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•  11 years of industry leadership •  200+ US-based staff •  98% customer satisfaction rating •  99.9% verified uptime •  315 agencies on the 2014

HomeCare Elite List

Experience. Reliability. Stability.

SHARON HARDER President C3 Advisors, LLC

ABOUT THE PRESENTERS

FINAL RULE HIGHLIGHTS •  Payment rates updated for the 2nd year of rebasing

•  Case Mix weights have been recalibrated

•  Face to Face changes have been clarified

•  Quality reporting thresholds have been set •  Therapy reassessment

timeframes have been revised

•  SLP qualifications have been established

•  New rule regarding Civil Monetary Penalties

OTHER GUIDANCE

•  ICD-10 HH PPS Grouper

•  Coverage of Insulin injections

•  Value Based Purchasing – Pay for Performance

2015 PAYMENT UPDATES • National standard episode payment

•  2015 standard episode will be $2,961.38 •  2% reduction for agencies that do not submit quality data

•  Increases in visit payment amounts by 3.5% of the 2010 national per visit payment

Discipline  2014 Visit Payment  

2015 Adjustment  

2015 Visit Payment  

2015 Adjusted Payment – No Data  

SN   $121.10   $3.96   $127.83   $125.33  PT   $132.40   $4.32   $139.75   $137.02  OT   $133.30   $4.35   $140.70   $137.95  SP   $143.88   $4.70   $151.88   $148.90  MSW   $194.12   $6.34   $204.91   $200.89  HHA   $ 54.84   $1.79   $ 57.89   $ 56.75  

NON-ROUTINE SUPPLIES NRS payments are computed by severity level using an updated conversion factor of $53.23

Severity Level   Points  

Relative Weight  

NRS Payment Amount  

NRS – No Data

Submission  1   0   0.2698   $ 14.36   $ 14.08  2   1 – 14   0.9742   $ 51.86   $ 50.84  3   15 – 27   2.6712   $142.19   $139.41  4   28 - 48   3.9686   $211.25   $207.12  5   49 – 98   6.1198   $325.76   $319.39  6   >98   10.5254   $560.27   $549.32  

RURAL ADD-ON Rural areas will continue to see the 3% add-on to the national standard episode payment, visit rates and NRS conversion

•  Rural standard episode rate will be $3,050.22, adjusted to $2,990.47 for agencies that do not submit quality data

•  Rural NRS conversion factor will be $54.83, adjusted to $53.76 if quality data is not submitted

RURAL ADD-ON VISIT RATES

Discipline  2015 Visit

Rate  2015 Rural Visit Rate  

Rural Adjustment – No Data  

SN   $127.83   $131.66   $129.09  PT   $139.75   $143.94   $141.13  OT   $140.70   $144.92   $142.09  SLP   $151.88   $156.44   $153.37  MSW   $204.91   $211.06   $206.92  HHA   $ 57.89   $ 59.63   $ 58.45  

RURAL ADD-ON NRS RATES

Severity Level   Points  

Relative Weight  

NRS Payment

Rural  

NRS Payment – No Data  

1   0   0.2698   $ 14.79   $ 14.50  2   1 – 14   0.9742   $ 53.42   $ 52.37  3   15 – 27   2.6712   $146.46   $143.60  4   18 – 48   3.9686   $217.60   $213.35  5   49 – 98   6.1198   $335.55   $329.00  6   99+   10.5254   $577.11   $565.85  

CASE MIX RECALIBRATION

• Aligning payments with costs

• Case mix weights are driven by: •  Mix of services provided •  Costs of services provided •  Number of visits provided

• Case mix weights were last changed in 2012 using 8 year old data

•  2015 change based using 2013 data and payment groups

CASE MIX RECALIBRATION

• Recalibration does not take into account any clinical time that is spent outside of the visit.

• Changes in weights are due to shifts in utilization patterns

•  Fewer aides and more intensive therapy interventions

• Comparison to 2014 case mix weights shows that 60% of normal episodes would have a change of 5% of less

OUTLIERS

• Outliers are for episodes where estimated costs exceed a threshold amount for the assigned HHRG

•  Intended to approximate 2.5% of total payments

•  There are no changes for 2015 • Fixed dollar loss remains at .45 • Loss sharing ratio remains at .80

ABOUT THE PRESENTERS

JILL DYER, BSN, RN, HCS-D, ICD-10, HCS-O Home Health Executive, Consultant J.I.D. Consulting

FACE TO FACE ENCOUNTERS • Narrative portion of the certification has been eliminated

effective January 1, 2015

• Documentation of homebound status and skilled need is still required in the physician or discharging facility’s medical record for the patient

• Required whenever there is a new SOC OASIS

• Physician claims for certification of eligibility will be denied when the patient is found to have not met home health eligibility requirements

FACE TO FACE REQUIREMENTS

• Physician or facility medical records must:

•  Establish that the patient is eligible for home health services

•  Demonstrate that the Face to Face encounter is related to the primary reason the patient requires home health services

•  Occurred within the required timeframe

•  Was performed either by the certifying physician, an acute or post-acute care physician that cared for the patient in that setting or an allowed non-physician practitioner (NPP)

PHYSICIAN RECORDS

• HHAs are responsible for acquiring the physician or facility documentation that is used as the basis for certification

•  If requested, the HHA must provide the physician or facility documentation that substantiates eligibility

•  Guidance suggests that there is room for incorporation of HHA produced information as to homebound status or skilled need into the physician or facility medical record

ELIGIBILITY DOCUMENTATION •  Permissible for the agency to communicate and provide

information to the physician about homebound status and need for skilled care

•  Physician must review and sign off on anything that is

provided by the HHA that is later incorporated into the certification record

•  Information must corroborate physician’s or facility’s records including the diagnoses and condition that is recorded on the HHA’s comprehensive assessment

TIMELINESS ISSUES

• Obtaining documentation should not lead to delays in accepting patients for service

• Noted that the encounter can still occur up to 30 days after the start of care

•  “ . . . it is not acceptable for HHAs to wait until the end of the 60-day episode to obtain a completed certification supporting documentation from the . . . physician and/or the acute or post-acute facility.”

CONTINUOUS SERVICES

• When there will be a second or subsequent continuous episode, the recertification must contain an estimate of how much longer skilled services will be required

• Be aware of the new rules for face to face whenever there

is a SOC OASIS

•  There could be a difference between the new documentation rules and the payment methodologies where there are short gaps between episodes!

QUALITY REPORTING

• New rule establishes data submission thresholds starting in 2015

•  “Failure to submit sufficient OASIS assessments to allow calculation of quality measures including transfer and discharge assessments is a failure to comply with the CoPs.”

• Payment reductions are calculated based on submissions starting July 1st of the calendar year 2 years prior and ending on June 30th of the following year

REPORTING THRESHOLD

• Each HHA expected to submit a minimum set of “matching” quality assessments

• Reporting threshold goes into effect on July 1, 2015

• For episodes beginning on or after July 1, 2015 and before June 30, 2016, the HHA must score at least 70% on the Quality Assessments Only (QAO) formula or be subject to the 2% payment reduction for the entirety of the following 12 months.

QAO DEFINITIONS

• Quality assessment = SOC/ROC OASIS + EOC OASIS • Definitions

•  Late SOC/ROC – starts in final 60 days of performance period •  Early EOC – EOC assessment that could end a prior period episode •  SOC/ROC Pseudo – SOC/ROC with follow up assessments the last of

which occurs in the last 60 days of the performance period •  EOC Pseudo – preceded by one or more follow up assessments the

last of which occurs in the first 60 days of the performance period •  One Visit – SOC/ROC that is part of a 1 visit episode

• Non-Quality Assessment – Every assessment not defined above

• Neutral Assessments are not counted – M0100 = 04 or 05

QAO FORMULA

QAO = # of Quality Assessments * 100 # of Total Assessments

•  2015-2016 score must be at least 70% to protect payment levels in 2017

•  Overall goal is to reach an 80% to 90% submission rate in years 2 and 3

•  Compliance in the first half of the performance period will be evaluated for next year’s rule

QAO Example •  Best Home Health has determined that it has 1,800 total assessments for its quality measurement period.

•  300 of the assessments were “Neutral” -- Recerts or Significant Changes/Follow Ups that are not included in the calculation

•  260 assessments were either not submitted, late or submitted with fatal errors – Non-Quality Assessments

•  There are 1,240 Quality Assessments

•  1,240 Quality Assessments / 1,500 Total Counted Assessments = .82666 * 100 = 83% Compliance

ENFORCEMENT •  Agencies that are not in compliance with the submission

requirements will be sent a notice of non-compliance

•  Response will be required within 30 days from the notice date

•  In order to be considered, response letters must include specific information about the applicable facts

•  HHAs not certified from 4/1/2014 through 3/31/2015 are exempt

•  Remember that agencies can obtain current submission

statistics from CASPER reports

INSULIN INJECTIONS •  No regulatory change, per se, but the rule does

discuss the appropriateness of skilled services for insulin injections

•  Policy is that coverage is available for visits to perform insulin injections only when patients are physically or mentally unable to self inject and no other person is available

•  CMS analysis found that episodes that qualified for very high outlier payments had, on average, 160 skilled nursing visits in an episode of care. Most were in FL, TX and CA.

GUIDANCE FOR INSULIN •  Irrespective of whether insulin pens or the vial

and syringe method is used, education for starting and monitoring insulin should be provided by a nurse and typically should entail between 5 and 10 visits.

•  Final rule includes approximately 175 diagnosis codes that would support an inability on the part of the patient to self inject.

•  Medical record must support the clinical legitimacy of the secondary condition(s) and resulting limiting disability.

SECONDARY DIAGNOSIS CODES • Acceptable secondary diagnosis codes for

insulin administration include codes from the following categories:

• Amputation • Vision • Cognitive/Behavioral • Arthritis • Movement Disorders • Late Effect from Stroke/Disorders of

CNS/Intellectual Disabilities

THERAPY REASSESSMENTS •  For episodes ending on or after January

1, 2015, a qualified therapist must provide the needed therapy service and functionally reassessment patient at least every 30 days.

•  Where more than one therapy discipline is involved, service and reassessment must be provided for each discipline.

•  Therapy reassessments must include objective measurement to enable comparison of successive measurements and the effectiveness of therapy goals.

SLP QUALIFICATIONS

• Clarification of SLP Qualifications •  Master’s or doctoral degree in speech-language pathology •  Licensed as a speech-language pathologist in the state where he/she

practices

•  For those practicing in US territories where licensure is not required

•  SLP must complete 350 hours of supervised clinical practicum (or be in the process)

•  SLP must perform not less than 9 months of supervised service •  SLP must complete a national examination approved by the Secretary

of HHS

ICD-10 •  ICD-10 HH PPS Grouper will be released on April 1, 2015 to

give 6 months of lead time to prepare for the October 1, 2015 transition

•  Draft of the grouper information will be available on or about January 1, 2015

Providers interested in beta testing can get more information at:

http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/

HomeHealthPPS/CaseMisGroupSoftware.html

SURVEY ENFORCEMENT • Alternative sanctions for HHAs were introduced in 2012

along with enforcement action guidance

• Civil Monetary Penalties became effective on July 1, 2014

• HHAs who are found to be out of compliance with a CoP can request a hearing or can waive their hearing right for a reduced penalty

• New language is being added to clarify and restrict the ability of an ALJ or other hearing authority to overturn an imposed CMP

CIVIL MONETARY PENALTIES

• Rule is clarified so that when noncompliance that support imposition of a CMP is found, the ALJ or hearing authority must retain some amount of penalty consistent with established ranges and penalty amounts

Upper range $8,500 to $10,000 per day Mid range $1,500 to $8,500 per day Low range $500 to $4,000 per day Per instance $1,000 to $10,000

• Maximum of $10,000 per day

VALUE BASED PURCHASING • VBP already implemented for hospitals

in 2014

• ACA calls for a VBP plan for HHAs to “effectively link payment to quality”

•  The HHA model is being considered to potentially reward high performing HHAs and penalize those that are considered low performers

•  If implemented, the model could begin in 2016 in 5 to 8 states where all HHAs would be required to participate

• Range of payment adjustments would be from 5% to 8%

VBP INCENTIVES

•  To be eligible for an incentive, an HHA will need to achieve a minimum quality threshold

•  Incentive will depend on the level of quality achieved above the threshold

•  Incentives will also depend on how high achieving providers compare to others in their state

SUMMARY Now, more than ever before, agencies must be proactive

•  Agency financial and clinical teams should understand how the payment rules, particularly the recalibration of case mix weights will affect them

•  Clinical operations teams should review the adequacy of processes to ensure timely acquisition of Face to Face documentation

•  Financial teams should ensure that billing processes are redesigned to account for the changed frequency of Face to Face documentation

•  Agency management must take care to ensure that the agency meets or exceeds the required OASIS submission thresholds for 2015 and beyond

•  Scheduling functions should be reviewed to ensure that assigned therapists are scheduled for therapy visits that include timely reassessments for 60-day episodes that started on or after November 2nd

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