitation of input on a Value-Based Purchasing model and guidelines on when patients are unable to self-inject insulin.
NAHC provided comments on all of the CMS proposals.
2015 HHPPS PAYMENT RATES
The 2015 proposed rule includes the second year phase-in of the most significant change in payment rates since the inception of the Home Health Prospective Payment System in October 2000. In its comments, NAHC expressed that over 57% of existing home health agencies (HHAs) will be paid less than the cost of care under the continuing rate rebasing. NAHC views the rebasing methodology to be inconsistent with the rate rebasing authority delegated by Congress to CMS, counter to the publicly available data set out in Medicare cost reports, and a vast regulatory overreach if the goal is to reset payment rates while maintaining access to essential services.
Overall, NAHC recommended that CMS utilize a fairer and more accurate approach to rate rebasing as the methodology employed for the rate rebasing presents serious care access consequences. The problems with the methodology outlined by NAHC in its comments include:
It limits rebasing consideration to an “average cost” end product with no consideration of what it takes to maintain access to care. A “zero margin” approach to HHA rate setting will result in a significant loss of access to care.
It splits a bundled payment model into four distinct components where the sum of the parts is less than the whole.
It relies on proxies for payment and cost determinations while such are readily available from cost report data.
It does not properly forecast the impact of rate cuts that succeed the base data year used.
It fails to account for and address the wide range in revenue/cost per episode experience by disparately located HHAs serving a very diverse patient population. A single payment rate adjusted with available adjusters leads to significant payment inaccuracies requiring a rate “cushion” to maintain access to care.
It does not recognize all current costs, in particular new regulatory compliance costs and the use of clinical technologies and services permitted to be used in a home health episode of care.
It neglects to factor in the essential need for operating capital.
While setting out a series of specific recommendations for change in the rebasing methodology, NAHC recommended overall that CMS should “return to the drawing board.” Specifically, NAHC recommended that all methodological and calculation options should be explored and evaluated by CMS. The option that results in the greatest degree of financial stability in the delivery system should be implemented. With an additional year of cost/revenue data from 2013 now available, CMS can determine whether the current rebasing methodology achieves the essential outcome of providing sufficient payment to assure access to high quality care nationwide.
Case Mix Adjuster Weights Recalibration
The proposed rule also includes a complete recalibration of the case mix weights for the 153 case mix categories. In its comments, NAHC explains that the recalibrations cannot be sufficiently evaluated as CMS has not provided full and adequate technical information and data on the nature and basis for the changes in case mix adjuster weights. Unlike previous recalibrations, CMS has not provided a technical report so that stakeholders such as NAHC have the opportunity to fully review the proposed action.
NAHC notes that the lack of transparency is especially concerning the changes in weights given to the therapy utilization variables. The proposed rule references that “(t)hese adjustments were made to discourage inappropriate use of therapy while addressing concerns that non-therapy services are undervalued.” As such, it is confusing how the ultimate case mix weights for therapy related episodes disproportionately increase over those with limited or no therapy visits.
Under the proposal, payment levels for episodes with 20+ therapy visits increase significantly while CMS claims to have reduced the impact of high volume visits on the case mix weights.
NAHC’s comments express that:
“It is essential that CMS fully validate the recalibration before implementation. It would be very valuable for CMS to make public the complete technical report on the recalibration methodology and regression analysis to allow stakeholders to conduct their own comprehensive evaluations as well. With the criticisms levied on the home health industry over the years related to therapy utilization, we are concerned that the increased payment rates will be viewed again as incenting the overutilization of therapy visits. We have long supported a reform of the HHPPS case mix adjuster model to eliminate the Service Utilization domain. We hope that CMS efforts in that regard are progressing smoothly.”
Outlier Payment Proposal
The proposed Outlier episode policy remains the same as in 2013 and 2014. This had led to Medicare under-spending the outlier budget in previous years. In other words, CMS has deprived HHAs that provide outlier care with appropriate reimbursement. NAHC recommended that it would be reasonable and prudent to adjust the loss-sharing ratio to address the estimated shortfall in spending. Also, this approach would not increase the number of episodes subject to outlier payments. Instead, it would more fairly reimburse them.
Wage Index Changes
CMS proposes to transition to new wage index geographic area designations using revised OMB standards in 2015. NAHC comments expressed support for this transitional blending as a way to avoid significant, overnight shifts in the wage index values for certain CBSAs. At the same time, NAHC recommends that CMS extend the rural add-on in 2015 to all geographic areas considered rural in either the 2014 or 2015 area designations. In 2006, CMS denied rural providers the add-on if the service area lost its rural status in the transition to new CBSAs. However, NAHC contends that it is necessary to provide the former rural areas with the add-on to be consistent with the policy behind the transition blend. Otherwise, 106 counties will face a significant, overnight reduction in reimbursement—the exact consequence that CMS is attempting to avoid with the transition blend of 2014 and 2015 CBSA designations.
FACE-TO-FACE PHYSICIAN ENCOUNTER RULE
NAHC wholeheartedly supports the proposal to eliminate the narrative requirement in the face-to-face physician encounter rule. However, NAHC comments explain that CMS must consider further actions to deal with the difficulties faced by home health agencies in past months as they attempted in good faith to comply with the full requirements of the face-to-face rules. In that regard, NAHC recommended that there are reasonable steps that CMS can take to remedy the concerns related to the past claim denials that were issued solely on the basis of an insufficient physician narrative, including a reopening and payment of those denials solely based on an insufficient narrative. The NAHC recommendations are as follows:
CMS should reopen any claim denials that were based on the sufficiency of the narrative and return any monies recouped from HHAs subject to such denials
Alternatively, CMS should provide clarifying guidance on what constitutes a “sufficient” narrative and instruct Medicare contractors to find that any HHA claim that includes a narrative of any form or content should not be subject to recovery based on a finding that any such provider is without fault in receiving payment.
CMS should suspend any auditing of the face-to-face physician narratives on the basis that the NPRM makes clear that such audits are fraught with subjectivity and victims of unclear standards of narrative sufficiency.
New Proposed Requirement on Physician Documentation
CMS proposes to institute a new documentation requirement relative to the physician face-to-face encounter requirements. The new standard would require that a certifying physician maintain sufficient documentation in his/her own files to support the certification. NAHC objected to the proposal that the certifying physician have sufficient documentation within his/her files to support the homebound and skilled care need certification.
NAHC comments state,
“Creating responsibility and liability over something outside the control of an entity is actually a step more problematic than the narrative requirement that is proposed for elimination because of the burdens and problems it created. While we firmly support the proposed elimination of the narrative requirement, substituting the proposal that requires HHAs to ensure that the documentation in a physician’s file is sufficient will only make matters worse. Neither requirement should be used.”
NAHC recommended that CMS should withdraw its proposal to require that HHA be responsible for the documentation contained in certifying physician’s patient files. A determination as to the validity of a certification and the patient’s entitlement to Medicare coverage should be based upon the overall patient record. NAHC also recommended that CMS provide training on the F2F requirements to physicians and home health agencies along with issuing improved guidance on standards of documentation.
The CMS proposed rule included two other changes relevant to the face-to-face encounter rule. First, CMS proposes to deny physician payment for care plan certification if the home health is denied payment for certain reasons. Also, CMS proposes to require an additional face-to-face documentation when a patient is discharged from care with goals met and is readmitted before the expiration of the 60-day episode. NAHC recommended that CMS withdraw both proposals.
Proposed Changes to Therapy Reassessments
NAHC comments support the elimination of the requirement that professional therapists reassess patients on the 13th and 19th visit. However, NAHC recommended that CMS modify its proposal to require a therapy assessment every 14 days, instead using a 30 day standard.
Insulin Injections Coverage
CMS proposes to require an additional diagnosis on claims that supports why a diabetic patient who requires skilled nursing visits to inject insulin is not able to self inject. NAHC comments agree with CMS’ proposed policy to require inclusion on claims of a diagnosis that supports why a diabetic patient requires skilled nursing visits to inject insulin. NAHC also agreed that the conditions on the list in the proposed rule would support a patient’s inability to self inject insulin. However, NAHC expressed concern as to whether the list is a comprehensive list.
NAHC recommended that in cases where a patient possesses an insulin pen and /or a second diagnosis is either absent or is not a condition that CMS has included on a their list of acceptable conditions, that the Medicare claims review contractors be required to review the entire medical record to determine whether skilled nursing visits are required to inject insulin. Determining whether skilled nursing visits for insulin injections are reasonable and necessary Medicare services can only be accomplished through a complete review of the medical record. Further, NAHC recommended that the coverage standards should be developed and implemented through the CMS National Coverage Determination process.
OASIS Data Submission
CMS proposes to define a more explicit performance requirement for the submission of OASIS quality data in order for home health agencies to receive the full market basket update for the payment year. Agencies that do not submit the required quality data receive a 2% reduction in payments. NAHC supports the three year phase-in of the new requirement and is asking for clarifications on the standards for submission and acceptance along with the application of the rule to follow-up assessments. NAHC also recommends that HHAs be given compliance training and at least 6 months lead time for compliance.
Value Based Purchasing
CMS sets out, in the NPRM, a base-level concept of a value-based purchasing (VBP) model and invites comments on it and a possible implementation in the near future. The presentation is not a formal proposal or rule change. Instead, it is an early invitation to comment on the development of a VBP in Medicare home health services.
NAHC has long supported the development and implementation of a reasonable VBP as providers should be encouraged and rewarded for positive patient outcomes. In its comments, NAHC sets out 10 principles for a reasonable and reasoned VBP. NAHC expressed in its comments that the CMS outline of VBP in the NPRM falls short of the detail necessary to offer in-depth constructive comments on the VBP model itself.
However, the VBP outline does include two elements that are essential parts of any VBP roll-out: the pilot test framework and the amount (range) of payment that would be withheld to finance the incentive pool. As set out, NAHC explained that there are serious concerns regarding CMS’s potential VBP. In that regard, NAHC objected to the use of a 5-8% payment withhold for a VBP along with the use of an untested VBP on a mandatory basis in 5-8 states as CMS suggests.
The full comments submitted by NAHC are available here.
To view all 354 comments submitted to CMS, go here.
CMS is expected to issue a Final Rule no later than November 2, 2014. If CMS is true to its usual schedule, the Final Rule may be released at 4:15PM ET on October 31.