Action needed: Register for an iQIES Account

The Quality Improvement and Evaluation System (QIES), which providers and vendors use to submit assessment data, is being upgraded to make the system more reliable, scalable, secure, and accessible.  The enhancements will occur in phases (by provider type) and began with Long- Term Care Hospitals (LTCHs) in March 2019, followed by Inpatient Rehabilitation Facilities (IRFs) in October 2019 and Home Health Agencies (HHAs) in January 2020. The enhanced system is referred to as the Internet Quality Improvement and Evaluation System (iQIES).

The rollout of iQIES will not require providers or vendors to change current processes related to submission of data. However, iQIES will require a new user management system because virtual private network (VPN) and CMSNet are no longer needed to access this system. All users will have to create an account and establish credentials in the Healthcare Quality Information System (HCQIS) Access, Roles and Profile system (HARP). HARP is a secure identity management portal that the Centers for Medicare & Medicaid Services (CMS) provides.

Through HARP, the level of access for iQIES will be similar to the roles that exist in QIES but with the addition of a Provider Security Official (PSO). The individual designated as the PSO will be responsible for approving or rejecting iQIES user access requests for their respective organizations, including vendors. For your organization to receive access to iQIES, you must first identify a PSO. For instructions on obtaining access to iQIES, descriptions of the iQIES roles applicable to HHAs and important iQIES information, please refer to the following link: https://qtso.cms.gov/news-and-updates/register-iqies-account-action-required-1.

Please note that at this time, only certified Home Health Agencies will be onboarded to iQIES. For questions, please contact our service desk at: help@qtso.com or by phone: 800-339-9313.

***Although onboarding for HHAs is in progress, iQIES assessment submission functionality for HHAs will not be available until January 1, 2020. Although this functionality will not be available immediately, we encourage HHA security officials to request access to iQIES as soon as possible. CMS advises that HHAs register two security officials, if possible, as doing so will allow for a smoother transition prior to the January go live date. Upon receiving access, security officials will have access to ‘My Profile’ and ‘Help’ in iQIES. Please note that failure to obtain access to iQIES prior to December 23, 2019 will impact your ability to submit assessment data needed for payment purposes, as the system will have a scheduled downtime so that the data migration can occur in preparation for the January 1, 2020 release. Claims that cannot be matched to assessments will be returned to the HHA, preventing Medicare payment.

To comply with federal security mandates, CMS is initiating new security requirements for access control to CMS Quality Systems through Remote Identify Proofing (RIDP) via HARP. Users will need to create an account in HARP to gain access to the iQIES system. CMS has prepared a fact sheet with more information about this process. To view the fact sheet, visit: https://qtso.cms.gov/news-and-updates/remote-identify-proofing-requirements-internet-quality-improvement-evaluation-0

Frequently Asked Questions (FAQs) related to HARP can be accessed using the following link: https://harp.qualitynet.org/login/help

Source: www.cms.gov

Congress Debates Bill to Automate Prior Authorization in Medicare Advantage Plans

Recently the House of Representatives’ Small Business Committee convened for a hearing on utilization management and barriers to care in small medical practices. In particular this hearing focused on the application of prior authorization within Medicare Advantage (MA) plans and the associated challenges faced by patients and providers of services due to prior authorization requirements.

The underlying theme of the hearing was support for H.R. 3107, the Improving Seniors’ Timely Access to Care Act, a bill that would automate the prior authorization process in Medicare Advantage plans. This automation would be through electronic submission of prior authorization requests with real-time determinations by the MA plans. The legislation encourages integration of the electronic prior authorization submission into electronic medical record systems. The Secretary of Health and Human Services would be tasked with developing standards in conjunction with stakeholder input. In addition, certain transparency requirements would be put in place. These include:

  • A list of services and items subject to prior authorization;
  • The percentage of prior authorization requests approved during the previous plan year by the plan for each item and service;
  • The percentage of requests that were initially denied and then subsequently appealed, and the percentage of such appealed requests that were overturned for each such item and service; and
  • The average amount of time elapsed from request submission to determination

This legislation would have impact on all provider types that contract with Medicare Advantage plans that are subject to prior authorization.

Testifying at the hearing were four different physician-focused trade associations; Radiation Oncologists, Anesthesiologists, Family Physicians, and Dermatologists. Each of the four witnesses outlined the challenges that prior authorization places on their practice, as well as the impact the requirement has on their patients. In particular witnesses focused on delays in care, inappropriate request denial, non-licensed professionals reviewing requests, and the prior authorization requirement being used as an unnecessary delay tactic to deter provision of care. In one testimony a 2018 report from the Office of the Inspector General (OIG) evaluating appeal outcomes in Medicare Advantage Organizations (MAO) was quoted with “MAOs may have an incentive to deny preauthorization of services for beneficiaries, and payments to providers, in order to increase profits.”

The National Association for Home Care and Hospice will continue to monitor this legislation for updates and further activity within the Congress.

Source: nahc.org

Physician Stark Law Rules Revamped: New Rules Address Care Coordination

This is the first major update to rules for the Stark law since 1989, according to HHS. An HHS press statement explained that the new rules would give providers in value-based arrangements “greater certainty” and “ease the compliance burden for healthcare providers across the industry,” while maintaining protections against fraud and abuse.

Clinicians and hospital groups have argued that the Stark Law hampers value-based payment arrangements and makes coordinating patient care more difficult. When the law was enacted, most of the healthcare system relied on fee-for-service payments.

HHS Secretary Alex Azar said in a statement. “Our proposed rules would be an unprecedented opportunity for providers to work together to deliver the kind of high-value, coordinated care that patients deserve.”

Examples of Change: 9 Things To Know

HHS offered specific examples of the types of care coordination, patient engagement and data sharing practices that would be encouraged under the draft proposals.

  1. The proposed rule enables hospitals to provide patients with remote monitoring technology to alert physicians and caregivers when he or she needs help; and permit physicians to give patients free “smart pillboxes” which let the physicians and caregivers know when a patient misses a dose. And, would allow specialty physicians to share data analytics services with a primary care physician’s practice;
  2. Patient engagement and support arrangements are covered by the proposed safe harbors, and could include using a home health aide to help patients with medication or medical devices.
  3. The safe harbors include allowing hospitals to pay physicians incentives as part of CMS-sponsored care models; care coordination activities to increase quality, outcomes or efficiency; and value-based care relationships with significant downside risk.
  4. The new rule allows a nephrologist or dialysis facility to give patients technology that provides “two-way, real-time interactive communication” with physicians.
  5. Specialty physician practices could share patient information with primary-care physicians to manage care or work with hospitals on discharges using data analytics.
  6. The safe harbor proposals would also create more flexibility for outcome-based payments and part-time provider relationships, and ease local transportation restrictions for rural areas and discharged patients. They would also codify existing remuneration exceptions for the Medicare Shared Savings Program.
  7. The proposed rule would also allow a local hospital to enhance its own cybersecurity by providing physician practices that refer patients to that hospital with free cybersecurity software. “The hospital and the physicians often share information about their patients, so it is important that there are no weak links that might compromise everyone else,” the HHS statement explained.
  8. Proposed rules would increase flexibility, innovation and coordinated care through outcome-based payment arrangements. See fact sheet.
  9. CMS is soliciting comments regarding price transparency in relation to the Stark Law, around “whether to require cost-of-care information at the point of a referral for an item or service,” the agency noted

The American Hospital Association  (AHA) celebrated the new rules as long overdue.

“Despite widespread agreement by Congress, and even previous administrations, that these regulations needed to be modernized, the proposal is the first major step toward achieving that goal,” said Rick Pollack, president and CEO of AHA.

“The changes proposed should help to supplant numerous waivers of these same regulations needed to experiment with collaborative and innovative programs to provide cost-effective comprehensive care through new value-based models, such as Accountable Care Organizations (ACOs). And, they do so without sacrificing the law’s original purpose — to prevent physicians from referring patients to facilities in which they have a financial stake.”

Source: remingtonreport.com

Home Care Agencies Often Wrongly Deny Medicare Help To The Chronically Ill

Colin Campbell needs help dressing, bathing and moving between his bed and his wheelchair. He has a feeding tube because his partially paralyzed tongue makes swallowing “almost impossible,” he said.

Campbell, 58, spends $4,000 a month on home health care services so he can continue to live in his home just outside Los Angeles. Eight years ago, he was diagnosed with amyotrophic lateral sclerosis, or “Lou Gehrig’s disease,” which relentlessly attacks the nerve cells in his brain and spinal cord and has no cure.

The former computer systems manager has Medicare coverage because of his disability, but no fewer than 14 home health care providers have told him he can’t use it to pay for their services.

That’s an incorrect but common belief. Medicare does cover home care services for patients who qualify, but incentives intended to combat fraud and reward high quality care are driving some home health agencies to avoid taking on long-term patients such as Campbell, who have debilitating conditions that won’t get better, according to advocates for seniors and the home care industry. Rule changes that took effect this month could make the problem worse.

“We feel Medicare coverage laws are not being enforced and people are not getting the care that they need in order to stay in their homes,” said Kathleen Holt, an attorney and associate director of the Center for Medicare Advocacy, a nonprofit, nonpartisan law firm. The group is considering legal action against the government.

Campbell has ALS, which attacks the nerve cells in the brain and the spinal cord. The former computer systems manager uses a walker, wheelchair and built-in fixtures to help him get around. (Heidi de Marco/KHN)

Campbell developed drop foot due to his ALS and needs to wear a brace. He relies on help from a home health worker to get dressed and bathed every day. (Heidi de Marco/KHN)

Federal law requires Medicare to pay indefinitely for home care — with no copayments or deductibles — if a doctor ordered it and patients can leave home only with great difficulty. They must need intermittent nursing, physical therapy or other skilled care that only a trained professional can provide. They do not need to show improvement. Those who qualify can also receive an aide’s help with dressing, bathing and other daily activities. The combined services are limited to 35 hours a week.

Medicare affirmed this policy in 2013 when it settled a key lawsuit brought by the Center for Medicare Advocacy and Vermont Legal Aid. In that case, the government agreed that Medicare covers skilled nursing and therapy services — including those delivered at home —to maintain a patient’s abilities or to prevent or slow decline. It also agreed to inform providers, bill auditors and others that a patient’s improvement is not a condition for coverage.

Campbell said some home health care agencies told him Medicare would pay only for rehabilitation, “with the idea of getting you better and then leaving,” he said. They told him that Medicare would not pay them if he didn’t improve, he said. Other agencies told him Medicare simply did not cover home health care.

Medicaid, the federal-state program for low-income adults and families, also covers home health care and other home services, but Campbell doesn’t qualify for it.

Securing Medicare coverage for home health services requires persistence, said John Gillespie, whose mother has gone through five home care agencies since she was diagnosed with ALS in 2014. He successfully appealed Medicare’s decision denying coverage, and afterward Medicare paid for his mother’s visiting nurse as well as speech and physical therapy.

“You have to have a good doctor and people who will help fight for you to get the right company,” said Gillespie, of Orlando, Fla. “Do not take no for an answer.”

Yet a Medicare official did not acknowledge any access problems. “A patient can continue to receive Medicare home health services as long as he/she remains eligible for the benefit,” said spokesman Johnathan Monroe.

But a leading industry group contends that Medicare’s home health care policies are often misconstrued. “One of the myths in Medicare is that chronically ill individuals are not qualified for coverage,” said William Dombi, president of the National Association for Home Care and Hospice, which represents nearly half of the nation’s 12,000 home care providers.

Part of the problem is that some agencies fear they won’t be paid if they take on patients who need their services for a long time, Dombi said. Such cases can attract the attention of Medicare auditors who can deny payments if they believe the patient is not eligible or they suspect billing fraud. Rather than risk not getting paid, some home health agencies “stay under the radar” by taking on fewer Medicare patients who need long-term care, Dombi said.

And they may have a good reason to be concerned. Medicare officials have found that about a third of the agency’s payments to home health companies in the fiscal year ending last September were improper. 

Campbell’s adjustable wheelchair allows him to recline, which makes breathing easier. (Heidi de Marco/KHN)

Shortages of home health aides in some areas might also lead an overburdened agency to focus on those who need care for only a short time, Dombi said.

Another factor that may have a negative effect on chronically ill patients is Medicare’s Home Health Compare ratings website. It includes grades on patient improvement, such as whether a client got better at walking with an agency’s help. That effectively tells agencies who want top ratings “to go to patients who are susceptible to improvement,” Dombi said.

This year, some home care agencies will earn more than just ratings. Under a Medicare pilot program, home health firms in nine states will start receiving payment bonuses for providing good care and those who don’t will pay penalties. Some criteria used to measure performance depend on patient improvement, Holt said.

Another new rule, which took effect last Saturday, prohibits agencies from discontinuing services for Medicare and Medicaid patients without a doctor’s order. But that, too, could backfire. 

“This is good,” Holt said. “But our concern is that some agencies might hesitate to take patients if they don’t think they can easily discharge them.”

This article was written with the support of a journalism fellowship from New America Media, the Gerontological Society of America and the Silver Century Foundation.

Source: https://khn.org/news/home-care-agencies-often-wrongly-deny-medicare-help-to-the-chronically-ill/

3 Benefits of Value-Based Care

The U.S. healthcare industry is moving toward value-based care, encouraged by reimbursement initiatives from the Centers for Medicare and Medicaid Services (CMS). In a value-based model, providers are paid depending on patient outcome rather than on volume of procedures performed. Theoretically, this would promote a focus on patient wellness and preventative medicine, which would improve overall health and reduce incidence and severity of chronic illness in the general population.

In addition to improving population health, value-based care (VBC) is intended to reduce healthcare costs for patients and providers. Though providers and patients are the primary beneficiaries in a value-based system, payors and suppliers may also profit.

1. Providers: improve patient satisfaction and increase operational efficiency

When allied health professionals and care organizations address a patient’s overall health rather than an acute episode of care, the patient is likely to report greater satisfaction. Focusing solely on symptom management is ineffective if a physician doesn’t also take into account other factors impacting patient health, such as environment, diet, and pre-existing conditions. A holistic approach may also increase trust in physicians, which positively impacts patient engagement and has been shown to improve care outcomes.

Lowering costs associated with chronic illness management frees up funds that can be used to institute more efficient workflows, including technologies like telehealth and check-in kiosks that reduce wait times and can improve care outcomes. Providers can also spend more time focusing on preventative medicine and population health issues rather than struggling to keep up with high patient demand and readmissions.

2. Suppliers: demonstrate how products improve outcomes at lower costs

Any sales rep knows that the key to closing a deal is to demonstrate value. Suppliers who are familiar with the healthcare market understand the role of value-based care in purchasing decisions and can use this knowledge to target hospitals and health systems based on diagnoses, procedures, and value-based care performance.

For example, if a medical device supplier offers antibiotic-infused surgical sutures that can reduce the risk of patients developing surgical site infections, that would improve care outcomes and the facility would be reimbursed at a higher rate under VBC. The higher supply costs that may be associated with specialty sutures pale in comparison to the costs and patient health risks associated with treating hospital-acquired infections, making it an easy sell for suppliers.

3. Payors: value-based care reduces risk and lowers spending

Healthcare payors assess risk by balancing smaller populations of unwell patients with a larger population of generally healthy patients. The healthier the general population is, the fewer claims will be filed, saving payors money and reducing the risk of significant financial loss. In the long run, healthier patient populations can reduce individual premiums and copays.

Source: https://blog.definitivehc.com by Alanna Moriarty

CMS Delays Collapsing of E/M Payment Rates Until 2021

Implementation of a single E/M payment rate for office visit Levels 2 through 4 won’t go into effect until 2021, CMS stated in the new Physician Fee Schedule rule.

– CMS will collapse evaluation and management (E/M) payment rates, but not until the 2021 calendar year, according to the recently released final 2019 Physician Fee Schedule (PFS) rule.
After industry pushback, the federal agency will delay the implementation of a single, blended payment rate for E/M office/outpatient visit levels 2 through 4 for established and new patients. The PFS will maintain the payment rate for E/M office/outpatient visit level 5 to “better account for the care and needs of complex patients,” CMS noted.

To account for the additional resources needed for E/M visits levels 2 through 4, CMS will also offer a new “extended visit” add-on code in 2021. The federal agency will also offer add-on codes for primary care visits and visits for particular types of non-procedural specialized medical care.

The final 2019 PFS rule also paired E/M payment changes with documentation requirement updates. The rule will reduce E/M documentation requirements for all visit levels starting in CY 2019. Documentation changes in the final rule include:

  • Elimination of the requirement to document medical necessity of a home visit in lieu of an office visit
  • Providers can choose to choose their documentation on what has changed since the last visit or on pertinent items that have not changed for established patient visits when relevant information is already documented in the medical record
  • Providers will not have to re-enter information on a patient’s chief complaint and history in the medical record that has already been recorded by an ancillary staff or the beneficiary
  • Removal of potentially duplicative requirements for medical record notations that may have been previously included in the medical records by residents or other medical team members for E/M visits performed by teaching physicians

CMS will continue to reduce E/M documentation burdens into CY 2021. In conjunction with Medicare reimbursement updates, the federal agency will also implement several E/M documentation changes, such as allowing provider to choose to document E/M office/outpatient visits Levels 2 through 5 using medical decision-making or time instead of applying the current 1995 or 1997 E/M documentation coding guidelines.

“Today’s rule finalizes dramatic improvements for clinicians and patients and reflects extensive input from the medical community,” CMS Administrator Seema Verma stated in an official press release. “Addressing clinician burnout is critical to keeping doctors in the workforce to meet the growing needs of America’s seniors. Today’s rule offers immediate relief from onerous requirements that contribute to burnout in the medical profession and detract from patient care.”

Providers have praised CMS for proposing to update E/M documentation requirements, but industry leaders have opposed the collapsing of E/M payment rates for office visits.

The American Hospital Association (AHA) said that by “reducing payments for many providers, the proposal to collapse the payment rates for E/M visits devalues providers’ time, increasing the already heavy pressure they face to maximize the number of patients they see each day.”

The AMGA agreed, adding “pairing paperwork reforms with a significant change in categorizing patient complexity and reimbursement may very likely undermine care quality and coordination and cause disruption in physician workflow and referral patterns.”

Despite several industry groups calling for the abandonment of the E/M payment changes, CMS finalized reduced rates for several E/M office/outpatient visit levels. But the federal agency intends for the implementation delay to help providers prepare.

“[The rule] also delays even more significant changes to give clinicians the time they need for implementation and provides time for us to continue to work with the medical community on this effort,” Verma stated in the press release.

While the final 2019 PFS rule contained major changes to E/M payment and documentation, the rule also included key policy changes intends to modernize Medicare. CMS pointed out that the rule will also:

  • Reimburse providers for two newly define physician services furnished using communication technology (Brief communication technology-based service, e.g. virtual check-in Remote evaluation of recorded video and/or images submitted by an established patient)
  • Expansion of telehealth use for treatment of opioid use disorder and other substance use disorders
  • Pay for communication technology-based services and remote evaluation services furnished by rural health clinics and federally qualified health centers
  • Implement wholesale acquisition cost-based payment for certain Part B drugs

“The historic reforms CMS finalized today move us closer to a healthcare system that delivers better care for Americans at lower cost,” stated HHS Secretary Alex Azar. “Among other advances, improving how CMS pays for drugs and for physician visits will help deliver on two HHS priorities: bringing down the cost of prescription drugs and creating a value-based healthcare system that empowers patients and providers.”

Source: Xtelligent Healthcare Media
By Jacqueline LaPointe

 

Increased Enforcement Against Home Health Agencies

With the recent rise in medical services provided outside of a doctor’s office, there has been a surge of FCA enforcement actions against home health agencies (HHAs). HHAs are public or private agencies or organizations that are primarily engaged in providing skilled nursing services and other therapeutic services to patients in their residence.[1] The last several years have seen an increase in the provision of these services, with 11,869 Medicare certified HHAs and more than five million beneficiaries served in the United States in 2018.[3] This increase may be the result of the growth of the United States’ elderly population,[2] as older persons are projected to outnumber children for the first time in US history by 2030.[4] Thus, along with the rise in the elderly population and home healthcare comes increased oversight of HHAs.

OIG Pushes for More Oversight and Funding

OIG recently addressed the rapid growth in HHAs by issuing a report discussing, in part, the specific issues arising out of HHAs and seeking additional funding to investigate HHA cases. In late July 2019, the OIG released a report entitled “Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs: OIG’s Top Recommendations.”[5] Within the report, the OIG made several recommendations relating to home health and hospice services, including implementation of the statutory mandate requiring surety bonds for HHAs that enroll in Medicare. According to the report, the implementation of surety bonds for HHAs would have led to the recovery of at least $39 million in uncollected overpayments between 2007 and 2011. Additionally, with respect to hospice providers, the OIG recommended that the Centers for Medicare and Medicaid Services seek statutory authority to establish additional remedies in order to address poor performance.

Further, in March 2019, the OIG sought an additional $10 million in its 2020 budget in order to deal with fraud in home- and community-based services.[6] The OIG specifically requested funding in order to expand capabilities to surveil home health, hospice, personal care and other home-based services, and reserved at least $4.5 million of the budget for “boots on the ground” in order to open more investigations. The budget request notes that the increased funding is necessary in order to combat what OIG sees as growing fraud in the home health industry, estimating that in 2017 there were $808 million in improper payments to home health providers. The 2020 budget request seeks three times more funding than last year, with a budget increase of only $3 million sought between 2018 and 2019, and serves as an acknowledgment by the OIG that HHAs will be under increased scrutiny.

Recent Cases

According to the OIG, between 2013 and 2017, HHA investigations resulted in more than 450 criminal and civil actions and generated $1.3 billion in expected receivables.[7] The OIG additionally estimates that Medicare paid $3.2 billion in improper reimbursements for home health services in 2018.[8] Further, the OIG noted that in 2016 it identified more than 500 HHAs and 4,500 physicians with suspicious practices potentially giving rise to FCA actions.[9]

Given the trends already seen in 2019, it appears that HHA enforcement actions have meaningfully increased. Since the beginning of 2019, there have been at least 22 DOJ announcements concerning HHAs involving almost $200 million in alleged fraud total.[10] Individuals involved in these cases have been sentenced to a total of more than 1,000 months in prison (with sentences ranging from 24 to 188 months) and approximately $74 million in restitution.[11] On January 28, 2019, alone, DOJ announced five separate HHA actions amounting to more than $21 million in fraud.[12]

In addition to increased HHA oversight and investigations, DOJ also appears determined to impose longer sentences and higher monetary restitution than in prior years. In one of the toughest sentences of 2019 thus far, the former director of nursing and administration of two Houston home health companies was sentenced to 10 years in prison and a restitution order of more than $20 million based on allegedly false certifications and falsified patient records.[14] Further, the director allegedly paid patient recruiters to locate Medicare beneficiaries and paid doctors to certify false plans of care. This sentence represents a trend in harsher sentencing, with more than half of the prison terms given in 2019 exceeding five years and several restitution awards exceeding $8 million. [14]

Recruiters and Hospice Care

In addition to concentrating on HHAs, DOJ also appears to have increased its focus on recruiters and hospice providers. Since the beginning of 2019, at least eight patient recruiters have been convicted or pleaded guilty to fraud schemes involving HHAs.[15] Often these recruiters are charged in conjunction with home health company owners and administrators for both the payment and receipt of kickbacks. In these matters, recruiters are often alleged to have referred patients for home health who are not eligible under Medicare, do not need home health services, or were never actually provided services. In May 2019, DOJ announced the sentencing of a Houston recruiter to 188 months in prison and a restitution payment of $12.9 million in connection with a $20 million scheme in which the recruiter paid kickbacks and bribes to both physicians and patients in exchange for the paperwork necessary for five separate HHAs to bill Medicare.[16] This sentence represents the largest recruiting-related sentence and the longest prison term awarded relating to HHA actions thus far this year.

Finally, although hospice providers are not always considered HHAs, there is often an intersection between the two, with the OIG frequently discussing home health and hospice together because of the similar nature of the services provided and the nature of the alleged fraud. With the recent surge in HHA prosecutions and investigations, there has been a similar increase in hospice-related FCA actions.

Since 2018, DOJ has settled several large FCA cases relating to hospice care, including the prominent example of Chemed Corporation, the owner of the largest for-profit hospice services company in the United States. Chemed, Vitas Hospice Services and Vitas Healthcare settled with DOJ in 2017 for $75 million arising out of allegations that the company knowingly submitted hospice claims for patients who were not terminally ill.[17] With the increased scrutiny of HHAs, hospice providers should likewise expect more oversight and investigations in the years ahead.

Nonetheless, hospice providers can take some solace based on the recent dismissal of FCA claims against HCR ManorCare, Inc., and its subsidiaries.[18] On June 26, 2019, the Northern District of Ohio dismissed the FCA claims brought by a former consultant turned relator who alleged that the defendant billed for patients that did not qualify for hospice care and failed to return overpayments. The Northern District dismissed the case with prejudice on the basis that the Rule 9(b) pleading requirements had not been met and the relator failed to plead her claims with particularity.

PRACTICE NOTE: Moving forward, providers practicing in the home health and hospice industry should expect to see more oversight activity, and should stay abreast of compliance issues relating to patient eligibility, use of recruiters, and submission of claims to Medicare and other government programs.

[1] See Centers for Medicare & Medicaid Services, Home Health Providers (July 25, 2019), https://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/CertificationandComplianc/HHAs.html.
[2] See Centers for Medicare & Medicaid Services, Home Health Quality Reporting Program (June 6, 2019), https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/index.html (stating that “5,125,575 beneficiaries were served through 7,228,721 episodes of care.”).
[3] Tracy L. Mitzner et al., Older Adults’ Needs for Home Health Care and the Potential for Human Factors Interventions, Proc. of the Hum. Factors & Ergonomics Soc’y Ann. Meeting, 718-722 (Oct. 1, 2009), https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4270052/.
[4] See US Census Bureau, Older People Projected to Outnumber Children for First Time in U.S. History (Mar. 13, 2018), https://www.census.gov/newsroom/press-releases/2018/cb18-41-population-projections.html.
[5] See US Dep’t of Health & Human Servs. Office of Inspector General, Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs: OIG’s Top Recommendations (July 2019), https://oig.hhs.gov/reports-and-publications/compendium/files/compendium2019.pdf.
[6] Dep’t of Health & Human Servs. Office of the Inspector General, Justification of Estimates for Appropriations Committees Fiscal Year 2020 (2019), at 40-41, https://oig.hhs.gov/reports-and-publications/archives/budget/files/2020budget.pdf.
[7] Id.
[8] US Dept. of Health & Human Servs. Office of Inspector General, Solutions to Reduce Fraud, Waste, and Abuse in HHS Programs: OIG’s Top Recommendations (July 2019), https://oig.hhs.gov/reports-and-publications/compendium/files/compendium2019.pdf).
[9] See US Dep’t of Health & Human Servs. Office of Inspector General, HHS OIG Data Brief: Nationwide Analysis of Common Characteristics in OIG Home Health Fraud Cases (June 2016), https://oig.hhs.gov/oei/reports/oei-05-16-00031.pdf.
[10] See, e.g., Press Release, US Dep’t of Justice, Co-Owners of Chicago-Area Home Health Agency Plead Guilty to Kickbacks Conspiracy Charges (May 31, 2019), https://www.justice.gov/opa/pr/co-owners-chicago-area-home-health-agency-plead-guilty-kickbacks-conspiracy-charges; and Press Release, US Dep’t of Justice, United States Files False Claims Act Complaint Against Home Health Agency and Two of Its Owners (May 24, 2019), https://www.justice.gov/opa/pr/united-states-files-false-claims-act-complaint-against-home-health-agency-and-two-its-owners; and Press Release, US Dep’t of Justice, Michigan Doctor Pleads Guilty to Role in $2.5 Million Medicare Fraud Scheme (May 20, 2019), https://www.justice.gov/opa/pr/michigan-doctor-pleads-guilty-role-25-mil….
[11] See id.
[12] See, e.g., Press Release, US Dep’t of Justice, California Doctor Sentenced to Prison for Role in Medicare Kickback Conspiracy (Jan. 28, 2019), https://www.justice.gov/opa/pr/california-doctor-sentenced-prison-role-medicare-kickback-conspiracy; Press Release, US Dep’t of Justice, Houston Medical Clinic Owner Convicted in $11 Million Medicare Fraud Scheme (Jan. 28, 2019), https://www.justice.gov/opa/pr/houston-medical-clinic-owner-convicted-11-million-medicare-fraud-scheme; Press Release, US Dep’t of Justice, Miami Woman Sentenced to More Than Three Years in Prison for Role in $1.36 Million Medicare Fraud Scheme (Jan. 28, 2019) https://www.justice.gov/opa/pr/miami-woman-sentenced-more-three-years-prison-role-136-million-medicare-fraud-scheme; Press Release, US Dep’t of Justice, Miami Woman Sentenced to Prison for Role in $4.66 Million Medicare Fraud Scheme (Jan. 28, 2019), https://www.justice.gov/opa/pr/miami-woman-sentenced-prison-role-466-million-medicare-fraud-scheme; Press Release, US Dep’t of Justice, Miami Woman Sentenced To Prison For Role In $750,000 Medicare Fraud Scheme (Jan. 28, 2019), https://www.justice.gov/opa/pr/miami-woman-sentenced-prison-role-750000-medicare-fraud-scheme.
[13] See Press Release, US Dep’t of Justice, Former Administrator of Two Houston Home Health Companies Sentenced to Prison in $20 Million Medicare Fraud Scheme (Apr. 4, 2019), https://www.justice.gov/opa/pr/former-administrator-two-houston-home-health-companies-sentenced-prison-20-million-medicare.
[14] See Press Release, US Dep’t of Justice, Houston Patient Recruiter Sentenced to 188 Months in Prison for Role in $20 Million Medicare Fraud Scheme(May 29, 2019), https://www.justice.gov/opa/pr/houston-patient-recruiter-sentenced-188-months-prison-role-20-million-medicare-fraud-scheme; Press Release, US Dep’t of Justice, Michigan Home Health Agency Owner Sentenced to Prison for $8.3 Million Medicare Fraud (Apr. 22, 2019), https://www.justice.gov/opa/pr/michigan-home-health-agency-owner-sentenced-prison-83-million-medicare-fraud; Press Release, US Dep’t of Justice, Florida Home Health Services Company Owner and Co-Conspirator Sentenced to Prison for Role in $8.6 Million Health Care Fraud Scheme (Feb. 27, 2019), https://www.justice.gov/opa/pr/florida-home-health-services-company-owner-and-co-conspirator-sentenced-prison-role-86.
[15] See, e.g., Press Release, US Dep’t of Justice, Patient Recruiter Found Guilty in $1.3 Million Medicare Kickback Scheme (Jul. 30, 2019), https://www.justice.gov/opa/pr/patient-recruiter-found-guilty-13-million-medicare-kickback-scheme.
[16] Press Release, US Dep’t of Justice, Houston Patient Recruiter Sentenced to 188 Months in Prison for Role in $20 Million Medicare Fraud Scheme (May 29, 2019), https://www.justice.gov/opa/pr/houston-patient-recruiter-sentenced-188-months-prison-role-20-million-medicare-fraud-scheme.
[17] See Press Release, US Dep’t of Justice, Chemed Corp. and Vitas Hospice Services Agree to Pay $75 Million to Resolve False Claims Act Allegations Relating to Billing for Ineligible Patients and Inflated Levels of Care (Oct. 30. 2017), https://www.justice.gov/opa/pr/chemed-corp-and-vitas-hospice-services-agree-pay-75-million-resolve-false-claims-act.
[18] See United States v. Heartland Hospice, Inc., No. 3:10-cv-1875, 2019 WL 2611077 (N.D. Ohio Jun. 26, 2019).

Source: natlawreview.com

American medical students less likely to choose to become primary care doctors

Despite hospital systems and health officials calling out the need for more primary care doctors, graduates of U.S. medical schools are becoming less likely to choose to specialize in one of those fields.

A record-high number of primary care positions was offered in the 2019 National Resident Matching Program—known to doctors as “the Match.” It determines where a medical student will study in their chosen specialty after graduation. But this year, the percentage of primary care positions filled by fourth-year medical students was the lowest on record.

“I think part of it has to do with income,” said Mona Signer, the CEO of the Match. “Primary care specialties are not the highest paying.” She suggested that where a student gets a degree also influences the choice. “Many medical schools are part of academic medical centers where research and specialization is a priority,” she said.

The three key primary care fields are internal medicine, family medicine, and pediatrics. According to the 2019 Match report, 8,116 internal medicine positions were offered, the highest number on record and the most positions offered within any specialty, but only 41.5% were filled by seniors pursuing their M.D.s from U.S. medical schools. Similar trends were seen this year in family medicine and pediatrics.

In their final year of medical school, students apply and interview for residency programs in their chosen specialty. The Match, a nonprofit group, then assigns them a residency program based on how the applicant and the program ranked each other.

Since 2011, the percentage of U.S.-trained allopathic, or M.D., physicians who have matched into primary care positions has been on the decline, according to an analysis of historical Match data by Kaiser Health News.

But, over the same period, the percentage of U.S.-trained osteopathic and foreign-trained physicians matching into primary care roles has increased. 2019 marks the first year in which the percentage of osteopathic and foreign-trained doctors surpassed the percentage of U.S. trained medical doctors matching into primary care positions.

Medical colleges granting M.D. degrees graduate nearly three-quarters of U.S. students moving on to become doctors. The rest graduate from osteopathic schools, granting D.O. degrees. The five medical schools with the highest percentage of graduates who chose primary care are all osteopathic institutions, according to the latest U.S. News & World Report survey.

Beyond the standard medical curriculum, osteopathic students receive training in manipulative medicine, a hands-on technique focused on muscles and joints that can be used to diagnose and treat conditions. They are licensed by states and work side by side with M.D.s in physician practices and health systems.

Although the osteopathic graduates have been able to join the main residency match or go through a separate osteopathic match through this year, in 2020 the two matches will be combined.

Physicians who are trained at foreign medical schools, including both U.S. and non-U.S. citizens, also take unfilled primary care residency positions. In the 2019 match, 68.9% of foreign-trained physicians went into internal medicine, family medicine, and pediatrics.

But, despite osteopathic graduates and foreign-trained medical doctors taking up these primary care spots, a looming primary care physician shortage is still expected.

The Association of American Medical Colleges predicts a shortage of between 21,100 and 55,200 primary care physicians by 2032. More doctors will be needed in the coming years to care for aging baby boomers, many of whom have multiple chronic conditions. The obesity rate is also increasing, which portends more people with chronic health problems.

Studies have shown that states with a higher ratio of primary care physicians have better health and lower rates of mortality. Patients who regularly see a primary care physician also have lower health costs than those without one.

But choosing a specialty other than primary care often means a higher paycheck.

According to a recently published survey of physicians conducted by Medscape, internal medicine doctors’ salaries average $243,000 annually. That’s a little over half of what the highest earners, orthopedic physicians, make with an average annual salary of $482,000. Family medicine and pediatrics earn even less than internal medicine, at $231,000 and $225,000 per year, respectively.

Dr. Eric Hsieh, the internal medicine residency program director at the University of Southern California’s Keck School of Medicine, said another deterrent is the amount of time primary care doctors spend filling outpatients’ electronic medical records.

“I don’t think people realize how involved electronic medical records are,” said Hsieh. “You have to synthesize everything and coordinate all of the care. And something that I see with the residents in our program is that the time spent on electronic medical records rather than caring for patients frustrates them.”

The Medscape survey confirms this. Internists appear to be more burdened with paperwork than other specialties, and 80% of internists report spending 10 or more hours a week on administrative tasks.

The result: Only 62% of internal medicine doctors said they would choose to go into their specialty again—the lowest percentage on record for all physician specialties surveyed.

Elsa Pearson, a health policy analyst at Boston University, said one way to keep and attract primary care doctors might be to shift some tasks to health care providers who aren’t doctors, such as nurse practitioners or physician assistants.

“The primary care that they provide compared to a physician is just as effective,” said Pearson. They wouldn’t replace physicians but could help lift the burden and free up doctors for more complicated care issues.

Pearson said more medical scribes, individuals who take notes for doctors while they are seeing patients, could also help to ease the doctors’ burden of electronic health record documentation.

Another solution is spreading the word about the loan forgiveness programs available to those who choose to pursue primary care, usually in an underserved area of the country, said Dr. Tyree Winters, the associate director of the pediatric residency program at Goryeb Children’s Hospital in New Jersey.

“The trend has been more so thinking about the amount of debt that a student has, compared to potential income in primary care,” said Winters. “But that’s not considering things like medical debt forgiveness through state or federal programs, which really can help individuals who want to choose primary care.”

By Victoria Knight – Kaiser Health News

Medicare decides a cost-saving strategy costs too much

After pushing more medical care out of hospitals and into patients’ homes, the federal government wants to pay less for home health care.

Impending changes in Medicare’s home health payment system would dramatically alter how agencies are reimbursed for services, cutting payments by 8 percent. Lower rates would squeeze profit margins in what has been a reasonably lucrative business. Companies that can’t make acceptable returns as profitability shrinks will likely get out, leaving patients with fewer choices. Those that remain will look to get bigger, triggering consolidation and putting more pressure on smaller players.

Some local hospital networks, such as Amita Health, aim to grow under the new system. Others are walking away.

Northwestern Memorial HealthCare exited the market in June. The Chicago-based hospital chain won’t explain its decision to sell its home health and hospice programs to JourneyCare, an expanding Glenview-based hospice and palliative care provider that’s entering the home health market just in time for sweeping change. Northwestern could have been reacting to looming Medicare payment cuts, risks associated with home health like high employee turnover, or the need to focus on other areas of the business amid pressure to rein in medical spending, sources say.

Hospital chains focused on covering the so-called care continuum, from primary care to end-of-life care, want to “hold on to their home health and hospice agencies,” says Kathleen Gunderson, Amita’s vice president of ancillary services. “The challenge, though, is if they don’t manage them with an eye to costs and how this kind of business is run, it can be a drain on the system financially.”

While home health agencies used to manage just fine with about 150 patients, they now need at least 300 to guarantee positive cash flows, Gunderson says.

The new Patient Driven Groupings Model, or PDGM, is expected to apply even more pressure—even as an aging population boosts demand for home health care. Scheduled to take effect Jan. 1, PDGM aims to prevent unnecessary therapy visits and medical care by placing patients into payment categories based on diagnoses, chronic conditions and other factors. Healthy reimbursements under the current system, as well as payments for each therapy visit, had made it possible for agencies of various sizes to turn a profit. Other changes, such as cutting the payment period in half to 30 days, could cause cash flow problems for some agencies.

‘VALID DATA’

The industry has been particularly vocal about CMS’ proposed 8.01 percent cut to 30-day payments, which reflects assumptions about how providers might try to game the system by using certain medical codes to maximize payments. Lawmakers have introduced legislation to scrap the front-loaded cut and instead use “valid data” to make a determination once the program takes effect.

Home health agencies will be affected differently by the new system, based on patient acuity and other factors. Amita, for example, expects a 5 percent payment decline based on an analysis of its electronic medical record data.

CMS predicts total home health payouts will rise 1.3 percent—a total of $250 million—but agencies don’t expect the amount to make much of a difference.

Home health agencies nationwide are concerned about the effects PDGM might have on the industry’s financial stability, says Joanne Cunningham, executive director of the Partnership for Quality Home Healthcare, which represents home health care agencies nationwide, including 30 locations in Illinois. The industry is bracing for closures and mergers as rate cuts and new requirements increase fiscal pressure, she adds.

More closely aligning payments with patient characteristics is a good thing in theory, Cunningham says, but there could be unintended consequences, such as fewer therapy visits for patients in need.

Though not all providers agree, the independent agency that advises Congress on Medicare maintains that payments to home health agencies have “substantially exceeded costs” since the current payment system launched 20 years ago. It’s worth noting that before the current system, an interim payment system forced many home health agencies—sources say up to 20 percent—out of business.

Agencies need financial stability to improve their programs by investing in new technology, like remote patient monitoring, and staffing, given the industry’s more than 20 percent turnover rate, according to one estimate.

At a time when fewer procedures require long hospital stays and the federal government is cracking down on high hospital readmission rates, the investments are worth it for Amita and other hospitals that view home health as a way to gain more control over patient care.

Many patients in need of post-acute care and help managing chronic conditions also prefer to remain at home.

For four years, Gail Newman says she’s been treated by Amita in her Medinah home for as many as 15 “complicated issues,” partly due to an old smoking habit. The Medicare beneficiary, who has also spent time at skilled nursing facilities, says the arrangement is “priceless,” enabling her to remain in her own bed and use her own kitchen.

Source: chicagobusiness.com

Medicare Sequester Extended Two Years

The Bipartisan Budget Act of 2019, signed into law last week by President Donald J. Trump, includes an extension of the Medicare sequestration cuts for an additional two years. This across the board cut of two percent applies to all Medicare provider payments.

The Bipartisan Budget Act of 2019 will increase federal spending by $320 billion over the next two years compared to existing law, and the debt ceiling – the cap on how much money the federal government may borrow — has been suspended through July 2021.

The extension of the Medicare sequestration cuts was originally created in the Budget Control Act of 2011 and set to go into effect in 2013 should a bipartisan Joint Select Committee on Deficit Reduction not succeed in crafting legislation to reduce the deficit by $1.5 trillion between 2012 – 2021. The Joint Committee was not successful, triggering the two percent reduction, which began on April, 2012.

Congress enacted subsequent legislation extending sequestration, most recently in the Bipartisan Budget Act of 2018 to a 2027 termination date, followed by this year’s Bipartisan Budget Act with a new extension to 2029.

Due to the delayed triggering of sequestration into 2013, and the requirement that the reduction be applied for a full 12 months the effective time period of the reduction carries over to the following year. In this case sequestration has been extended to 2029 but will be in effect until April 2030.

NAHC does not anticipate Congress will end the Medicare sequestration cuts as evidenced any time soon.

Source: NAHC