Home Health Stakeholders Call On CMS To Rectify ‘Significant’ Forecast Errors From 2021, 2022

Home Health Care News

Home health stakeholders are urging the Centers for Medicare & Medicaid Services (CMS) to address an alleged forecast error in the home health market basket for 2021 and 2022.

Broadly, CMS calculates the expected impact of cost inflation for home health agencies annually. In order to do this, CMS relies on a forecasting methodology from a private entity that is applied to the most recent cost data available for home health care.

“That forecasting tool attempts to gauge cost trends as an indicator of where future costs in the upcoming year will end up,” William A. Dombi, the president of the National Association of Home Care & Hospice, told Home Health Care News in an email. “As with any forecasting, errors can and do occur once actual cost changes are known. Over the years, these errors have sometimes been in the provider’s favor and other times not.”

The forecasting errors for 2021 and 2022 were significant, according to Dombi.

They resulted in a 5.1% shortfall in the annual payment rate updates for those years.

Last month, The Partnership for Quality Home Healthcare (PQHH) and the NAHC penned a joint letter to CMS. In the letter, PQHH and NAHC recommended that CMS advance a proposal for a one-time forecast error correction for 2021 and 2022 in the upcoming proposed rule.

“After a conversation we had with senior officials at CMS – who were asking about some of the economic conditions related to workforce, and the costs of retention and recruitment – we did take the opportunity to follow up our conversation with a letter that really focused on showcasing the fact that in 2021 and 2022, for home health, the market basket was significantly off,” PQHH CEO Joanne Cunningham told HHCN. “This translates to billions of dollars that did not go into the rate structure for home health, which is really important.”

Read Full Article

Free Homecare & Hospice Virtual Reality Employee Training Pilot (Keep the VR Headsets!)

Some of you have heard about the free Virtual Reality Pilot being run by the non-profit organization, Jobs for the Future (JFF).

This is a great opportunity for eligible agencies to participate in an employee training program that improves empathy and quality of care through first-person patient experiences, and helps improve personnel interactions through interactive real-life scenarios. As an added bonus, once the short pilot is over, you get to keep the VR headsets! 

Interested agencies can watch the HHAC webinar recording through the following link to the demo. Also refer to the attached flier and file. 

Contact Carol Azeez at [email protected] with questions. 

OIG Study Shines Spotlight on Medicare Advantage Plans’ Payment Practices

©2023 Elizabeth E. Hogue, Esq. All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.

Enrollment  in Medicare Advantage Plans (MAPs) recently exceeded the number of beneficiaries in the Medicare fee-for-service (FFS) program. The number of enrollees in MAPs will undoubtedly continue to increase. In April of 2022, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services (HHS) issued Report OEI-09-18-00260, “Some Medicare Advantage Organization Denials of Prior Authorization Requests Raise Concerns About Beneficiary Access to Medically Necessary Care” concerning the payment practices of MAPs. 

First, the OIG confirmed that MAPs must cover the same services as FFS. According to the OIG, MAPs must follow Medicare coverage rules that specify what items and services are covered and under what circumstances. MAPs may not impose limitations that are not present in FFS Medicare. The OIG also pointed out that MAPs may impose additional requirements; such as the use of in-network providers for certain health care services, requiring prior authorization, and referrals for specialty services.

Since MAPs are paid on a capitated basis, the OIG is concerned that payments create incentives for MAPs to deny access to services and payment in order to increase profits. The purpose of the Report was to assess the extent to which denied requests for preauthorization and payment met Medicare rules and would likely have been approved in FFS Medicare.

Based upon this review, the OIG concluded that:

1. MAPs sometimes delayed or denied beneficiaries access to services even though the requests met Medicare coverage rules.
2. MAPs also denied payments to providers for some services that met both Medicare coverage rules and MAP billing rules.
3. Regarding prior authorization requests that MAPs denied, 13% met Medicare coverage rules and these services likely would have been approved for beneficiaries under FFS.
4. Common causes of denials of prior authorization requests included MAPs’ use of clinical criteria that are not included in Medicare coverage rules and MAP staff members who overlooked documentation that showed that the services were medically necessary.
5. The OIG also concluded that 18% of requests for payment denied by MAPs met Medicare Coverage rules and MAP billing rules. Most of these denials were caused by human error during manual processing of claims, such as overlooking documents, and system processing errors, such as outdated programs.
6. Denials of both prior authorization and payment requests were often reversed when beneficiaries or providers disputed the denials.

What providers have long suspected has been confirmed by the OIG. Now fix it!

Renewed ABN Form

NAHC

Home health and hospice providers are reminded that the Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, and form instructions have been approved by the Office of Management and Budget for renewal.

The use of the renewed form with the expiration date of 01/31/2026 will be mandatory on 6/30/23. Providers may continue to use the ABN form with the expiration date of 6/30/23 until the renewed form becomes mandatory on 6/30/23. The ABN form and instructions may be found here in the downloads section.

The ABN, Form CMS-R-131, is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service – FFS) beneficiaries in situations where Medicare payment is expected to be denied. The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances.

Guidelines for issuing the ABN can be found beginning in Section 50 in the Medicare Claims Processing Manual, 100-4, Chapter 30 (PDF).