Indiana Health Coverage Program Change in Medicare Replacement Claim Processing

The Office of Medicaid Policy and Planning (OMPP) published notice on May 31, 2013 that a change will be made on Medicare replacement claim processing.  For claims received on or after June 27, 2013, the Indiana Health Coverage Programs (IHCP) will require a claim filing indicator of "16" when providers file Medicare replacement plan claims through an 837 electronic data interchange (EDI) transaction and Web interChange. Previously, providers were instructed to use a claim filing indicator of "MA" or "MB" when filing Medicare replacement claims. The IHCP will begin to validate Medicare replacement plan payer IDs based on the contract number published by the Centers for Medicare & Medicaid Services (CMS).  To view the posting, see http://provider.indianamedicaid.com/news,-bulletins,-and-banners/news-summary/the-ihcp-to-implement-change-in-medicare-replacement-claim-processing-.aspx.

Indiana Medicaid Nursing Facility Rate Cuts to be Partially Restored

The Office of Medicaid Policy and Planning (OMPP) published notice on May 29, 2013 that it will reduce the existing nursing facility rate cut from 5% to 3% on January 1, 2014. The notice can be accessed in the Members Only section of the IHCA website. Once implemented, the reduction in the rate cut will be in effect at least until June 30, 2015.  This partial restoration of the rate cut is a direct result of the intense lobbying effort that IHCA led during the 2013 session of the Indiana General Assembly where IHCA staff and lobbyists contacted key legislative leaders and personnel within Governor Pence’s administration.

The reduction of the rate cut results in approximately $68M being restored to the Indiana Medicaid nursing facility rate.  Prior to the announcement of the partial rate restoration, the estimated impact of a 5% cut for State Fiscal Years 2014 and 2015 was $160M in Federal and State funds.  The reduction of the rate cut to 3% will result in an estimated impact of $92M in Federal and State funds during the same period, a restoration of approximately $68M.

More details will be forthcoming from OMPP on exactly which components of the rate will be impacted by the cut, but the general, and positive, financial impact noted above is welcomed good news.  Please contact Zach Cattell at zcattell@ihca.org or 317-616-9001 with any questions.

Value Based Purchasing State Plan Amendment Notice

The Office of Medicaid Policy and Planning (OMPP) published notice on May 29, 2013 to amend the Indiana Medicaid State Plan to implement the Value Based Purchasing (VBP) add-on to the nursing facility Medicaid rate. The notice can be accessed in the Members Only section of the IHCA website. The VBP add-on will replace the current Report Card Score add-on as of July 1, 2013.  Due to how the State Plan Amendment approval process works with CMS, IHCA expects retroactive adjustment of claims once the amendment is approved.  For more on the VBP add-on, click here to read more detail about the VBP program, including how to earn points under the new system, or contact Zach Cattell at zcattell@ihca.org or 317-616-9001.

Medicare Signature Requirements

Transmittal 465, CMS Manual System Pub 100-08 Medicare Program Integrity was released on May 17, 2013 (see http://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R465PI.pdf).  It clarifies the use of a rubber stamp for signature for medical review purposes. For those purposes, Medicare requires that services provided/ordered be authenticated by the author. The method used shall be a handwritten or electronic signature. Stamped signatures are not acceptable. There are four exceptions; Exception 4 has been added in the recent transmittal. The four exceptions are:

EXCEPTION 1: Facsimiles of original written or electronic signatures are acceptable for the certifications of terminal illness for hospice.
EXCEPTION 2: There are some circumstances for which an order does not need to be signed. For example, orders for some clinical diagnostic tests are not required to be signed. The rules in 42 CFR 410 and Pub.100-02 chapter 15, §80.6.1 state that if the order for the clinical diagnostic test is unsigned, there must be medical documentation (e.g., a progress note) by the treating physician that he/she intended the clinical diagnostic test be performed. This documentation showing the intent that the test be performed must be authenticated by the author via a handwritten or electronic signature.
EXCEPTION 3: Other regulations and the CMS’ instructions regarding conditions of payment related to signatures (such as timeliness standards for particular benefits) take precedence. For medical review purposes, if the relevant regulation, NCD, LCD and CMS manuals are silent on whether the signature needs to be legible or present and the signature is illegible/missing, the reviewer shall follow the guidelines listed below to discern the identity and credentials (e.g., MD, RN, etc.) of the signator. In cases where the relevant regulation, NCD, LCD and CMS manuals have specific signature requirements, those signature requirements take precedence.
EXCEPTION 4: CMS would permit use of a rubber stamp for signature in accordance with the Rehabilitation Act of 1973 in the case of an author with a physical disability that can provide proof to a CMS contractor of his/her inability to sign their signature due to their disability. By affixing the rubber stamp, the provider is certifying that they have reviewed the document.  

CMS Survey & Certification Memorandum 13-34-ALL – Mandatory Surveyor Training on Care of Persons with Dementia

CMS released S&C: 13-34-ALL that provides information about the third and final training video in the three-part series of mandatory surveyor trainings CMS has prepared on this topic.  The first two modules of the training program were released earlier this year. This third installment of the training addresses how to cite severity level and other aspects of deficiency citations in more detail, based on the new guidance at F309, Care of Residents with Dementia, and revised guidance at F329 referenced in S&C: 13-35-NH.  This training module is 35 minutes in length and will be available after May 31.  The memorandum provides instructions for accessing this content.

To access the memorandum, go to http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-13-34.pdf.

CMS Survey & Certification Memorandum 13-35-NH – Dementia Care and Reduction of Antipsychotic Drug Use

CMS released S&C 13-35-NH that clarifies Appendix P and Appendix PP of the State Operations Manual.  These revisions are to the surveyor guidance and re-emphasize key principles in nursing facility regulations.  Updates to Appendix P include changes to the resident sampling process for the traditional survey (changes to QIS were included in the recent 10.1.3 release), intended to ensure that the survey sample includes an adequate number of residents with dementia who are receiving an antipsychotic medication. 

Updates to Appendix PP include:
•             A new section of interpretive guidance at F309 related to the review of care and services for a resident with dementia;
•             Revisions to the antipsychotic medication section of Table 1 at F329;
•             New severity example at the end of the interpretive guidance at F329 (Unnecessary drugs);
 
A surveyor checklist that may be used in either the traditional or QIS process (modeled after the Critical Element pathways) is also provided  in the memorandum. This checklist is not part of the State Operations Manual.  To access the memorandum, go to http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Policy-and-Memos-to-States-and-Regions-Items/Survey-and-Cert-Letter-13-35.html?DLPage=1&DLSort=2&DLSortDir=descending (as of May 28, 2013, the advance copy of the memo has not been posted, but when it is it will be at this link).

Survey Schedule

The subcontractors have released a schedule for the resident, family/friend, and employee surveys, which is provided below:

• Resident Surveys (onsite at the facility)
o 200 facilities in July
o 200 facilities in August
o 80 facilities in September

• Family/Friend Survey (by mail)
o Wave 1 – July 1, 2013
o Wave 2 – July 22, 2013
o Wave 3 – August 5, 2013

• Employee Survey (by mail or internet)
o Wave 1 – July 1, 2013
o Wave 2 – July 17, 2013
o Wave 3 – July 29, 2013
o Wave 4 – August 5, 2013
o Wave 5 – August 12, 2013

The State has communicated that if any of the onsite interviews of residents conflict with a survey conducted by the Indiana State Department of Health, that the satisfaction surveys of residents will be rescheduled.

If you have any questions about the satisfaction survey process, or about the VBP program, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.

Nursing Facility Data Requests

The two subcontractors, GoResource Link and Knowledge Services, have already begun contacting Nursing Facilities across the state to obtain the names and addresses of employees and the family/friend of a resident so that they can be contacted to complete a survey.  The State will be providing the subcontractors each facility’s MDS file from the prior month (June MDS file for surveys conducted in July, and so on) in order for the subcontractors to perform the in-person surveys of residents.  Each Nursing Facility Administrator will be contacted via letter and email concerning the survey process and the request for data submission.  Residents of Assisted or Independent Living are to be excluded from the surveys, and employees who are 100% dedicated to Assisted or Independent Living units are also to be excluded.

Letters will be sent to the designated family/friend and to each nursing facility employee along with the respective survey.  Drafts of those letters and the surveys for residents, family/friend, and employees may be accessed in the Members Only section of the IHCA website.

The State has indicated willingness to set up a central point of contact for multi-facility entities for purposes of coordinating data submissions company-wide.  To set up that single point of contact, please contact Division of Aging Deputy Director Karen Filler at 317-232-4651 or Karen.Filler@fssa.in.gov.

Indiana Medicaid to Perform Satisfaction Surveys of Nursing Home Residents, Families/Friends, and Employees

As part of the effort led by the Indiana Division of Aging and the Office of Medicaid Policy and Planning (collectively, the “State”) to incorporate performance measures into Indiana Nursing Facility reimbursement rates, the State has contracted with Press Ganey Associates of South Bend, IN to conduct satisfaction surveys of nursing home residents, family/friends, and employees.  The satisfaction surveys are to be conducted this summer, during July, August, and September.  Surveys of residents will be in-person at the facility, and surveys of family/friend and employees will be done via mail.

While the data collected this summer will not immediately impact Nursing Facility reimbursement rates, it will set the stage for a discussion between the State and Nursing Facility representatives on how the data can be incorporated into the State’s Value Based Purchasing program (“VBP”).  The VBP program permits up to $14.30 per patient day to be paid as an add-on to the Medicaid reimbursement rate based on Nursing Facility performance on annual ISDH surveys, the number of nursing hours per resident day, and nursing and administrator retention and turnover metrics.

Webinars to Explain the Satisfaction Survey Process
Press Ganey Associates has subcontracted with GoResource Link and Knowledge Services to conduct the satisfaction surveys.  Nursing Facility residents will be interviewed in-person, as long as they are deemed interview-able based on a cognitive test.  Friends/Family of Nursing Facility residents and employees of Nursing Facilities will receive letters from one of the subcontractors that will contain a survey to be returned to the subcontractor.  The State has held two webinars for Nursing Facilities that provide an overview of the interview process – one was held on May 10th, and the second on May 17th.  For a copy of the webinar, click here.

Nursing Facility Data Requests
The two subcontractors, GoResource Link and Knowledge Services, have already begun contacting Nursing Facilities across the state to obtain the names and addresses of employees and the family/friend of a resident so that they can be contacted to complete a survey.  The State will be providing the subcontractors each facility’s MDS file from the prior month (June MDS file for surveys conducted in July, and so on) in order for the subcontractors to perform the in-person surveys of residents.  Each Nursing Facility Administrator will be contacted via letter and email concerning the survey process and the request for data submission.  Residents of Assisted or Independent Living are to be excluded from the surveys, and employees who are 100% dedicated to Assisted or Independent Living units are also to be excluded.

Letters will be sent to the designated family/friend and to each nursing facility employee along with the respective survey.  Drafts of those letters and the surveys for residents, family/friend, and employees may be accessed in the Members Only section of the IHCA website.

The State has indicated willingness to set up a central point of contact for multi-facility entities for purposes of coordinating data submissions company-wide.  To set up that single point of contact, please contact Division of Aging Deputy Director Karen Filler at 317-232-4651 or Karen.Filler@fssa.in.gov.

Subcontractor Training
Press Ganey, the main contractor, will be holding training sessions for the subcontractor’s employees that will perform the in-person resident satisfaction surveys.  Training sessions will be held on June 24, 25, and 26 at the Knowledge Services’ Carmel, IN location.  The training will include a Project Overview, discussion of the nursing home environment, HIPAA training, overall project logistics, and how to conduct an interview.
Survey Schedule
The subcontractors have released a schedule for the resident, family/friend, and employee surveys, which is provided below.

• Resident Surveys (onsite at the facility)
o 200 facilities in July
o 200 facilities in August
o 80 facilities in September

• Family/Friend Survey (by mail)
o Wave 1 – July 1, 2013
o Wave 2 – July 22, 2013
o Wave 3 – August 5, 2013

• Employee Survey (by mail or internet)
o Wave 1 – July 1, 2013
o Wave 2 – July 17, 2013
o Wave 3 – July 29, 2013
o Wave 4 – August 5, 2013
o Wave 5 – August 12, 2013

The State has communicated that if any of the onsite interviews of residents conflict with a survey conducted by the Indiana State Department of Health, that the satisfaction surveys of residents will be rescheduled.

If you have any questions about the satisfaction survey process, or about the VBP program, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.

Residential Survey Update

Thirty-three (33) tags were cited in surveys of residential care facilities in April, 28 of which were Deficiency tags and the remaining 5 were Offense tags.  The top citation for April was Tag 217, cited 5 times, concerning identification and documentation of services to be provided to residents following completion of a resident evaluation.  Documentation of the scope, frequency, need, and preference for services is necessary, and it also must be signed and dated by the resident.  If administration of medications or provision of residential nursing services are needed, a licensed nurse must be involved with identification and documentation of the services to be provided.  In addition, 3 citations were issued for Tag 214, another resident evaluation tag concerning initiation of an evaluation prior to admission and upon a change of condition after admission.  A licensed nurse must also be involved to evaluate the nursing needs of the resident.

Several tags were issued in April regarding medication administration, labeling, and storage.  Tag 241 was cited 3 times due to failure to have medication administered either by licensed personnel or by a QMA.   Tag 246 was cited 2 times for failure to ensure that each PRN medication administered by a QMA is authorized by either a nurse or physician.  Tag 301 was cited once due to failure to properly label prescription drugs with the resident’s full name, physician’s name, prescription number, name and strength of drug, directions for use, date of issue and expiration (when applicable), and the name and address of the pharmacy that filled the prescription.  Tag 304 was also cited once for failure to ensure medication storage areas/cabinets are locked at all times unless authorized personnel are present.

Citations were also issued in April in the Sanitation & Safety Standards area, for a total of 11 of the month’s 33 tags.  Citations ranged from failure to keep grounds and facilities clean and good state of repair to failure to have an effective waste disposal program in place.  Tag 90 was also cited three times in April for failure to ensure that the Administrator inform the ISDH within 24 hours of an unusual occurrence that threatens the health or safety of a resident.

A summary of the April Residential Care Facility Tags can be found in the Members Only section of the IHCA website.

April ISDH IJ/SSQC Report

There were two events in April that led to 2 IJ citations, one of which was also SSQC.  The 2567s of April’s IJ/SSQC citations can be found in the Members Only section of the IHCA website, as is a summary chart for 2013.

The first, an F323 tag that was cited by Federal surveyors after a complaint, related to a physically and verbally aggressive male resident, and the 5 other residents that were impacted by his behaviors.  The residents, a child in a children’s facility, was extremely aggressive towards staff and other residents that could not defend themselves.  Since his admission 2/18/13 and through March, the facility had logged 79 aggression incidents, 121 cussing incidents, and 15 resistant to care incidents.  The resident was prescribed Seroquel and diagnosed bipolar, in addition to other diagnoses, but the mother refused the medication and the diagnosis.  The physician’s services were discontinued at that time by the mother.  The IJ was removed when the facility issued 30-day notice of discharge along with continuous one-on-one and/or two-on-one supervision until discharge, provided psyhocsocial assessments on the other 5 impacted residents, reviewed and updated care plans, initiated staff education on behavior recognition that may affect other residents, and daily review of behavior reports and nursing notes. 

The second, an F441 tag was cited due to surveyor observation of improper disinfection practices on a blood glucometer.  During one observation, an RN used a blood glucometer without having cleaned it first, then after the use the RN did clean it with a Clorox wipe.  The facility policy called for the blood glucometer to be cleaned with a Clorox wipe prior to and after each use.  The surveyor noted that Clorox wipes are not effective in disinfecting blood borne pathogens, which was confirmed in a discussion with a Clorox representative. In a second observation, an LPN used the blood glucometer and returned it to the cart without cleaning it.  During interview with the DON, the DON indicated there had not been any in-services regarding blood glucometer disinfection practices.
Through April of 2013 there have been 5 IJ citations issued and 6 SSQC citations, which is about half of the 2012 totals for the same period (13 IJs and 10 SSQCs), IJs are down more than half as compared to the same period in 2012.  F323 continues to be the most cited tag during IJ/SSQC events with 3 so far in 2013 (4 tags through April of 2012, and 3 in 2011).  The downturn in IJ/SSQC citations so far this year continues a downward trend that began in 2012 as compared to 2011.

Summary of the CMS SNF PPS Proposed Rule

Courtesy of Peter Gruhn of the American Health Care Association, a summary of the CMS SNF PPS Proposed Rule and the full proposed rule can be located in the Members Only section of the IHCA website.  The proposed rule provides for a net market basket increase for SNFs of 1.4% beginning October 1, 2013. The 1.4% market basket update reflects a full market basket increase of 2.3 percentage points, less a 0.4 percentage point multifactor productivity adjustment required by Section 3401(b) of the Affordable Care Act (ACA), and a 0.5 percentage point reduction to correct for an error in forecasting the market basket in FY 2012. CMS estimates that the net market basket update would increase Medicare SNF payments by approximately $500 million in FY 2014 (a little over $7 per Medicare patient day).

Managed Care and Indiana Medicaid – A Summary from the 2013 Legislative Session

Though the utilization of managed care for Medicaid programs is certainly not new across the country, or in Indiana, IHCA did not expect to be dealing with a specific effort to include the Medicaid Aged, Blind and Disabled population (ABD) into managed care during this session of the Indiana General Assembly.  The first sign of an effort to require enrollment of the Medicaid ABD population into managed care was seen in an amendment to HB 1591, authored by the House Public Health Committee Chairman, Rep. Ed Clere (R-New Albany).  The language would have required the state to apply for a waiver to move the Medicaid ABD population into risk based managed care by October 1, 2013.  Oddly, the language also called for state to study such a program at the same time it was supposed to design and submit a plan to actually implement a program  IHCA testified and shared its concerns about including long term care into any ABD managed care program, and especially doing so without considering key factors such as the potential impact on resident services, access to care, provider networks, the Quality Assessment Fee, and the IGT/UPL program with county hospitals, as well as the expedited timeframe that was essentially impossible to meet. 

While the language in HB 1591 did not continue on in the process, the very next week the Chairman of the House Ways and Means Committee, Rep. Tim Brown, M.D. (R-Crawfordsville) inserted language in the House Budget Bill that would have required the state to study the issue and move the ABD population to risk based managed care by July 1, 2014.  IHCA met with Rep. Brown and expressed our concerns with the approach and implementation timeline.  The significant strategic concern was that managed care language was now in the House Budget Bill, which is a bill that must be passed and does not die.  This meant that the debate surrounding Medicaid ABD managed care was not going to go away.

A more reasonable approach to this issue was started in Senate Bill 551, authored by Sen. Patricia Miller (R-Indianapolis), that would have required a general study of the issue without an implementation mandate or deadline.  Similar to the fate of the initial House bill (HB 1591), SB 551 did not move out of the House after having passed through the Senate.  However, during this time IHCA, along with other provider organizations, was able to convince the Senate to remove the ABD managed care language from the Budget Bill during the Senate’s consideration of that bill.  This was a significant undertaking, which was led by IHCA.  The association’s staff and lobbyists provided legislators and the Governor’s office with information about what other states are doing in this space, and that a rushed implementation was not the right way to go for patients or providers.

In the end, IHCA and several provider groups worked with all of the relevant authors, budget conferees, and FSSA to reach a compromise on a written report concerning Medicaid ABD managed care that must be completed by December 15, 2013.  The report must include careful consideration of what cost savings may be achieved, how a program would impact beneficiary choice of providers, how provider rates would be set, how care would be coordinated for dual-eligible patients, whether certain beneficiaries should be excluded from a managed care program, and whether a managed care program would affect the Quality Assessment Fee and Upper Payment Limit supplemental payments.  We believe that this will be a more productive process that will allow us to provide critical information about what Medicaid ABD managed care means for the long term care industry and ensure that all important factors are being taken into consideration before any implementation of a Medicaid ABD managed care program.

CNA/QMA/Home Health Aide Registry and Criminal Background Checks

The ISDH alerted the IHCA that there have been a few persons that have cheated the CNA/QMA/Home Health Aide Registry in the past couple of months by using a former or married name to be re-listed on the registry after having been excluded for improper conduct.  The ISDH encourages all facilities to use a Criminal Background Check and all names listed on that background check to compare against the Registry to see if the person appears under a different name.  The ISDH cannot run Social Security numbers over the internet, but can confirm with a Social Security number if the facility calls the ISDH.  To contact the Aide Registry Program, call Darlene Jones at 317-233-7351.

Indiana Medicaid Satisfaction Surveys

Several IHCA members have been contacted by either GoResource Link or Knowledge Services concerning the Indiana Medicaid satisfaction survey process that is part of the Value Based Purchasing program.  Over the past few of weeks letters have been sent to facility administrators providing notice and a broad overview of the survey process.  Since this letter went out, GoResource Link and Knowledge Services (contractors for the State) have begun calling facilities and sending emails containing instructions to report data on residents, family/friends, and employees to the contractors by May 13th (or May 17th depending on what material you received) in order that the contractors have information necessary to conduct surveys of these individuals.

Data Request
It has come to our attention that some administrators are receiving emails from the contractors without having been called first.  After discussion with the State, it appears that the contractors are calling first and obtaining the administrator’s email from whomever answers the phone.  In some cases, administrators are speaking with the contractors, but in other cases the administrator has not talked with the contractor and the first contact  the administrator has is the receipt of the email with instructions on data submission.  The requests from the contractors are legitimate requests.  Though it would seem that some of the data will be stale by the time July, August and September roll around, the State is asking for facilities to cooperate with the submission of data this month to the contractors.
Residents/Employees of Residential or Unlicensed AL/IL – Excluded from Survey Process
The State has also indicated that residents of licensed residential units/beds and unlicensed AL/IL are not to be included in the survey process.  In addition, if you have employees that are 100% dedicated to licensed residential units/beds and/or unlicensed AL/IL these employees are not to be included in the survey process.  I have requested that the State communicate this to the contractors so the contractors can in turn communicate to providers.

Survey Schedule
The contractors indicate that they intend to perform resident, family/friend, and employee surveys according to the below schedule:
• Resident Surveys (onsite at the facility)
o 200 facilities in July
o 200 facilities in August
o 80 facilities in September
• Family/Friend Survey (by mail)
o Wave 1 – July 1, 2013
o Wave 2 – July 22, 2013
o Wave 3 – August 5, 2013
• Employee Survey (by mail or internet)
o Wave 1 – July 1, 2013
o Wave 2 – July 17, 2013
o Wave 3 – July 29, 2013
o Wave 4 – August 5, 2013
o Wave 5 – August 12, 2013

A sample of the letter to facility administrators and a presentation about the satisfaction survey process that was provided to the IHCA, and other trade associations, may be accessed in the Members Only section of the IHCA website.

If you have any questions or concerns about the survey process, or about the Medicaid VBP program generally, please contact Zach Cattell at 317-616-9001 or zcattell@ihca.org.