Resources to Keep Up with Industry Regulatory Changes

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By Rhonda Oakes, Regulatory Analyst, Change Healthcare and Crystal Tyson, Business Analyst, Change Healthcare
Resources to Keep Up with Industry Regulatory Changes

There is much discussion over the executive order signed by President Trump to reduce regulations and control regulatory cost, and how that impacts home health and hospice.

As we know, regulations for home health and hospice were set in motion prior to the executive order. The National Association for Homecare and Hospice submitted a letter the Department of Health and Human Services asking for a stay from the pending Home Health Conditions of Participation that were slated to go into effect July 2017. However, CMS is looking to delay implementation until January 13, 2018. Hospice agencies continue to prepare for the updated Hospice Item Set because there is no indication this rule will be delayed.

To maintain compliance, a competitive edge and to optimize revenue, post-acute care providers must stay on top of regulatory initiatives. When reviewing transmittals, change requests and the Unified Regulatory Agenda, the intensity and frequency of changes have not slowed in our space, and keeping pace with these changes can strengthen your organization’s position for continued success.

We recommend that you pay close attention to the following programs to help make sure your organization is meeting the appropriate standards and, where appropriate, providing input on current and future regulatory proposals.

Comprehensive Error Rate Testing (CERT)

Each November, the Comprehensive Error Rate Testing document is published. The Centers for Medicare & Medicaid Services (CMS) later publishes more detailed improper payment rate information in the form of the annual Medicare Fee-for-Service (FFS) Improper Payments Report and Appendices.

CERT applies to these error categories:

  • No documentation
  • Insufficient documentation
  • Medical necessity
  • Incorrect coding
  • Other

Analysis of the recent errors identified by the CERT review contractor shows a continuing increase in denials related to documentation for face-to-face encounters. The most common error is insufficient documentation of clinical findings. Specific errors include failure to show how the encounter was related to the primary reason for home health, how the patient’s condition supports the patient’s homebound status or how the patient’s condition supports the need for skilled services.

CMS needs to hear from home health organizations that discover OASIS diagnosis coding guidance that is in conflict with ICD-10-CM coding guidelines during annual rate update comment periods. Hospice organizations should provide comments if a conflict is discovered with current coding guidance. Providing CMS examples when these issues arise from the agency level is critical to maintaining, updating and improving the coding logic to support current post acute care practices.

Medicaid Eligibility Quality Control and Payment Error Rate Measurement (PERM)

A final rule has not been released, but the goals include reducing the burden on states and lowering the incidence of improper payment rates. The proposed changes include:

  • Changing to July through June state time frames to review payments
  • Moving PERM eligibility reviews from states to a federal contractor
  • Citing improper payments if the federal share amount is incorrect
  • Calculating a national sample size to meet national Medicaid and CHIP improper payment rate precision requirements
  • Adding more stringent requirements for states with consecutive PERM eligibility improper payment rates

CAHPS Hospice Survey

Outcomes from the Consumer Assessment of Healthcare Providers and Systems (CAHPS) Hospice Survey help CMS understand the experiences of hospice patients and their families. It was developed with input from key stakeholders within government, industry groups, consumer groups and others.

The CAHPS Hospice Survey helps hospices with their internal quality improvement efforts and external benchmarking with other facilities. It also provides CMS with information for monitoring the care provided. Selected measures could be part of public reporting on the Hospice Compare site expected to go live June 2017.

Home Health CAHPS Survey

The Consumer Assessment of Healthcare Providers and Systems Home Health Care Survey (HHCAHPS) publicly reports certain data to enhance accountability of providers and create incentives to improve quality. Certain data are published publicly so consumers can make more informed choices about home health.

Guidepost measures for the CAHPS Hospice Survey can be found through Quality Assurance Performance Improvement (QAPI). Taking baseline measurements allow your organization to create focus areas, create measurable goals and monitor your progress.

Program for Evaluating Payment Patterns Electronic Report (PEPPER) summarizes Medicare claims data statistics for home health or hospice in target areas that may be at risk for improper payments. PEPPER compares an organization’s Medicare claims data statistics with Medicare data for the nation, Medicare administrative contractor (MAC) jurisdiction and state.

The program supports CMS’s program integrity initiative. PEPPER does not identify improper payments. Rather, it is an education tool intended to help providers assess their risk for improper payments.

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