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.