Brady Anti-fraud Bill Addresses Drug Prescribing Issues for Hospices; Audit and Education Reform and DME F2F Modifications
December 9, 2014 01:23 PM
In recent weeks, the House Ways and Means Health Subcommittee Chairman Kevin Brady (R-TX) and Ranking Member Jim McDermott (D-WA) introduced the Protecting the Integrity of Medicare Act (PIMA) (H.R. 5780). The bill includes a provision that would impose a home health surety bond of not less than $50,000 that is “commensurate with the volume of payments to the home health agency.”
The bill also contains several provisions that would affect hospices and how they may administer certain controlled substances. While it appears that the legislation will not see action prior to the end of this legislative session, it may be a starting point for discussions early next year. Below is a synopsis of those issues:
Part D Enrollees at Risk for Abuse of Opioids, Other Pain Meds would have Limits on Prescribers, Pharmacies for these Drugs, with Exemption for Hospice Enrollees
As part of H.R. 5780, Rep. Brady and his colleagues seek to address concerns about potential “drug seeking” as part of the Medicare program through establishment of a drug management program for at-risk beneficiaries starting January 1, 2017. Under the program, Part D enrollees determined to be at-risk for prescription drug abuse could be limited to one or more physicians and one or more pharmacies for certain opioids and similar drugs. Once a beneficiary has been determined to be not at risk, he or she will be removed from the drug management program.
Part D plans will be expected to notify at-risk beneficiaries prior to their inclusion in the drug management program and to honor a beneficiary’s request regarding preferred pharmacy(ies) and provider(s), to the extent feasible. The legislation includes an exemption for Medicare hospice enrollees and other individuals as determined by the Secretary of Health and Human Services. It is important to note that while Medicare hospice patients will not be subject to enrollment in the drug management program, non-hospice patients (including those that receive Medicare services under a provider’s palliative care program) are not exempted as a class of individuals. An across-the-board exemption for palliative care patients would not be possible under Medicare since the program does not cover “palliative care” as a type of services.
NPI as Identifier for Part D Prescribers
Also included in the legislation is a provision that would require that CMS use the National Prescriber Identifiers (NPIs) as the only allowed prescriber identifier for the Medicare prescription drug program; in order for a prescription order to process under Part D, the prescription would be required to include a valid prescriber NPI. This provision would be effective for the 2016 Part D plan year.
It should be noted that under existing regulations CMS is requiring that, effective December 1, 2015, prescriptions may not be processed under the Medicare Part D program if the prescriber is not either:
Enrolled in Medicare in an approved status; or
Have a valid record of opting out
For additional information on this requirement, please see the following NAHC Report storyand Medlearn Mattersarticle.
H.R. 5780 also contains several other provisions that could affect both home care and hospice providers:
Audit and Education Reform
PIMA proposes to try to reduce claim errors through education, outreach, and provider supports. Originally, the sponsors intended to include reforms solely directed towards Recovery Audit Contractors (RACs) in an attempt to bring some transparency to the RAC audit process. As the bill developed, the focus shifted towards ways to reduce claim errors in the first place. It does not focus on any particular sector - as would have occurred with a RAC-directed approach that would have not had much impact in hospice or home health services.
NAHC had asked the sponsors for a broader focus that was designed as a preventative type measure as well.
Entitled as “Improper Payment Outreach and Education Program,” the bill proposes to reduce improper payments by requiring that each Medicare Administrative Contractor (MAC) establish an improper payment outreach and education program under which the contractor, through outreach, education, training, and technical assistance or other activities, provides detailed information about types of payment errors and how to avoid them.
Specifically, the contractors would be required to provide:
A list of the providers' or suppliers' most frequent and expensive payment errors over the last quarter.
Specific instructions regarding how to correct or avoid such errors in the future.
A notice of new topics that have been approved by the Secretary for audits conducted by RACs under section 1893(h).
Specific instructions to prevent future issues related to such new audits.
The final bill retains a focus on RACs to an extent, with requirements on the disclosure of information and data to Medicare administrative contractors to assist in carrying out their provider education requirements. The RACs would share data with other Medicare contractors - such as the identities of providers of services and suppliers that have the highest rate of improper payments, the greatest total dollar amounts of improper payments, the highest rates of improper payments, and the items and services that are responsible for the greatest amount of improper payments.
In discussions with Ways and Means Committee staff, NAHC was invited to continue a dialogue focused on reforms of non-RAC contractors that have been more involved in home health services and hospice claims audits.
DME Face-to-Face Physician Encounters
The bill proposes to expand the types of practitioners qualified to perform face-to-face encounters to support the certification of need for durable medical equipment to include Nurse Practitioners, Physician Assistants, and other non-physician practitioners. This change would establish standards comparable to those applied in the home health services face-to-face encounter requirements. However, hospice face-to-face encounters still require either a physician or a nurse practitioner.
If bill amendments are permitted with this legislation, NAHC will be pushing for expanding the authorization on non-physician practitioners to the hospice face-to-face encounter requirements.
An Update on the Surety Bond Proposal
Earlier this week, NAHC was informed that the PIMA bill, including the home health surety bond proposal, will not be brought up for a vote this year, meaning that NAHC and home health advocates can continue to make the case against imposing a surety bond requirement on all home health agencies, as well as to advocate for other issues addressed in this article. While there are some positive provisions contained in this legislation, there is now an opportunity to try modify the legislation prior to it being reintroduced next year during the new Congress.
To send a message through the NAHC Legislative Action Network opposing the home health surety bond proposal, click here: Write your Legislators.
For more on this legislation, please see NAHC Report, December 5, 2014.