CMS Launches the Home Health Value-Based Purchasing Program: What Providers Need to Know

michellebedoyaheadshotBy Michelle Bedoya

According to the 2016 Home Health Final Rule, published on November 5, 2015, the Centers for Medicare and Medicaid Services (CMS) is launching a value-based purchasing (VBP) pilot program for Medicare home health care agencies (HHA). The VBP model is designed to support greater quality and efficiency of care among Medicare-certified HHAs across the nation.  Starting on January 1, 2016, HHAs in nine states representing each geographic area in the nation will be required to participate in the VBP program. HHAs that provide services in Massachusetts, Maryland, North Carolina, Florida, Washington, Arizona, Iowa, Nebraska and Tennessee will compete on value in the VBP model, where payment is tied to quality performance.

What Exactly is Value-Based Purchasing?

CMS launched the VBP model due to the growing concern that the existing payment system (which focuses on volume of services provided) does not provide the necessary incentives for HHAs to provide high quality patient-focused care. The VBP model is considered to be an innovative step towards revamping how Medicare pays for health care services, moving the program towards rewarding HHAs for better value, outcomes and patient-focused care. HHAs will compete where payment is tied to quality performance and will then have their payments adjusted in the following manner:

–    A maximum payment adjustment of 3 percent (upward or downward) in 2018;

–    A maximum payment adjustment of 5 percent (upward or downward) in 2019;

–    A maximum payment adjustment of 6 percent (upward or downward) in 2020;

–    A maximum payment adjustment of 7 percent (upward or downward) in 2021; and

–    A maximum payment adjustment of 8 percent (upward or downward) in 2022.

The Bottom Line: VBP Payment Changes.

The VBP model will adjust aggregate claim payments up to the maximum percentage for each year. As a result, high performing HHAs will experience a greater reward whereas, low performing HHAs will experience a greater downside risk. Payment adjustments for each year will be calculated on improvements achieved and on comparative performance achievement levels. Adjustments will be based on each HHA’s performance relative to other competing agencies of similar size in the same state.

What Providers Should Do NOW.

HHAs participating in the VBP model are encouraged to:

(a)    Establish their HHA VBP point of contact by providing the HHVBP Help Desk (HHVBPquestions@cms.hhs.gov) with the name and email address of a primary point of contact for each CMS Certification Number (CCN).

(b)    Obtain a User Account on the CMS Secure Portal. This is an essential first step towards registration for the VBP Model portal where HHAs will receive performance reports and enter data for new measures.

(c)    Review the CY 2016 Home Health Final Rule here.

Conclusion.

The post-Affordable Care Act environment enables CMS to facilitate a complete turnaround of the home health industry. Due to the launching of VBP models, HHAs are compelled to review and reinvent their standard operating practices. Providers must develop a sense of urgency to review their current operating structure and adapt operations according to ensuing reforms.

Still Want to Know More?

Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent health care providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other health care providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620.

Sources:

Medicare and Medicaid Programs; CY 2016 Home Health Prospective Payment System Rate Update; Home Health Value-Based Purchasing Model; and Home Health Quality Reporting Requirements, 80 F.R. 68623 (proposed Nov. 5, 2015) (to be codified at 42 C.F.R. pt. 409).

“Home Health Value-Based Purchasing Model.” The Centers for Medicare & Medicaid Services. (December 10, 2015). Web.

About the Author: Michelle Bedoya is a long-time consultant to home health agencies and is currently a graduating senior at Barry University School of Law.  She currently works, as well, for The Health Law Firm, which has a national practice.  Its main office is in the Orlando, Florida area.  www.TheHealthLawFirm.com. The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

KeyWords: Home Health Agencies (HHA), Centers for Medicare and Medicaid Services, (CMS), Work Plan 2016, Medicare fraud defense attorney, Medicaid fraud defense attorney, LEIE legal counsel, List of Excluded Individuals and Entities, Medicare Fraud Strike Force, Zone Program Integrity Contractor (ZPIC) audit lawyer, Recovery Audit Contractor (RAC) lawyer, Florida health attorney, health law attorney, Florida health lawyer, The Health Law Firm, health law defense lawyer, health professional attorney, Medicare fraud defense lawyer, Medicaid fraud defense lawyer, home health final rule, value based repurchasing (VBP), Medicare and Medicaid audit defense lawyer, Medicare and Medicaid compliance, Medicare and Medicaid investigation defense lawyer, home health agency attorney, HHA Medicare reimbursement claims, Medicaid audit appeal, Florida Health Care law attorney

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2015 The Health Law Firm. All rights reserved.

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CMS Requires Home Health Claims to be Selected for Probe and Education Review

michellebedoyaheadshotBy Michelle Bedoya and George F. Indest III, J.D., M.P.A., LL.M., Board Certified by The Florida Bar in Health Law.

Medicare Administrative Contractors (MACs) in conjunction with the Center for Medicare and Medicaid Services (CMS) have initialized the “Home Health Probe and Educate” medical review strategy. The reason for CMS’s coined “Probe and Educate Review Strategy” is to assess and promote provider understanding and compliance with the Medicare home health eligibility requirements.

Pre-Payment Claim Review.

The strategy requires home health MACs to select a sample of five claims for pre-payment review from every home health agency within the MACs jurisdiction. Probe reviews shall assess claims submitted by home health agencies related to Medicare home health services and patient eligibility. Home health episodes that began on or after August 1, 2015, will be selected during the “Probe and Educate” program.


The Probe: Initial Review.

Reviews will appear to each home health provider in the form of Additional Development Requests (ADRs) on any date after October 15, 2015. It is anticipated that the first round of claims reviewed will conclude in approximately one year from October 15, 2015.

Providers must affirmatively look out for ADRs from their MACs. Since ADRs adhere to strict deadlines, providers should ensure that they allow ample time for mailing and processing of documentation. Doing so will prevent the claim from inadvertently being denied.

Upon initial review, CMS has instructed MACs to deny each non-compliant claim. If claims are denied, a letter outlining the reasons for denial will be sent to the home health agency at the conclusion of the review.


The Education: Post Review Results.

MACs will conduct provider specific educational outreach based on the results of the initial reviews. The outreach shall consist of an offer by MACs to provide individualized telephone calls/education to all providers who produced non-compliant claims. During the call, the MAC will:

1. discuss the reasons for denial;
2. provide education relevant to those reason;
3. provide reference materials; and
4. answer questions.


Further Review: Providers Having Moderate/Major Concerns.

As a result of the initial reviews, providers will be classified into two categories:

1. No or Minor Concerns; or
2. Moderate/Major Concerns.

For those providers that are categorized as having moderate or major concerns, MACs will repeat the “Probe and Educate Process” for dates of service occurring after the education was provided. CMS is silent as to action if improvement is not realized during the second review.


Conclusion.

CMS maintains it has no authority to pay claims where the criterion for Medicare coverage is not evident. Thus, it is vital that providers ensure that medical records are compliant and adhere to Medicare guidelines.


Need Guidance?

Consult with a Health Law Attorney Experienced in Medicare and Medicaid Issues Now.

The attorneys of The Health Law Firm represent health care providers in Medicare audits, ZPIC audits and RAC audits throughout Florida and across the U.S. They also represent physicians, medical groups, nursing homes, home health agencies, pharmacies, hospitals and other healthcare providers and institutions in Medicare and Medicaid investigations, audits, recovery actions and termination from the Medicare or Medicaid Program.

For more information please visit our website at www.TheHealthLawFirm.com or call (407) 331-6620.


Sources:

“Selecting Home Health Claims for Probe and Educate Review: Episodes that Begin on or After August 1, 2015”, MLN Matters SE1524. U.S. Department of Health and Human Services: Centers for Medicare & Medicaid Services, 2015.

About the Author:
Michelle Bedoya is a long-time consultant to home health agencies and is currently a student at Barry University School of Law. George F. Indest III, J.D., M.P.A., LL.M., is Board Certified by The Florida Bar in Health Law. He is the President and Managing Partner of The Health Law Firm, which has a national practice. Its main office is in the Orlando, Florida area. www.TheHealthLawFirm.com. The Health Law Firm, 1101 Douglas Ave., Altamonte Springs, FL 32714, Phone: (407) 331-6620.

Keywords: OIG, Office of the Inspector General, Centers for Medicare and Medicaid Services, CMS, Work Plan 2015, audit attorney, enforcement, Medicare fraud defense attorney, Medicaid fraud defense attorney, LEIE legal counsel, List of Excluded Individuals and Entities, Medicare Fraud Strike Force, home health attorney, Zone Program Integrity Contractor (ZPIC) audit lawyer, Recovery Audit Contractor (RAC) lawyer, Medicare audit,. defense attorney, defense lawyer, Florida health attorney, health law attorney, Florida health lawyer, The Health Law Firm, health law defense lawyer, health professional attorney, Medicare fraud defense lawyer, Medicaid fraud defense lawyer, Medicare Administrative Contractors defense attorney, MACs, home health care lawyer, MAC defense attorney

“The Health Law Firm” is a registered fictitious business name of George F. Indest III, P.A. – The Health Law Firm, a Florida professional service corporation, since 1999.
Copyright © 1996-2015 The Health Law Firm. All rights reserved.