In The News

CMS Official: Don't expect a lot of fully risk-based payment models going forward

Fierce Healthcare
Don’t expect a lot more fully risk-based payment models from the Center for Medicare and Medicaid Innovation (CMMI), a top official said.
Centers for Medicare & Medicaid Services Chief Operating Officer Jon Blum detailed the agency’s vision for value-based care during the National Association of Accountable Care Organizations' fall conference Thursday.
“I don’t think that CMS will be promoting models that have more risk just for the sake of having more risk,” said Blum.
Although Blum said it is still important to have risk-based models, there are data that show downsides of full-risk payment models.
“We know that when we [incentivize] risk we see some downsides to that,” Blum said. “We see stronger incentives for more diagnosis code submissions, some of which might be appropriate, some of which not.”
Another concern is when you have “more transformation towards risk that tends to favor those who are better capitalized and can afford risk,” he added.
ACOs agree to take on a share of financial risk and meet spending and quality benchmarks. ACOs that don’t meet the benchmarks will have to repay Medicare but will get a share of savings if they do.
CMS has offered payment models that require providers to take on a high degree of risk. However, one of those models, the Next Generation ACO model, was sunset by the Biden administration.
Blum said that doesn't mean CMS won't adopt any high-risk models.

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CMS Releases 2019 Post-Acute Care and Hospice Utilization and Payment Data

CMS, indicated that they have just released the latest Post-Acute and Hospice Public Use File (PUF), which includes data from 2019.  The 2019 PAC PUF summarizes information on nearly 15 million claims and over $69 billion in Medicare payments for 2019, including information on 9,001 home health agencies and  4,584 hospices. The data is supplied by state as well as on an individual provider level, and is a great source for agencies to compare their own data with that of their peers. 

Link to 2013-2019 PAC PUFs:


FY 2022 Medicaid Hospice Rates Released

On Tuesday, September 28, 2021, CMS posted the FY 2022 Medicaid hospice rates with a letter from the CMS Medicaid Office of Financial Management to state Medicaid agencies. The rates for FY 2022 will begin on October 1, 2021. NHPCO's Regulatory Alert provides additional details

See rates at:


CY 2022 Med-Advantage Carve-In Expansion[Update from NAHC]

CMS has finally released the list of participants in the MA VBID Model for CY2022, including those that will cover the hospice benefit.  The number of plans that will cover hospice has increased from 9 to 13 but the number of plan benefit packages increases from 53 to 115.  The number of counties covered by these plans will increase from 206 to 461.  

The information below is excerpted from the CMS press release.  Please note that the plans marked with an asterisk are plans that will cover hospice during CY2022.  The states where these plans will cover hospice in select counties are listed beside the name of the plan for your convenience.  

Additional information (including access to a list of covered counties) is available at:     

Members Click to Read Full Article




What Your Agency Needs to Know About Targeted Probe & Educate (From McBee Associates)

Last month, the Centers for Medicare & Medicaid Services (CMS) reported the Targeted Probe & Educate (TPE) program resumed after being suspended in March 2020 due to the COVID-19 public health emergency (PHE). Palmetto GBA and CGA released the TPE program resumed on September 1, 2021.

The National Association for Home Care & Hospice (NAHC) is advocating CMS to continue the TPE suspension until the PHE ends.

Each Medicare Administrative Contractor (MAC) studies the claim data submitted by each provider to determine providers who have high potential for claim error rates or unusual billing practices.  In addition, the MACs are also identifying trends for services that impose a high financial risk to Medicare.  If an agency has had high denials from Additional Documentation Requests (ADRs) in the past, they are at a high risk of being selected for the TPE program.

Common TPE claim errors include:

  • The signature of the certifying provider was not included
  • Face-to-Face (F2F) encounter notes did not support all elements of eligibility
  • Documentation does not meet medical necessity
  • Missing or incomplete initial certifications or recertifications

Click to Visit 'How the Targeted Probe and Educate Process Works' Resources

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