CMS Finalizes 2015 Home Health Prospective Payment System Rule


The Centers for Medicare & State medicaid programs Services (CMS) printed the annual final rule around the Medicare home health prospective payment system (HH PPS) rates for twelve months (CY) 2015 within the November 6, 2014, Federal Register (Final Rule). As noted within our commentary around the suggested rule, CMS printed this rulemaking to update the 2015 payment rates and face-to-face needs, but additionally make changes towards the home health quality reporting program and therapy reassessment needs. Based on CMS, the ultimate Rule is among several reflecting an “Administration-wide technique to deliver better care at less expensive.Inches

HH PPS Payment Rates

Within the final rule, CMS projects a $60 million internet reduction in payments by health agencies (HHAs) in 2015. This figure includes CMS’ implementation of rebasing alterations in the nation’s, standardized 60-day episode payment rate, the nation’s per-visit payment rate and also the non-routine medical supply conversion factor for any collective 2.4 % (or $450 million) decrease. Additionally, it has a 2.1 % increase towards the payment rates through the home health payment update percentage (in the quantity of $390 million). CY 2015 would be the second year of the four-year phase-set for rebasing alterations in the HH PPS rates, as needed through the Affordable Care Act. As a result of comments expressing worry about the financial impact of those adjustments, CMS referenced your comments ought to posted through the Medicare Payment Advisory Commission (MedPAC), which articulated this problem is likely unfounded because of the 12 % or greater margin for for-profit and non-profit HHAs this year.

Face-to-Face Encounter Requirement

The ultimate rule considerably revised the doctor face-to-face encounter requirement, an ailment of payment underneath the HH PPS. The present rules, promulgated as needed through the ACA, require that the physician or permitted non-physician provider (NPP) narratively document that she or he were built with a face-to-face encounter having a beneficiary just before certifying a beneficiary’s requirement for home health services. This face-to-face encounter must occur within 3 months prior to the care begins or within thirty days of the beginning of the house healthcare.

As a result of industry concerns, CMS suggested first to get rid of the narrative requirement like a condition of payment, although the certifying physician or NPP would be needed to approve a face-to-face encounter happened inside the appropriate period of time. Second, CMS suggested to limit review to some beneficiary’s medical records using their certifying physician or even the acute/publish-acute care facility (when the beneficiary was directly accepted by health) to be able to determine initial eligibility for home health services. Finally, CMS suggested to not compensate physician claims for his or her expertise associated with the certification or recertification of eligibility when the HHA claim itself was non-covered since the certification/recertification of eligibility was incomplete, or there is inadequate documentation within the permanent medical record.

Almost all commenters were supportive of CMS’s proposal to get rid of the requirement of the face area-to-face narrative, though MedPAC voiced its recommendation to support the requirement. CMS described that commenters elevated a substantial quantity of concerns associated with the narratives, varying from challenges in acquiring certifications to unintended failures by physicians and HHAs to satisfy certification needs. Consequently, CMS finalized its proposal to get rid of the narrative requirement, as well as individually clarified the face-to-face encounter must occur just for purpose of certifications (not re-certifications).

Regarding its second proposal, CMS noted that many commenters opposed only using the beneficiary’s medical records using their certifying physician or even the acute/publish-acute care facility, but ultimately finalized this proposal. CMS agreed with commenters the physician and/or facility ought to provide these details towards the HHA upon request, as well as supported comments that will enable the HHA to make contact with the doctor and/or facility to explain the way the patient meets the factors for home healthcare, although the information supplied by the HHA must corroborate the physician’s or even the facility’s own documentation.

Ultimately, CMS finalized its proposal to not compensate physician claims for certification/recertification of patient eligibility for Medicare-covered home health services once the HHA claim itself was non-covered because of a partial certification/recertification of eligibility or due to inadequate documentation to aid eligibility for that benefit. Although some commenters supported efforts to improve physician responsibility for the certification needs, most opposed this decision, that will affect physician services billed under two G codes, G0180 and G0179.

Quality Reporting

In the suggested rule, CMS announced intends to initiate a pay-for-reporting requirement of instances of care beginning on or after This summer 1, 2015. This requirement would set threshold compliance scores for HHAs on quality assessments only (QAO) metrics: when the HHA doesn’t meet or exceed the brink score, the marketplace basket percentage increase relevant towards the HHA could be reduced by 2 percentage points. CMS suggested a threshold score of 70 % around the QAO metric for episodes beginning on or after This summer 1, 2015, and before June 30, 2016, having a decrease in 2 percentage suggests the marketplace basket update for CY 2017 when the 70 % threshold wasn’t met. The QAO metric would then increase by 10 % times in subsequent years, ending having a score of 90 % around the QAO metric that will make an application for episodes beginning on or after This summer 1, 2017, and before June 30, 2018, and every year after that.

After receiving persuasive comments around the suggested rule, such as the potentially enormous financial impact this pay-for-performance requirement might have, CMS only finalized the establishment from the 70 % reporting requirement of This summer 1, 2015, to June 30, 2016. CMS described it might monitor provider performance in the period duration of This summer 1, 2014, through June 30, 2015, to assist evaluate exactly what the pay-for-reporting performance requirement is going to be set at within the second and subsequent years.

Therapy Reassessment Needs

CMS suggested to lessen the needs for therapy reassessment by permitting a professional counselor to supply the treatment and reflect on the individual at least one time every 14 calendar days. The present regulation necessitates the reassessments to become performed on or “close” towards the 13th and 19th therapy visit, and a minimum of once every thirty days.

Within the Final Rule, CMS eased the necessity even more, concluding that the reassessment only must be performed at least one time every thirty days. CMS clarified the reassessment doesn’t have to become conducted on precisely the 30th day, however when the counselor deems it necessary or clinically appropriate.

Preview of Potential HHA Value-Based Purchasing Model for CY 2016

In the suggested CY 2015 rule, CMS asked comments with an HHA Value-Based Purchasing (VBP) model that will reduce and sometimes increase Medicare payments, inside a five percent to eight percent range, with respect to the amount of quality performance in a variety of measures to become selected. CMS has implemented a medical facility VBP program where 1.five percent of hospital payments in fiscal year 2015 are associated with the caliber of care the hospitals provide. Underneath the Affordable Care Act, the Secretary from the U.S. Department of Health insurance and Human Services (Secretary) was forwarded to create a intend to implement a VBP program for HHAs and also to issue a study to Congress. The Secretary’s Are accountable to Congress (“Plan to apply a Medicare Home Health Agency Value-Based Purchasing Program”) incorporated a guide for HHA VBP implementation, and outlined the necessity to create a HHA VBP program that aligns along with other Medicare programs and coordinates incentives to enhance quality.

The HHA VBP model into consideration by CMS would come with a 5 to eight percent adjustment in payment made after each planned performance period within the five to eight states CMS projects it’ll select to have fun playing the model. CMS received numerous comments around the HHA VBP model, including worry about the magnitude of the 5 to eight percent payment adjustment on HHA margins when compared to payment adjustment provided within the hospital VBP model. If CMS decides to proceed with the implementation of the HHA VBP model in CY 2016, it promises to invite additional comments on the more in depth HHA VBP model, including selecting states and also the criteria employed for selection. Cellular the QAO metric being implemented underneath the Final Rule, stakeholders should stay attuned towards the potential impact of the HHA VBP model produced by CMS.

Chelsea Rutherford, an affiliate within the Washington, D.C., office, also led to this short article.




Please enter your comment!
Please enter your name here