Home Health & Hospice Week

CMS promises PPS billing info shortly in Open Door Forum.

Home health agencies thinking they'll take their PPS medicine and be done with it must think again.

In its proposed prospective payment system refinements issued in April, the Centers for Medicare & Medicaid Services wanted an 8.25 percent cut over three years to home health agency payments due to supposed case mix creep. In its PPS refinements final rule issued Aug. 22, CMS added a 2.71 cut in the fourth year to a total 10.96 percent cut (see Eli's HCW, Vol. XVI, No. 29).

But that may not be the last payment cut for case mix creep. CMS will continue to look for "growth of the nominal change in case-mix" in future years, it says in the final rule. If the agency finds it, "CMS may adjust the percentage reduction in the second and/or third year, elect to adjust the percentage reduction in only the fourth year, or adjust the percentage reduction in any combination of years."

The rule sounds like the case mix creep cuts could go on "in perpetuity," noted Bob Wardwell of the Visiting Nurse Associations of America in the Aug. 29 Open Door Forum for home care providers.

That regulatory language does indeed give CMS the "flexibility" to measure case mix increases and implement future cuts, said CMS' Randy Throndset in the forum. The provision will also help agencies avoid a whopping increased cut all in the last year if CMS finds more increases, Throndset said.

Implementation jitters: Forum listeners were eager to access the final billing logic, grouper and HAVEN software. HHAs' comment letters on the proposed rule frequently blasted the short time frame to ramp up on PPS refinement implementation, and the delay to those items is making it even shorter.

Throndset promised CMS is trying to get the software and billing information out as soon as possible. "Folks are working feverishly," he pledged.

Hit the books: HHAs that ran their patient mix through the proposed rule will have to start over to figure out how the final rule will affect them. That's because CMS changed many of the scoring rules and case mix weights in the final rule.

"There are hundreds of significant changes," said Wardwell, a former top CMS official who headed up PPS' original design. Agencies would like to know why the changes came about, Wardwell said. But Throndset declined to offer specifics in the forum that drew 430 listeners.

Watch for fixes: The final rule contained some wage index errors and an incorrect example of calculating an outlier adjustment, Throndset noted. CMS will issue corrections to those errors soon.

Other issues addressed in the forum include:

• Fraud demonstration. Don't expect CMS to cut you any slack if you fall in the HHA or durable medical equipment fraud demos. Field offices in Miami and Los Angeles have seen an "inordinate amount of fraudulent activity and fraudulent behavior by certain providers and suppliers in those areas," explained Kimberly Brandt, CMS' director of program integrity, in the forum. "The cost to the Medicare program has been in the billions of dollars."

Areas affected: For HHAs, the demo will take place in Harris County, TX and Los Angeles, Orange, Riverside and San Bernardino counties in California. Suppliers in those four California counties plus Miami-Dade, Broward and Palm Beach counties in Florida will fall under the project.

Watch your mailbox like a hawk if you are in those counties, because you'll have only 30 days to submit your entire enrollment application (855A) once you receive notification that it is required, Brandt advised. The letter will come from your intermediary or carrier, so make sure it has your correct contact information.

New requirements: CMS will run criminal background checks on all owners and managing employees during the reenrollment process. "This is a significant expansion," Brandt told listeners. And CMS will increase site visits. In addition to the visit before granting the provider/supplier number, providers will see more unannounced visits after receiving their numbers.

HHAs will have a special new burden--state surveys if they had a change in ownership in the past two years. That requirement arose "given some of the activity we've seen in Texas," Brandt explained.

"It is imperative when you receive that letter from your contractor, that you submit the 855 [and] that you abide by all the instructions and directives in the letter," Brandt exhorted. If not, CMS will revoke your billing privileges right away.

Not happy: Providers in affected areas are frustrated with their major unanswered questions about the demonstration, the Texas Association for Home Care's Heather Vasek protested in the forum. TAHC and the California Association for Health Services at Home haven't even been able to get an acknowledgement that CMS has received the long list of detailed questions the trade groups sent the agency, Vasek blasted.

• P4P. CMS is hoping to move ahead with its pay-for-performance demonstration as scheduled, but it's getting down to the wire with no Office of Management and Budget approval yet.

CMS wants to start recruiting agencies in four as-yet-announced states in October. "We're all hoping that approval comes swiftly and we can stay on track for [an] October beginning," a CMS official said.

• Hospice billing. Hospices are full of questions about the increased data requirements on Medicare claims starting Jan. 1 (see Eli's HCW, Vol. XVI, No. 29).

Multiple hospices from across the nation phoned in with questions ranging from technical claims issues to CMS' rationale behind collecting claims data on some disciplines' visits and not others.