Record Recovery of $4 Billion last year

The CMS Fraud Prevention Initiative aims to ensure that correct payments are made to legitimate providers for covered appropriate and reasonable services in all federal health care programs. 

Fraud prevention efforts focus on moving CMS beyond its former “pay and chase” recovery operations to a more proactive “prevention and detection” model that will help prevent fraud and abuse before payment is made.  A good example is the recent CMS announcement that for the first time, through the use of innovative predictive modeling technology similar to that used by credit card companies, the agency will have the ability to use risk scoring techniques to flag high risk claims and providers for additional review and take action to stop payments and remove providers from the program when necessary.

This information is available in the CMS Fraud Prevention Toolkit on the web at https://www.cms.gov/Partnerships/04_FraudPreventionToolkit.asp.

HOME HEALTH AGENCIES SHARE $15 MILLION IN SAVINGS FROM CMS QUALITY DEMONSTRATION

PAY FOR PERFORMANCE (HHP4P) INTERVENERS USED EFFICIENCIES, QUALITY MEASURES TO CUT HH COSTS

The Centers for Medicare and Medicaid Services (CMS) announced on Tuesday, July 05, 2011 that it will share nearly $15 million in additional savings with more than 100 Home Health Agencies (HHAs) that participated in the intervention group of the two-year Medicare Home Health Pay for Performance (HHP4P) demonstration.

All Medicare-certified HHAs in seven states representing the four U.S. Census regions were invited to participate in the demonstration:  

• the Northeast included HHAs in Connecticut and Massachusetts,
• the South included HHAs in Alabama, Georgia, and Tennessee, and
• the Midwest and West regions included HHAs in Illinois and California, respectively. 

A total of 123 HHAs out of 270 participating in the demonstration intervention group will receive incentive payments from savings based on their performance during the second year of the Medicare HHP4P demonstration.   For Year 2, the demonstration calculated aggregate savings of $14.95 million for two of the four demonstration regions.  The Midwest and the Northeast regions did not achieve any savings and, therefore, were not eligible to receive incentives.

 

The Medicare HHP4P demonstration is still being evaluated, with additional results expected later in 2011.  For the detailed press release, click here - http://go.cms.gov/nNqdQT

CMS PROPOSES 2012 MEDICARE HOME HEALTH PAYMENT CHANGES

The Centers for Medicare & Medicaid Services (CMS) announced on  07/05/11 at 4:15pm a number of proposed changes to Medicare home health payments for 2012 that if finalized will promote greater efficiency and payment accuracy.

A proposed rule was displayed at the Federal Register proposing a 3.35 percent decrease in Medicare payments to home health agencies (HHAs) for calendar year (CY) 2012. This would be an estimated net decrease of $640 million compared to HHA payments in CY 2011.  It would include the combined effects of market basket and wage index updates (a $310 million increase) and reductions to the home health prospective payment system (HH PPS) rates to account for increases in aggregate case-mix that are largely related to billing practices and not related to  changes in the health status of patients (a $950 million decrease). 

Provisions of the Affordable Care Act (ACA) mandate that CMS apply a one (1) percentage point reduction to the CY 2012 home health market basket amount; this would equate to a proposed 1.5 percent update for HHAs next year.  As part of the HH PPS rate update, CMS also proposes to reduce HH PPS rates by 5.06 percent in CY 2012 to account for the increase in the case-mix that is unrelated to changes in patient acuity.

The Medicare HHA proposed rule would also make structural changes to the HH PPS by removing two hypertension codes from the case-mix system (401.1 & 401.9), lowering payments for high therapy episodes and recalibrating the HH PPS case-mix weights to ensure that these changes result in the same amount of total aggregate payments.

Comments should be received no later  than than 5 p.m. on Sept. 6, 2011. Click here for the actual publication - CMS-1353-P

Are You Submitting a Handwritten Medicare Enrollment Application?

Medicare enrollment application forms are fillable on your computer.  This means that you can fill out the information required by typing into the open fields while the form is displayed on your computer monitor.  Filling out the forms this way before printing, signing and mailing means more easily-readable information – which means fewer mistakes, questions, and delays when your application is processed.  Be sure to make a copy of the signed form for your records before mailing.

 

You’ll find the Medicare provider enrollment application forms available on the CMS website:

§  CMS 855A – Application for Institutional Providers

§  CMS 855B – Application for Clinics, Group Practices, and Certain Other Suppliers

§  CMS 855I  – Application for Physicians and Non-Physician Practitioners

§  CMS 855R – Application for Reassignment of Medicare Benefits

§  CMS 855S – Application for Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) Suppliers

 

Signatures are still required to be handwritten.  Don’t forget to complete this important step prior to mailing your typed form(s).

 

Keep in mind that typed forms are easier for Medicare to process, but the most efficient method for submitting your enrollment application is to use the Internet –Based Provider Enrollment, Chain and Ownership System (PECOS).  PECOS guides you through the enrollment application so you only supply information relevant to your application.  PECOS also reduces the need for follow-up because of incomplete applications.  Using Internet-based PECOS results in a more accurate application and saves you time and administrative costs.  Visit Internet-Based PECOS to learn more.

 

Three Reminders to Medicare Providers for Billing Correctly for Ordered/Referred Services

Any Medicare-enrolled Part B organizational provider, DMEPOS supplier, or Part A Home Health Agency (HHA) provider may file claims with ordering or referring information.

1.  There are three basic requirements for ordering and referring:

• The physician or non-physician practitioner must be enrolled in Medicare or in an opt-out status.
• The National Provider Identifier (NPI) used for ordering/referring must be for an individual physician or non-physician practitioner (cannot be an organizational NPI).
• The physician or non-physician practitioner must be of a specialist type that is eligible to order and refer.

If you don’t meet the three basic requirements listed above, refer to item #3 below on how to obtain an NPI and enroll in Medicare for ordering and referring purposes.

2.  Only Medicare-enrolled individual physicians and non-physician providers of a certain specialist type are eligible to order/refer for Part B and DMEPOS Medicare beneficiary services.  (Organizational providers cannot order and refer.)  Eligible individual physicians and non-physician providers include:

• Doctor of Medicine or Osteopathy
• Doctor of Dental Medicine
• Doctor of Dental Surgery
• Doctor of Podiatric Medicine
• Doctor of Optometry
• Doctor of Chiropractic Medicine
• Physician Assistant
• Certified Clinical Nurse Specialist
• Nurse Practitioner
• Clinical Psychologist
• Certified Nurse Midwife
• Clinical Social Worker

3.  In order to order/refer, the provider must have an enrollment record in PECOS.

• Providers who order or refer should verify their enrollment in PECOS.  Note that receiving payments from Medicare does not necessarily mean you have an enrollment record in PECOS.  The easiest way to check on enrollment status is by visiting internet-based PECOS at https://pecos.CMS.hhs.gov and navigating to the “My Enrollments” page; if no record is displayed, you do not have an enrollment record in PECOS.  (More detailed instructions on accessing and navigating internet-based PECOS are available here.)  Another option is to check the Ordering and Referring Report.

• If you believe an enrollment application has been submitted but no enrollment record exists in PECOS, check the list ofpending applications, available at http://www.CMS.gov/MedicareProviderSupEnroll/06_MedicareOrderingandReferring.asp(scroll to the “Initial Physician Applications Pending Contractor Review” in the Downloads section of the page).

• Providers with neither an enrollment record in PECOS nor an entry on the list of pending applications should make arrangements to submit their enrollment application.  Internet-based PECOS is the fastest and most efficient way to do so.  For instructions, review the Basics of Internet-based PECOS for Physicians and Non-Physician Practitioners.

For additional information, review the Medicare Learning Network’s “Medicare Enrollment Guidelines for Ordering/Referring Providers” fact sheet at http://www.CMS.gov/MLNProducts/downloads/MedEnroll_OrderReferProv_FactSheet_ICN906223.pdf.

 

HH Face-to-Face Encounter NO postponement

Subject: Home Health Face-to-Face Encounter Requirement

Effective April 1, 2011, the Centers for Medicare & Medicaid Services (CMS) expects home health agencies and hospices have fully established internal processes to comply with the face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient’s eligibility for Medicare home health services and of recertification for Medicare hospice services.

Section 6407 of the ACA established a face-to-face encounter requirement for certification of eligibility for Medicare home health services, by requiring the certifying physician to document that he or she, or a non-physician practitioner  working with the physician, has seen the patient.  The encounter must occur within the 90 days prior to the start of care, or within the 30 days after the start of care.  Documentation of such an encounter must be present on certifications for patients with starts of care on or after January 1, 2011.

Similarly, section 3131(b) of the ACA requires a hospice physician or nurse practitioner to have a face-to-face encounter with a hospice patient prior to the patient’s 180th-day recertification, and each subsequent recertification.  The encounter must occur no more than 30 calendar days prior to the start of the hospice patient’s third benefit period.  The provision applies to recertifications on and after January 1, 2011.

On December 23, 2010, due to concerns that some providers needed additional time to establish operational protocols necessary to comply with face-to-face encounter requirements mandated by the Affordable Care Act (ACA) for purposes of certification of a patient’s eligibility for Medicare home health services and of recertification for Medicare hospice services, CMS announced that it will expect full compliance with the requirements, beginning with the second quarter of CY2011.  

Throughout the first quarter of 2011, CMS has continued outreach efforts to educate providers, physicians, and other stakeholders affected by these new requirements.  CMS has posted guidance materials including a MLN Matters article, questions and answers documents,  training slides, and  manual instructions which are available via  CMS’ Home Health  Agency Center and Hospice webpages.  CMS’ Office of External Affairs and Regional Offices contacted state and local associations for physicians and home health agencies and advocacy groups to ensure awareness about the face-to-face encounter laws, and to distribute the educational materials. 

CMS will continue to address industry questions concerning the new requirements, and will update information on our Web site at http://www.cms.gov/center/hha.asp and http://www.cms.gov/center/hospice.asp.

How should Medicare payments change in 2012?

Report to the Congress: Medicare Payment Policy | March 2011

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SUMMARY OF RECOMMENDATIONS

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8-1 The Secretary, with the Office of Inspector General, should conduct medical review activities in counties that have aberrant home health utilization. The Secretary should implement the new authorities to suspend payment and the enrollment of new providers if they indicate significant fraud.

COMMISSIONER VOTES: YES 16 • NO 0 • NOT VOTING 0 • ABSENT 1

IMPLICATIONS

Spending

The Congressional Budget Office has already scored savings from the PPACA provision, so its baseline assumes savings for the new authorities. Implementing this authority for home health care would lower home health spending if fraud were discovered. CMS and the Office of Inspector General would incur some administrative expenses to conduct these activities.

Beneficiary and provider

Appropriately targeted reviews would not significantly affect beneficiary access to care or provider willingness to serve beneficiaries.

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8-2 The Congress should direct the Secretary to begin a two-year rebasing of home health rates in 2013 and eliminate the market basket update for 2012.

COMMISSIONER VOTES: YES 16 • NO 0 • NOT VOTING 0 • ABSENT 1

IMPLICATIONS

Spending

This recommendation would reduce Medicare spending $250 million to $750 million in 2012 and $5 billion to $10 billion over 5 years.

Beneficiary and provider

Some reduction in provider supply is likely, particularly in areas that have experienced rapid growth in the number of providers. Access to appropriate care is likely to remain adequate, even if the supply of agencies declines.

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8-3 The Secretary should revise the home health case-mix system to rely on patient characteristics to set payment for therapy and nontherapy services and should no longer use the number of therapy visits as a payment factor.

COMMISSIONER VOTES: YES 16 • NO 0 • NOT VOTING 0 • ABSENT 1

IMPLICATIONS

Spending

The approaches could be implemented in a budgetneutral manner and should not have an overall impact on spending.

Beneficiary and provider

This recommendation would increase payments for hospital-based agencies, rural agencies, and small agencies. Patients who need therapy may see some decline in access, but these services would be available on an outpatient basis after the home health episode ended.

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8-4 The Congress should direct the Secretary to establish a per episode copay for home health episodes that are not preceded by hospitalization or post-acute care use.

COMMISSIONER VOTES: YES 13 • NO 1 • NOT VOTING 2 • ABSENT

IMPLICATIONS

Spending

A copay of $150 per episode (excluding low-use and post-hospital episodes) would reduce Medicare spending $250 million to $750 million in 2012 and $1 billion to 5 billion over five years. Expenditures for services would decrease because some beneficiaries

who would otherwise use home health services might decline them. Since many of these services are funded by Part B, decreases in spending growth would reduce Part B premiums.

Beneficiary and provider

Some beneficiaries might seek services through outpatient or ambulatory care, for which Medicare already has cost-sharing requirements. Some beneficiaries who need relatively few services would have lower cost sharing if they substituted ambulatory care for home health care.

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Recommendation 3B-2A from the Commission’s March 2010 report

The Congress should direct the Secretary to expeditiously modify the home health payment system to protect beneficiaries from stinting or lower quality of care in response to rebasing. The approaches should include risk corridors and blended payments that mix prospective payment with elements of cost-based reimbursement.

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