Reimbursement:
INDUSTRY DECLARES WAR ON CUT FOR CASE MIX CREEP
Published on Tue Jun 12, 2007
Reps pull out all the stops to argue against the slash to your Medicare reimbursement.
By this October, you should find out whether your Medicare payment rates will rise or fall next year.
The Centers for Medicare & Medicaid Services wants to cut home health agency payment rates 2.75 percent each year for three years due to supposed PPS upcoding, it said in its prospective payment system refinements proposed rule issued April 27.
CMS is likely to issue the PPS refinements final rule in September or October to make possible its targeted Jan. 1 implementation for the changes, notes Bob Wardwell with the Visiting Nurse Associations of America. Budget pressures will help ensure the rule's timely arrival, predicts Wardwell, a former top CMS official.
Up in arms: In submitted comment letters, trade groups across the nation argue vociferously against the proposed cut for case mix creep. The cut is "unfounded," charges the Minnesota Home Care Association. The Connecticut Association for Home Care blasts the reduction as "baseless" while the Home Care Alliance of Massachusetts dismisses CMS' ra-tionale for the cut as "weak."
The upcoding charges CMS levels at the industry are "speculative," says the Home Care Alliance of Maine. The resulting cut is "egregious," the alliance's Vickie Purgavie tells Eli.
CMS attributes the increase in average case mix from 1.0 in 1997 to 1.23 in 2003 too heavily toward "bad behavior" by agencies, protests Casey Blumenthal with MHA... An Association of Montana Health Care Providers. "All are punished by drop in base rate," Blumenthal says.
Innocent suffer most: If you buy CMS' argument that agencies' upcoding caused the case mix creep, then an across-the-board cut actually hurts most those agencies that did not upcode, VNAA points out in its comment letter. "By using the average case mix weight in this period as the measure of case mix creep adjustment, CMS is equally cutting payment to both high and low average case mix agencies," VNAA says. Patients Really Did Change, Reps Argue But many commenters on the rule did not buy CMS' rationale for the payment reduction due to the alleged case mix creep. The Home Care Association of New York State didn't even agree with CMS' estimate of the increase. Data shows that taking intermediary denials and downcodes into account brings the increase down to 1.15, the trade group contends in its comment letter. That's 15 percent instead of 23 percent.
Much if not all of the change in case mix was due to real changes in home care patient conditions, argues the National Association for Home Care & Hospice in its comments. Therapy use is a patient characteristic like the other PPS elements and CMS should consider its changes valid, the association says.
Patient changes also caused HHAs [...]
