NAHC Requests Regulatory Flexibility in Light of COVID-19 Emergency

WASHINGTON, D.C. (April 7, 2020)—The National Association for Home Care & Hospice (NAHC) has made a series of requests to the Centers for Medicare & Medicaid Services (CMS) for regulatory action designed to enable home health and hospice to fulfill its potential as the health care setting most suited to stopping the spread of the novel coronavirus (COVID-19) while continuing to treat needy patients.

HOME HEALTH

1. NAHC is asking CMS to suspend the 2020 4.36% behavior adjustment and the annual Productivity adjustment in the new PDGM payment system. Suspending the adjustment would provide some financial support to home health agencies while they are experiencing vast changes in the makeup of the patients served (including Covid-19 patients), increased costs for infection controls and emergency actions, staffing costs as caregivers face infections, and many other complications not built into the PDGM system. Simply, 2020 behavior and productivity has been turned inside out. The failsafe in suspending the adjustment is that the law includes a reconciliation authority to ensure budget neutrality.
2. NAHC asks CMS to waive or suspend the requirements that HHAs have signed and dated physician certifications and care orders prior to billing. Physicians are unavailable to sign orders during the emergency. Verbal orders should be sufficient to bill Medicare. In order to continue care for patients while maintaining social distancing, HHAs are planning on using telehealth services and remote monitoring in lieu of visits. In addition, patients are refusing to permit HHA staff into their home due to the COVID-19 outbreak. Telehealth and remote monitoring visits by HHAs are not reimbursable under the Medicare program and will cause significant financial hardship for both the agency and the staff.
3. NAHC asks CMS to restore RAP payment to 60% of payment for initial 30-day periods and 50% for subsequent 30-day periods. Under PDGM RAP payment were decreased to 20 percent for all 30-day periods. Increasing RAP payments will provide agencies with the necessary cash flow needed to maintain operations.
4. CMS should permit agencies to conduct an abbreviated comprehensive assessment, which includes the OASIS items, to include only items needed for care planning and payment. Many of the items in the assessment are required to be collected by the conditions of participation, but not required for payment or care planning. An abbreviated assessment will free up valuable clinician time that can be dedicated to patient care during a pandemic. CMS has approved such in the past emergencies and should do so again.

NAHC has made a series of other requests to help home health and hospice respond effectively to the public health crisis.

• NAHC welcomes the suspension of the Review Choice Demonstration (RCD) program, but suspension of post-pay review is also necessary, as it adds burden and increases risk to the agencies. NAHC woud also like an extension of RCD review choice selection deadline until an announcement is made about the new start date.
• Additionally, on the Medicare face-to-face requirement, CMS needs to permit audio telephonic communications as an acceptable alternative to direct contact with the physician.
• While Congress has passed legislation permitting nonphysician practitioners to certify a patient for the home health Medicare benefit, NAHC would like CMS to accelerate the process to implement this part of the CARES Act. Furthermore, it is important that CMS permit physician-ordered telehealth and remote monitoring visits to count as Medicare home health visits.
• The administration should also suspend Targeted Probe and Educate audits, institute national accelerated appeals settlements, and suspend the home health value-based purchasing demonstration. We are very supportive of the HHVBP demo. However, there has been a massive change in case mix and clinical practice while addressing the pandemic. As a performance year, 2020 would not be a good time to learn about how financial incentives and penalties impact patient outcomes.

HOSPICE

1. CMS should allow physician assistants (PAs) to conduct the hospice face-to-face encounter. PAs already may serve as hospice attending physicians; allowing them to conduct the face-to-face will ease demands on physicians and allow timely compliance with requirement
2. CMS should expand telehealth allowance to include General Inpatient Care and respite care when needed for consultations between hospice staff and the patient’s facility. This will help limit the spread of the virus, address growing concerns among seniors around admitting individuals into their homes, address difficulties in accessing patients in nursing homes and other facilities, maximize use of staff.
3. In addition, CMS should allow for flexibility regarding time frame for completion of initial and comprehensive assessments, and updates to the comprehensive assessment and review of the plan of care. NAHC would like to see a timeline extension on initial and comprehensive assessments.

to see the full list of NAHC regulatory requests, please read this chart. The chart sets out the provision of law, regulation, or policy involved along with our request. The fourth column is a status reference, as some matters have been completed, while others are previously pending requests and new requests. These are highlighted as to whether they are new or pending.