2023 Home Health Rule: 4.2% Reduction With Warnings of More to Come

APTA

After holding off on any big changes to home health payment in 2022, CMS plans to take some major steps in 2023 to address what it describes as the gaps between "assumed behavior changes and actual behavior changes" resulting from the Patient-Driven Groupings Model payment system implemented in 2020. Translation: The PDGM has cost significantly more than CMS hoped, so to reach its goal of budget neutrality compared with the previous system, the agency has proposed changes that would reduce payment by 4.2%, or about $810 million compared with 2022 amounts.

The bulk of the cuts is directed at the 30-day payment rate, but even if those reductions are put into place in 2023, CMS believes more changes will need to be made in the future to recoup the payment differences that have already occurred under the PDGM — an estimated $2 billion gap so far. To that end, the proposed rule also seeks public comment on how to best make up the difference.

APTA is preparing comments on the rule to submit by the Aug. 16, 2022, deadline. 

Read Full Article

Home Health Industry Pushes Back on CMS Budget-Neutrality Methodology for PDGM

Home Health Care News

Since the release of the U.S. Centers for Medicare & Medicaid Services’ (CMS) proposed payment rule, home health stakeholders have been sitting in their respective “war rooms” trying to navigate the proposal.

As providers geared up for the unveiling of the proposal, many knew that CMS’ analysis of whether the Patient-Driven Groupings Model (PDGM) led to higher, lower or equal spending compared to the old payment model would be a major factor, according to William A. Dombi, the president of the National Association for Home Care & Hospice (NAHC).

Many are pushing back against CMS’ methodology for assessing budget neutrality, with organizations such as NAHC expressing their concerns even prior to the release of the proposed rule.

“When we found out on Friday that CMS chose to use the same methodology which had been roundly condemned by anybody who had evaluated it, we had to conclude the CMS had effectively declared war against home health,” Dombi said. “I don’t mean that in an emotional sense, but in a practical sense, where the outcome of this proposal could be extraordinarily — not just disruptive — but devastating to the home health care community.”

He made these comments during NAHC’s latest webinar on Thursday.

Overall, the proposed rule comes with a decrease to payment rates by 4.2%, or $810 million less compared to 2022 rates.

“CMS only gets to that [$810 million] by adding in the inflation update, so the inflation update for 2023 is a meager 2.9%,” Dombi said.

The proposed rule also includes a 7.69% PDGM budget-neutrality adjustment.

Read Full Article

House Lawmakers Call Out ‘Bad Actors’ Within Medicare Advantage

Home Health Care News | By Joyce Famakinwa
 
House lawmakers are pushing for more oversight of Medicare Advantage (MA) plans in light of concerns over higher spending, improper claim denials and access to treatment.
 
A number of lawmakers on the House Energy and Commerce Committee’s oversight subcommittee examined the issue during a hearing that centered around the MA program on Tuesday.
 
“I am deeply concerned with recent reports that seniors in private sector Medicare Advantage plans are facing unwarranted barriers to accessing timely, medically necessary care,” Energy and Commerce Chairman Frank Pallone, Jr. (D-N.J.) said during the hearing. “Several studies have raised concerns that insurance companies are denying beneficiaries’ access to treatment and imposing burdensome requirements that delay care. Improper claim denials and increased use of prior authorizations are preventing beneficiaries from receiving the care they need.”
 
Pallone noted that while many Medicare Advantage plans seemed to be acting responsibly, “bad actors” were endangering the health of seniors and increasing costs for taxpayers.
 
Though several officials from federal agencies testified, including the U.S. Department of Health and Human Services Office of the Inspector General (HHS-OIG), the Medicare Payment Advisory Commission (MedPAC) and the Government Accountability Office. The U.S. Centers for Medicare & Medicaid Services (CMS) was not represented at the hearing.
 
“It’s a shame CMS did not agree to testify at this hearing to speak to the work the agency is doing to improve this program,” Rep. Morgan Griffith (R-Va.), a ranking member of the subcommittee, said.
 
Additionally, no MA plans spoke at the hearing.
 
During the hearing, Erin Bliss, the assistant HHS inspector general, pointed to OIG findings that plans were using chart reviews or in-home health risk assessments to diagnose patients. Oftentimes, there would be no follow-up.
 
In total, these diagnoses resulted in an estimated $2.6 billion in risk-adjustment payments for 2017.
 
Bliss also expressed that plans sometimes delayed or denied beneficiaries’ access to medical care, despite the requested care being medically necessary and meeting Medicare coverage rules.
 
“In other words, these Medicare Advantage beneficiaries were denied access to needed services that likely would have been approved if the beneficiary had been enrolled in original Medicare,” she said. “These denials likely prevented or delayed needed care for beneficiaries.”

Read Full Article

Health Care Fraud and Abuse Control Program FY 2021 Report Issued

From the Health Group

The Department of Health and Human Services and the Department of Justice have released the Health Care Fraud and Abuse Control Program Annual Report for Fiscal Year 2021. 

During FY 2021, the federal government won or negotiated more than $5 billion in health care fraud judgments and settlements.  The Report provides highlights of significant criminal and civil investigations by type including:

• Ambulance transportation services
• Clinics
• Diagnostic testing
• Drug companies
• Durable medical equipment
• Electronic health records
• Genetic testing
• Home health providers
• Hospice care
• Hospitals and health systems
• Laboratory testing
• Managed care
• Medical devices
• Nursing homes and facilities
• Pharmacies
• Physical therapy
• Physicians and other practitioners
• Prescription drugs and opioids
• Psychiatric and psychological testing and services
• Substance use treatment centers

The Report provides an all-inclusive look into the current and potential activities relating to the identification and pursuit of fraudulent and abusive activities, including Medicare provider screening.  All providers should be continuously aware of areas of focus as described in the Report.  The entire Report is available at FY 2021 HCFAC Report (hhs.gov).