IHCA
IHCA, HOPE and LeadingAge met with representatives from FSSA and Indiana Medicaid (OMPP) on February 3rd to discuss the proposed transition to RUGs IV. OMPP continues to push for RUGs IV 66 grouper to be implemented on July 1, 2016. Two weeks ago OMPP made a new proposal, which was to move to RUGs IV 66 grouper, to increase the Special Care Unit add-on in 2016 by $17M and then eliminated the add-on in the following year, and to increase the QAF. Per the direction of the IHCA Payment/Reimbursement Committee and IHCA Board, IHCA staff rejected that proposal. IHCA is working with HOPE and LeadingAge to develop a unified proposal to present to OMPP in the coming week or so.
If you have any questions, please contact Zach Cattell at zcattell@ihca.org or 317-616-9001.
Wednesday, February 4, 2015
CMS Resumes Part B Therapy Manual Medical Review (MMR) Program
Late last week, the Centers for Medicare and Medicare Services (CMS) sent a notice and a FAQ document to organizations representing providers that they were resuming the Medicare Part B therapy manual medical review (MMR) program immediately. As you may recall, the MMR program was implemented by CMS in October 2012 as part of a previous extension of the therapy caps exceptions process. Under MMR, Medicare recovery audit contractors (RACs) are to review Part B therapy claims over a $3700 threshold per beneficiary per year. Due to problems in the MMR process and delays in issuing new RAC contracts, the therapy MMR program was put on a 'pause' at the end of February 2014.
Below is a summary of the key elements of the MMR resumption that AHCA members and their clinical and billing staff should be aware of and prepare for:
1. Starting immediately, RACs may resume part B therapy MMR for all MMR eligible claims over the $3700 threshold for claims paid between March 1, 2014 and December 31, 2014.
2. The reviews will be post-pay review only in all states for the 2014 claim reviews.
3. Claims will be reviewed in chronological order so that, for example, claims paid in March 2014 will be reviewed before claims paid in April 2014.
4. There will be 5 waves of reviews conducted to address all 2014 MMR reviews which AHCA estimates will be conducted from February through August 2015. Providers with therapy MMR eligible claims should expect to receive therapy MMR additional development requests (ADRs) approximately every 45 days as follows:
• Phase 1 - One claim review request will be issued in the ADR.
• Phase 2 - Up to 10 percent of the total MMR eligible claims for 3/14-12/14 will be included in the ADR.
• Phase 3 - Up to 25 percent of the remaining MMR eligible claims for 3/14-12/14.
• Phase 4 - Up to 50 percent of the remaining MMR eligible claims for 3/14-12/14.
• Phase 5 - Up to 100 percent of the remaining MMR eligible claims for 3/14-12/14
CMS notes that this current resumption only applies to facility-based providers, including skilled nursing facilities. In addition, CMS has not identified a process yet for how they intend to conduct reviews for 2015 MMR eligible claims. While CMS state they do not plan to post additional information regarding these reviews, AHCA will continue to seek further clarification.
AHCA has been, and continues to be very concerned with the serious flaws in the arbitrary $3700 therapy MMR threshold that Congress established, and how CMS has interpreted to mean that 100 percent of claims above this threshold must receive burdensome complex review, regardless of beneficiary condition, or provider history of compliance with Medicare policy.
AHCA is actively engaged with Congress in advocating for therapy reforms like the therapy cap repeal provisions reported out by the Senate Finance Committee in the 113th Congress. However, since that may take some time, we are also seeking immediate reforms to the therapy MMR program as a bridge to the larger reforms, and are asking Congress to require CMS to target MMR reviews and education efforts to providers with a history of improper payments rather than the cumbersome 100 percent review process described above.
If you have any questions please feel free to contact Danie Ciolek, Senior Director, Therapy Advocacy, at dciolek@ahca.org or 302-740-7888.
Below is a summary of the key elements of the MMR resumption that AHCA members and their clinical and billing staff should be aware of and prepare for:
1. Starting immediately, RACs may resume part B therapy MMR for all MMR eligible claims over the $3700 threshold for claims paid between March 1, 2014 and December 31, 2014.
2. The reviews will be post-pay review only in all states for the 2014 claim reviews.
3. Claims will be reviewed in chronological order so that, for example, claims paid in March 2014 will be reviewed before claims paid in April 2014.
4. There will be 5 waves of reviews conducted to address all 2014 MMR reviews which AHCA estimates will be conducted from February through August 2015. Providers with therapy MMR eligible claims should expect to receive therapy MMR additional development requests (ADRs) approximately every 45 days as follows:
• Phase 1 - One claim review request will be issued in the ADR.
• Phase 2 - Up to 10 percent of the total MMR eligible claims for 3/14-12/14 will be included in the ADR.
• Phase 3 - Up to 25 percent of the remaining MMR eligible claims for 3/14-12/14.
• Phase 4 - Up to 50 percent of the remaining MMR eligible claims for 3/14-12/14.
• Phase 5 - Up to 100 percent of the remaining MMR eligible claims for 3/14-12/14
CMS notes that this current resumption only applies to facility-based providers, including skilled nursing facilities. In addition, CMS has not identified a process yet for how they intend to conduct reviews for 2015 MMR eligible claims. While CMS state they do not plan to post additional information regarding these reviews, AHCA will continue to seek further clarification.
AHCA has been, and continues to be very concerned with the serious flaws in the arbitrary $3700 therapy MMR threshold that Congress established, and how CMS has interpreted to mean that 100 percent of claims above this threshold must receive burdensome complex review, regardless of beneficiary condition, or provider history of compliance with Medicare policy.
AHCA is actively engaged with Congress in advocating for therapy reforms like the therapy cap repeal provisions reported out by the Senate Finance Committee in the 113th Congress. However, since that may take some time, we are also seeking immediate reforms to the therapy MMR program as a bridge to the larger reforms, and are asking Congress to require CMS to target MMR reviews and education efforts to providers with a history of improper payments rather than the cumbersome 100 percent review process described above.
If you have any questions please feel free to contact Danie Ciolek, Senior Director, Therapy Advocacy, at dciolek@ahca.org or 302-740-7888.
Tuesday, February 3, 2015
CMS Issues Clarification Requiring In-Person CPR Training of Facility Staff
On Friday Jan. 23, 2015, CMS sent to AHCA updated guidance at F-155 - Rights Regarding Refusal of Treatment and Participation in Experimental Research and Advance Directives. The memo and revised operations manual has not yet been posted to the CMS website, but can be accessed by clicking here.
The updated guidance makes changes related to one area: CPR Certification. According to the
memo summary:
CPR Certification - Staff must maintain current CPR certification for healthcare providers through CPR training that includes hands-on practice and in-person skills assessment. Online-only certification is not acceptable.
The content of the memo provides additional detail about the certification.
The updated guidance makes changes related to one area: CPR Certification. According to the
memo summary:
CPR Certification - Staff must maintain current CPR certification for healthcare providers through CPR training that includes hands-on practice and in-person skills assessment. Online-only certification is not acceptable.
The content of the memo provides additional detail about the certification.
AHCA Summary of Key Provisions in President's Proposed FY2016 Budget
On Monday, AHCA released the follow summary of President Obama's Fiscal Year 2016 Budget:
Today the President released his FY2016 budget proposal. There’s no question that a president’s budget wields considerable influence on how our government sets and defines its priorities, as well as to what Congress should subsequently pay attention. However, any changes must be implemented through the legislative process by Congress.
As it regards our profession, this budget looks similar in many ways to past years. As was true for last year’s budget, the Administration did not include cuts to provider taxes. We applaud President Obama for his continued efforts to protect Medicaid for the hundreds of thousands of our residents who rely on the program for their care.
When it comes to Medicare, however, the budget’s proposed cuts are ill advised. This year’s budget does propose significant cuts to Medicare, including reducing the market basket, cutting bad debt reimbursement and more. We will continue to strongly oppose the arbitrary, deep Medicare cuts suggested in this budget. The proposed cuts are particularly outrageous given the recent reports from MedPAC that our centers operate on a thin 1.9% margin. AHCA/NCAL will continue to oppose these arbitrary, deep cuts, and we don’t expect them to become law. In the past, our profession has worked with the White House and Congress to offer better ways of finding Medicare savings, and we will continue to do so.
Below is a short summary of the budget provisions in the President’s FY2016 budget that have direct impact on our profession.
Medicare
Post-acute care market basket cuts
• The budget reduces the home health, IRF and LTCH market basket update by 1.1% each year 2016 through 2025, with the floor set at a rate freeze. The budget reduces market basket updates for all PAC providers, but accelerates SNF cuts beginning with a -2.5% update in FY2016 and a reduction to -0.97% in FY2023. This is projected to save $102.1 billion from 2016-2025.
Reduce Medicare coverage of bad debts
• The President proposes reducing bad debt payments from 65% to 25% for all eligible providers over three years beginning in 2016. This proposal will save approximately $31.1 billion from 2016-2025. This proposal was included in the President’s FY2015 budget.
Implement bundled post-acute care payment
• Beginning in 2020, at least half of the payments for LTCHs, IRFs, SNFs and home health services would be bundled. Payments would be bundled for at least half of the total payments for post-acute care providers. A permanent and total cumulative 2.85% cut would be applied by 2022. This proposal is projected to save $9.3 billion from 2016-2025.
Implement value-based purchasing for PAC providers
• While it is budget neutral, it is important to note that the President’s Budget implements a value-based purchasing program for several additional provider types, including home health, SNFs, ambulatory surgical centers and hospital outpatient departments beginning in 2017. At least 2% of payments must be tied to the quality and efficiency of care in the first two years of implementation, and at least 5% beginning in 2019. This proposal has no budget impact.
Strengthen the Independent Payment Advisory Board
• The budget requires IPAB cuts to take effect when Medicare spending growth exceeds Gross Domestic Product (GDP) +.5%. Current law is GDP +1%. This is estimated to save $20.9 billion from 2016-2025.
Encourage appropriate use of inpatient rehabilitation facilities
• The President proposes adjusting the standard for classifying a facility as an inpatient rehabilitation facility (IRF) by requiring that at least 75% of patient cases admitted to an IRF meet one or more of 13 designated severity conditions beginning in 2016. The current standard is set at 60%. This proposal is projected to save $2.2 billion from 2016-2025.
Medicaid
Provider Assessments not cut in the President’s Budget:
• As was the case last year, the President’s budget does not propose reducing or eliminating the provider assessments. Since Congress is likely to consider such cuts as an area to save money, it is a positive that the President did not include it in his recent budget.
Structural changes for delivery of long term services and supports:
• The budget includes a number of proposed changes that would promote the use of home and community based services. These proposals were not included in last year’s budget. It is important to note that even if these options were to be passed into law, states would have to choose to include them in their Medicaid program.
Other
Strengthening program integrity
• The budget includes new investments in program integrity totaling $201 million in FY2016 and $4.6 billion over ten years. These investments include continuing to fund the full Health Care Fraud and Abuse Control discretionary cap adjustment, increasing mandatory Medicaid Integrity Program funding, and providing more funding to recovery auditors to undertake more corrective actions that will help reduce improper payments. In total program integrity investments would yield an estimated $21.7 billion in savings to Medicare and Medicaid over ten years.
As always, AHCA/NCAL will continue to provide you all the latest information on the President’s budget proposal, as well as other developments on Capitol Hill. If you’d like to read more about the President’s budget, you can view it online at http://www.whitehouse.gov/omb/budget/Overview.
If you have specific questions for AHCA/NCAL, please contact Government Affairs at 202.898.2816.
Today the President released his FY2016 budget proposal. There’s no question that a president’s budget wields considerable influence on how our government sets and defines its priorities, as well as to what Congress should subsequently pay attention. However, any changes must be implemented through the legislative process by Congress.
As it regards our profession, this budget looks similar in many ways to past years. As was true for last year’s budget, the Administration did not include cuts to provider taxes. We applaud President Obama for his continued efforts to protect Medicaid for the hundreds of thousands of our residents who rely on the program for their care.
When it comes to Medicare, however, the budget’s proposed cuts are ill advised. This year’s budget does propose significant cuts to Medicare, including reducing the market basket, cutting bad debt reimbursement and more. We will continue to strongly oppose the arbitrary, deep Medicare cuts suggested in this budget. The proposed cuts are particularly outrageous given the recent reports from MedPAC that our centers operate on a thin 1.9% margin. AHCA/NCAL will continue to oppose these arbitrary, deep cuts, and we don’t expect them to become law. In the past, our profession has worked with the White House and Congress to offer better ways of finding Medicare savings, and we will continue to do so.
Below is a short summary of the budget provisions in the President’s FY2016 budget that have direct impact on our profession.
Medicare
Post-acute care market basket cuts
• The budget reduces the home health, IRF and LTCH market basket update by 1.1% each year 2016 through 2025, with the floor set at a rate freeze. The budget reduces market basket updates for all PAC providers, but accelerates SNF cuts beginning with a -2.5% update in FY2016 and a reduction to -0.97% in FY2023. This is projected to save $102.1 billion from 2016-2025.
Reduce Medicare coverage of bad debts
• The President proposes reducing bad debt payments from 65% to 25% for all eligible providers over three years beginning in 2016. This proposal will save approximately $31.1 billion from 2016-2025. This proposal was included in the President’s FY2015 budget.
Implement bundled post-acute care payment
• Beginning in 2020, at least half of the payments for LTCHs, IRFs, SNFs and home health services would be bundled. Payments would be bundled for at least half of the total payments for post-acute care providers. A permanent and total cumulative 2.85% cut would be applied by 2022. This proposal is projected to save $9.3 billion from 2016-2025.
Implement value-based purchasing for PAC providers
• While it is budget neutral, it is important to note that the President’s Budget implements a value-based purchasing program for several additional provider types, including home health, SNFs, ambulatory surgical centers and hospital outpatient departments beginning in 2017. At least 2% of payments must be tied to the quality and efficiency of care in the first two years of implementation, and at least 5% beginning in 2019. This proposal has no budget impact.
Strengthen the Independent Payment Advisory Board
• The budget requires IPAB cuts to take effect when Medicare spending growth exceeds Gross Domestic Product (GDP) +.5%. Current law is GDP +1%. This is estimated to save $20.9 billion from 2016-2025.
Encourage appropriate use of inpatient rehabilitation facilities
• The President proposes adjusting the standard for classifying a facility as an inpatient rehabilitation facility (IRF) by requiring that at least 75% of patient cases admitted to an IRF meet one or more of 13 designated severity conditions beginning in 2016. The current standard is set at 60%. This proposal is projected to save $2.2 billion from 2016-2025.
Medicaid
Provider Assessments not cut in the President’s Budget:
• As was the case last year, the President’s budget does not propose reducing or eliminating the provider assessments. Since Congress is likely to consider such cuts as an area to save money, it is a positive that the President did not include it in his recent budget.
Structural changes for delivery of long term services and supports:
• The budget includes a number of proposed changes that would promote the use of home and community based services. These proposals were not included in last year’s budget. It is important to note that even if these options were to be passed into law, states would have to choose to include them in their Medicaid program.
Other
Strengthening program integrity
• The budget includes new investments in program integrity totaling $201 million in FY2016 and $4.6 billion over ten years. These investments include continuing to fund the full Health Care Fraud and Abuse Control discretionary cap adjustment, increasing mandatory Medicaid Integrity Program funding, and providing more funding to recovery auditors to undertake more corrective actions that will help reduce improper payments. In total program integrity investments would yield an estimated $21.7 billion in savings to Medicare and Medicaid over ten years.
As always, AHCA/NCAL will continue to provide you all the latest information on the President’s budget proposal, as well as other developments on Capitol Hill. If you’d like to read more about the President’s budget, you can view it online at http://www.whitehouse.gov/omb/budget/Overview.
If you have specific questions for AHCA/NCAL, please contact Government Affairs at 202.898.2816.
Residential Care Facility Citation Update
The December 2014 Offense and Deficiency citations followed a familiar pattern with Tag 273 being cited 6 times in the month. The failure to maintain food preparation and services areas in accordance with state and local sanitation and safe food handling standards is the leading tag for residential care facilities in 2014 (as it was in 2013). Next, Tag 217 was cited 5 times, the second highest amount for any month in 2014 for this tag. Failure to use appropriately trained staff for resident evaluation, and review of the plan with the resident signing off on any changes to the plan is ws the 3rd leading tag in 2014. Next, Tag 241 was cited 3 times in December for failure to have the medication(s) ordered by the resident’s physician administered by licensed nursing personnel or QMAs. Tag 241 was the 2nd most cited in 2014. Lastly, Tag 414 was cited 3 times in December for failure to ensure that staff washed their hands after each direct resident contact for which professional practice indicates that hand washing is appropriate. Tag 414 was 6th on the list of most frequent in 2014. Below is a chart of the top ten Offense and Deficiency citations in Residential Care Facilities in 2014.
To review a summary of all of the December Offense and Deficiency citations, click here.
.jpg)
To review a summary of all of the December Offense and Deficiency citations, click here.
ISDH IJ/SSQC Citation – 2014 Year in Review
This year there were 23 IJ events and 24 SSQC events in which 47 total tags were cited. This is a bit higher than in 2013, which saw historic lows for IJs and SSQCs. However, 2014 was still a positive when compared to 2011 and prior years. Since 2011, IJ and SSQC citations have been falling, relative to prior years.
.jpg)
The leading citations for 2014 were F225 and F226, with 10 citations each.
• The primary reason for the citation of F225 was alleged failure to timely report allegations of abuse or failure to thoroughly investigate such allegations. F226, accompanying F225, due to the facility’s policy and procedure requiring timely reporting and thorough investigation.
The third most cited tag was F323 with 7 citations
• Citations of F323 were related to inadequate supervision inadequate supervision leading to elopement, to protect other residents from sexually inappropriate advances and aggressive resident behaviors, inadequate supervision leading to choking and death
• No IJs cited under F323 for falls or for hot water temps!
The fourth most cited tag was F223, cited 5 times
• All were issued during or before August
• Cited twice in 2013, once in 2012, and 4 times in 2011
• Citations related to verbal and physical abuse from staff to residents, failure to prevent physical and verbal abuse between residents, prevention of sexual abuse
Below is a chart of all 2014 IJ and SSQC citations, listed in order of frequency.
.jpg)
The leading citations for 2014 were F225 and F226, with 10 citations each.
• The primary reason for the citation of F225 was alleged failure to timely report allegations of abuse or failure to thoroughly investigate such allegations. F226, accompanying F225, due to the facility’s policy and procedure requiring timely reporting and thorough investigation.
The third most cited tag was F323 with 7 citations
• Citations of F323 were related to inadequate supervision inadequate supervision leading to elopement, to protect other residents from sexually inappropriate advances and aggressive resident behaviors, inadequate supervision leading to choking and death
• No IJs cited under F323 for falls or for hot water temps!
The fourth most cited tag was F223, cited 5 times
• All were issued during or before August
• Cited twice in 2013, once in 2012, and 4 times in 2011
• Citations related to verbal and physical abuse from staff to residents, failure to prevent physical and verbal abuse between residents, prevention of sexual abuse
Below is a chart of all 2014 IJ and SSQC citations, listed in order of frequency.
ISDH IJ/SSQC Update
In December 2014 there were 3 events leading to 3 IJ citations, all of which were SSQC, and 2 additional SSQC citations. Also, a 23-day revisit took place in December for an IJ that occurred in November 2014. The first issue involved an allegation of abuse that the ISDH indicated was not thoroughly investigated and reported to the ISDH. The ISDH also indicated that the facility did not suspend the suspect employee and failed to follow their policies and procedures related to abuse investigations. The issue resulted in citation of F225 and F226 at scope and severity J. The issue involved a visitor overhearing an RN tell a resident to “shut up” and the resident replying “you b*****d nurse, you hit me.” The visitor, who was a family member of another resident, did not witness anything and did not report this to the DNS until a week later. The family member also said she saw some bruising on the resident’s face. Already documented in the resident’s file was information about the facial bruising as a self-inflicted injury, as the resident has exhibited self-injurious behavior in the past. Nevertheless, the allegation by the family member was not investigated or reported to the ISDH separate and apart from the prior documentation about the resident’s bruise.
The second issue in December also resulted in citation of F225 and F226, but at the scope and severity F. A CNA heard noises coming from two residents’ room and entered to find one resident over the top of the other and blood on the injured resident’s face, arms, and hands. The injured resident was treated and taken to the ER for further evaluation, then returned to the facility about 4 hours later. There was no documented history of incidents between the two roommates, but during interview with an RN the ISDH was told that the RN had heard a rumor that the aggressor roommate had been groping the injured roommate. The RN did not witness anything nor could indicated when or where she had heard this. During interview with the Administrator it became known that the Administrator had been aware of an allegation of groping based on a family member’s statement about a bit more than a week before the injury took place. The facility was cited for failure to investigate the allegation of groping and follow their policies and procedures concerning allegations of abuse.
The third issue in December involved a resident that had not executed an advance directive upon admission, then was later found without pulse and respirations and CPR was not immediately initiated. While CPR was initiated prior to emergency services arriving at the facility, it was not initiated immediately and only was after the interim DON directed it to be done. Notifications to the MD, family, and 911 were done correctly, but the CNA and LPN did not treat the resident as a full code, which is what should occur for a resident that has not execute an advance directive.
To review the December IJ and SSQC citations and a summary of all 2014 IJ and SSQC citations, click here.
The second issue in December also resulted in citation of F225 and F226, but at the scope and severity F. A CNA heard noises coming from two residents’ room and entered to find one resident over the top of the other and blood on the injured resident’s face, arms, and hands. The injured resident was treated and taken to the ER for further evaluation, then returned to the facility about 4 hours later. There was no documented history of incidents between the two roommates, but during interview with an RN the ISDH was told that the RN had heard a rumor that the aggressor roommate had been groping the injured roommate. The RN did not witness anything nor could indicated when or where she had heard this. During interview with the Administrator it became known that the Administrator had been aware of an allegation of groping based on a family member’s statement about a bit more than a week before the injury took place. The facility was cited for failure to investigate the allegation of groping and follow their policies and procedures concerning allegations of abuse.
The third issue in December involved a resident that had not executed an advance directive upon admission, then was later found without pulse and respirations and CPR was not immediately initiated. While CPR was initiated prior to emergency services arriving at the facility, it was not initiated immediately and only was after the interim DON directed it to be done. Notifications to the MD, family, and 911 were done correctly, but the CNA and LPN did not treat the resident as a full code, which is what should occur for a resident that has not execute an advance directive.
To review the December IJ and SSQC citations and a summary of all 2014 IJ and SSQC citations, click here.
Subscribe to:
Posts (Atom)
