In the News

New Legislation Would Expand Access to Occupational Therapy

NAHC Report

In a promising bipartisan effort, the Medicare Home Health Accessibility Act, H.R. 7148, has been introduced by a coalition of legislators including Reps. Lloyd Smucker (R-PA-11), Dr. John Joyce (R-PA-13), Paul Tonko (D-NY-20), and Lloyd Doggett (D-TX-37). This crucial bill aims to revolutionize home health care by allowing occupational therapy (OT) to be ordered as a stand-alone service for Medicare beneficiaries.

Currently, OT services are excluded from qualifying beneficiaries for Medicare’s Part A home health benefit. This limitation means that OT services can only be provided in a beneficiary’s home if other therapy services, such as nursing, physical therapy, or speech and language pathology, are simultaneously ordered at the start of care.

Congressman Lloyd Smucker (PA-11) expressed his enthusiasm for the bill, stating, “The Medicare Home Health Accessibility Act will ensure beneficiaries can receive the care they need in a setting that more and more prefer—at home. Our commonsense measure will tailor home health orders to each patient, maximizing their ability to thrive at home and avoid costly rehospitalizations.”

Congressman John Joyce, M.D. (PA-13), emphasized the bipartisan nature of the bill, calling it a “game changer for patients who wish to heal and recover in the comfort of their homes.” He stressed the importance of in-home occupational therapy, especially in rural communities.

The proposed legislation received widespread support from Congressman Lloyd Doggett (D-TX-37), who highlighted the critical role home- and community-based care play in the healthcare system. Removing unnecessary barriers to receiving health care at home, he said, would provide more patient choices and access, particularly benefiting seniors.

Congressman Paul Tonko (D-NY-20) pointed out that passage of the bill would better target home health services to meet specific patient needs, particularly in preventing falls and accidents, ultimately enabling Medicare beneficiaries to remain independently at home.

The National Association for Home Care and Hospice (NAHC) supports this new legislation and applauds the sponsors for their leadership. With the bill’s introduction NAHC President Bill Dombi said, “It is time that Congress rectify a long-standing weakness in the home health benefit by making occupational therapy a qualifying skilled service. OT is an essential service not only for patients, it also is a proven means to saving Medicare expenditures.”

 

‘A Monumental Shift’: Home Health Providers Believe Review Choice Demonstration Is Here To Stay

Home Health Care News | By Patrick Filbin
 
The Centers for Medicare & Medicaid Services (CMS) has been tight-lipped about its Review Choice Demonstration (RCD) plans beyond May 2024.
 
However, industry leaders believe RCD will be extended across the country on a more permanent basis — a development that agency leaders should recognize as a momentum shifting change.
 
“We’re seeing a monumental shift in home health care and how we actually operate,” Kim Gaffey, founder and CEO of Gaffey Home Nursing and Hospice, said during a webinar Thursday. “When we started RCD five years ago, we really had three silos inside our business: clinical, billing and administrative. Oftentimes those three silos worked somewhat independently. As we entered into this RCD world, we had to bring all three silos together and examine how they interacted with each other.”
 
The Illinois-based Gaffey Home Nursing and Hospice offers home health, home nursing and hospice services.
 
Generally, RCD requires home health care providers to submit claims documentation earlier on in the care process and is meant to target and combat fraud in the industry. CMS’ goal in RCD is to reduce improper billing under Medicare’s home health benefit.
 
In 2017, lawmakers successfully blocked the expansion of the Pre-Claim Review Demonstration (PCRD) — the precursor to RCD. The original iteration got off to a rocky start in Illinois, with providers and associations complaining of administrative burden, compliance costs and high non-affirmation rates.
 
A few years later, RCD was introduced in five states: Illinois, Ohio, Texas, North Carolina and Florida. CMS suspended the demonstration in late March of 2020 due to the COVID-19 crisis, but soon after announced that it would resume in August, much to the chagrin of providers in those states.
 
A year later, CMS made a major change to the way billing was processed, which was a reprieve for providers. Today, those providers are reflecting on how those changes have affected the way they do business.
 
“One of the first things that you realize once you’re in the RCD system is how many times each one of those silos touch the document or communicate with the provider,” Gaffey said. “From the first day of patient interaction to the final day of billing, we’re seeing that we are now a team instead of three independent departments. Without implementing and examining that process, you’ll fail at RCD.”
 
Because a premium is put on accuracy and communication in the documentation process of RCD, there are a lot of positives that come with the time consuming aspects of the program…

Read Full Article

 

Medicare Program; Request for Information on Medicare Advantage Data

CMS

This request for information (RFI) seeks input from the public regarding various aspects of Medicare Advantage (MA) data. Responses to this RFI may be used to inform general efforts to strengthen Centers for Medicare & Medicaid Services’ (CMS’) MA data capabilities and guide policymaking.

To be assured consideration, comments must be received at one of the addresses provided below, by May 29, 2024.

CLICK HERE to learn more or to comment

 

Key Lawmakers Urge CMS to Curb Medicare Advantage Fraud, Abuse

McKnight’s Home Care | By Adam Healy
 
The Centers for Medicare & Medicaid Services should take swift action to “curb abusive practices” by Medicare Advantage plans, senators said in a letter sent Thursday. 
 
“The MA program is based on the premise that private insurance companies can and would administer Medicare coverage more cost-effectively — but it has failed to do so every single year,” Sens. Pramila Jayapal (D-WA) and Elizabeth Warren (D-MA) wrote in their letter
 
The Medicare Payment Advisory Commission has estimated that MA plans average receiving as much as 6% more per enrollee than traditional Medicare, the letter writers said. On top of that, MA plans also spend roughly 25% less on healthcare services per enrollee, they noted.
 
“It is imperative for CMS to rein in these abuses and protect Medicare coverage for
the seniors and people with disabilities who rely on it,” the senators wrote.
 
Jayapal and Warren recommended improvements in four areas. First, they advised CMS to augment base MA payments to offset overpayments due to favorable selection. Since MA beneficiaries are typically younger and healthier, they wrote, MA insurers may receive higher-than-average reimbursement from CMS while also paying out fewer claims, resulting in “gross overpayments.”
 
They also recommended CMS get more aggressive about recouping overpayments, implement a “network quality” measurement to MA plans’ star ratings, and limit insurers’ use of health risk assessments — which have been criticized for their lack of transparency.
 
Jayapal and Warren also noted MA plans’ use of artificial intelligence to “systematically deny care.” In November, UnitedHealthcare, the largest MA insurer, was alleged in a class action lawsuit to have used artificial intelligence tools to deny hundreds of patients post-acute care services, including home health.
 
Also on Thursday, CMS issued an extensive request for information seeking details about nearly all aspects of the MA program. They include care access data, prior authorization results, statistics related to patients’ outcomes and more. Still, Jayapal and Warren sought further enforcement action in their letter to the agency.
 
They gave qualified praise to steps CMS has already taken to limit overpayments.
 
Nonetheless, they noted, the Committee for a Responsible Federal Budget has projected that CMS will overpay MA insurers by as much as $1.56 trillion over the next decade. 
 
“As enrollment in MA continues to grow, CMS must take more aggressive action to ensure Medicare’s sustainability, protect taxpayer dollars, and curb abusive practices,” they said.

 

As Denials Climb, MACPAC Approves Recommendations for Managed Care Oversight 

McKnight’s Home Care | By Adam Healy

The Medicaid and CHIP Payment Advisory Commission on Friday approved seven recommendations to enhance congressional oversight of Medicaid managed care organizations as recent reports reveal startlingly high rates of prior authorization denials.

MACPAC’s recommendations aim to improve the prior authorization and appeals process by requiring MCOs to report relevant data to the Centers for Medicare & Medicaid Services. CMS would be required to release public reports on the data, as well as update regulations and create additional guidelines for MCOs’ use of prior authorization.

recent investigation by the Office of the Inspector General found that 12.5% of prior authorization requests were denied by Medicaid MCOs, and about 2.7 million Medicaid beneficiaries were enrolled in MCOs with denial rates greater than 25%.

Thousands of prior authorization requests for elderly, chronically ill or disabled patients requiring home care were denied by MCOs, according to the report. 

“Few denials are appealed and little is known about the beneficiary experience,” Lesley Baseman, senior policy analyst at MACPAC, said during the Thursday meeting. “The appeals process is also challenging and burdensome for beneficiaries. Denial notices can be late in the mail and the content is often unclear, and beneficiaries encounter multiple barriers in accessing continuation of benefits.”

Part of the challenge, OIG’s investigation found, was that few guidelines for MCOs’ prior authorizations requests are currently in place.

States are not federally required to collect data on denials, continuation of benefits, or appeals outcomes, according to Baseman. Federal rules do not require states to assess clinical appropriateness of denials, she said, and they do not require that states publicly report information on denials and appeal outcomes.

OIG’s report also found that many MCOs employed staff who were not qualified to approve or deny requests, and most states lack safeguards to identify improper prior authorization denials.

 
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