Addressing Recent Policies
by Thomas Threlkeld, Calvin McDaniel and Theresa Forster
July 6, 2018

The dramatic increase in the need for and popularity of home health and hospice has drawn the attention of lawmakers and regulators.

While 2018 is an election year, NAHC nevertheless believes there will be plenty of action in Congress on subjects important to the entire home health and hospice community. These are the industry issues we believe Congress should and will be focused on.

Home Health

Pre-claim review is a process by which a request for provisional affirmation of coverage for home health care is submitted to Medicare administrative contractors (MACs) for review before a final claim is submitted for payment. The process was used in Illinois and planned for four other states in 2016 and early 2017, before being suspended on April 1, 2017. The pre-claim review demonstration created considerable havoc in Illinois, causing massive cash flow problems for numerous agencies and leaving some patients without timely access to home health care.

In late May, the Centers for Medicare & Medicaid Services (CMS) announced the return of pre-claim review, revised to allow home health agencies the choice of three options—pre-claim review, post-payment review, or minimal post-payment review with a 25 percent payment reduction for all home health services in the demonstration states. If either of the first two options is selected, pre-claim or post-payment review will be required for every episode of care.

The new version of pre-claim review is currently in the comment phase of the proposal, and the demonstration will not be restarted before October 1, 2018, when Illinois is scheduled to endure pre-claim review again. Ohio and North Carolina and later Texas and Florida would follow Illinois later during the five-year demonstration.

The problem is that pre-claim review may be entirely unnecessary to maintain program integrity, and CMS has not taken advantage of what it learned during the demonstration in Illinois in 2016–2017, where claims errors that related to documentation were easily correctible. In addition, the homecare community has presented multiple, less-burdensome alternatives to CMS that will work as well or better than pre-claim review in maintaining program integrity. Unfortunately, CMS has not pursued any of these alternatives and is instead focused on a time-consuming and unnecessary process that takes staff away from patient care to chase after endless paperwork.

NAHC and its partnering state homecare associations have initiated advocacy efforts to secure public release of all the data from the original project, conduct a thorough evaluation of the outcomes from that project, evaluate the best alternatives to pre-claim review that can address any deficiencies uncovered through the project, and institute appropriate corrective measures that do not needlessly increase administrative burdens and costs of care.

Included in the 21st Century Cures Act was a provision requiring the use of Electronic Visit Verification (EVV) in the Medicaid program. The new law called for EVV to be implemented for personal care services starting in 2019 and for home health services beginning in 2023. States not operating EVV by these deadlines will be subject to reductions in their Federal Medical Assistance Percentage (FMAP) match rate. The requirement has proven to be problematic for some states. As a result, legislation has been introduced in both chambers of Congress seeking the delay of the FMAP reduction by one year, to 2020.

Impactful reforms were made to the Medicare home health prospective payment system via the Bipartisan Budget Act (BBA) signed into law in February. Notable among these changes were a shift to a 30-day unit of service and the removal of therapy utilization in determining reimbursement rates. Since this law’s passage, concerns have been raised about the broad impact that could be felt by home health providers. Chief among these concerns is the broad authority granted to the Secretary of Health and Human Services to make payment rate adjustments based on assumptions of provider behavior in response to the payment system reforms. These rate adjustments can be temporary or permanent as well as prospective or retrospective. This authority poses a significant threat to agencies’ ability to provide care.

Further, as worded in the BBA, the new law calls for a 30-day unit of service. The intent behind a shift to 30 days was to affect the payment alone. There is fear within the industry that CMS could apply the 30-day standard to the OASIS patient assessment and certification windows.

NAHC’s advocacy efforts in response to the BBA have sought to shift the Secretary’s broad authority of rate adjustments based on assumptions to one based on observable evidence, where data and statistics would be the basis for adjustments. Further, NAHC is pushing for a change from a 30-day unit of service to a 30-day unit of payment. Additionally, NAHC is requesting that the start date be adjusted from 2020, to no earlier than 2020. This change will allow agencies additional time to prepare for these reforms.

The Home Health Care Planning Improvement Act enjoys broad bipartisan support and would allow non-physician practitioners the authority to certify home health services under Medicare. This much-needed legislation would modernize the home health benefit, allow beneficiaries the ability to continue to receive care from their provider of choice, and increase access to care in rural and underserved areas.

Hospice

As federal legislators move to address the widespread opioid epidemic facing our nation, they must take appropriate steps to ensure the safe disposal of controlled medications in hospice care by eliminating opportunities for diversion and misuse. Under existing federal law, hospice employees are not permitted to dispose of controlled medications that will no longer be used by hospice patients. As a result, these unused medications are being left in hospice patients’ homes and are at risk for diversion or misuse. Congress should enact provisions (such as those included in HR 5041 and S 2680) that allow hospice employees to safely and appropriately destroy controlled medications in the home that are no longer of use to hospice patients.

Medicare patients need access to multidisciplinary advanced-illness care and coordination, as well as appropriate support to develop advance care plans. Our nation must also work to ensure that advance directives, once executed, are honored. The Patient Choice and Quality Care Act (S 334/HR 2797) works to address these and other important end-of-life-care-related needs by:

  • Creating a Medicare advanced illness care and management model program to test targeted advanced illness management and early use of palliative care
  • Providing access to advance care planning support tools
  • Promoting the portability of advance directives
  • Facilitating the development and use of quality measures for advanced illness andend-of-life care