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Posts tagged ‘home health agency’

Hospice Meds and Medicare Part D


If you are a hospice provider there is a good chance that there is no new information in this blog for you.  If you are in home care, pay close attention.  This isn’t as unrelated as you think.

The Hospice CoPs were updated for 2014.  There were a couple of minor changes to the reporting system and some rate changes and page after page of references to the original 1983 hospice benefit.  After 20 years of paying for hospice care to providers who were clueless about the complexity of diagnosis coding, Medicare began enforcing ICD-9 coding according to regulations.

Medicare also stated in that rule that the hospice benefit was to cover all care for the terminal illness and related conditions.  There has been a lot of debate on what is or is not ‘related’.

Medicare has some strong opinions on the relationships among illnesses and has now offered the guidance that Hospices should pay for pretty much all medications the patient needs.  They have identified 12M and change in analgesics that were billed to Part D for patients receiving the hospice benefit. However, if the patient wants a medication that the hospice does not feel is reasonable and necessary, the patient is free to pick up the tab.

I have no reason to believe that Medicare will stop at analgesics (their catch-all term for all pain meds – likely includes Ora-Jel for a toothache present before the terminal illness began).  The March Med-Pac report was even more critical (in a misguided sort of way) about the role of Hospice.

This leaves us with a huge gap, folks.  On the one hand there are imminently terminal patients who should be in hospice and on the other side of the spectrum there are home health care agencies who are tasked with providing short term intermittent care.  There is no palliative care benefit.

These are very narrow margins of white and black on opposite sides of a huge grey area.  Consider the following patients:

    • Mr. Jones, now 50, has been diabetic since his late 30’s.  He also has COPD and two years ago he had a heart attack which left his left ventricle almost useless.  He got tired of all the trips to the ICU where he was intubated and heat caths, etc., and just wants to go home and die.  Until such time, he would also like to breath.  Lasix may keep the symptoms of heart failure at bay but what about the inhalers for COPD?  What about his blood sugar?
    • Ms. Smith has rheumatoid arthritis that responds very well to IV medications once a month.  Her Orenica costs in excess of $21,937.50 per year.  (Ideally, she will only need half that much).  She is admitted to hospice with a terminal diagnosis of brain CA.  Do you continue to provide the Orenica?  What if her intention is to refuse narcotic pain relief for as long as possible because she wants to be alert to visit with her family?

The first patient really illustrates the grey area.  Why continue diabetic treatment for a terminally ill patient?  Can you really make yourself believe that a long standing history of diabetes was not related to the heart attack?  What if extremes in blood sugars cause him to be confused and uncomfortable?  What if the ‘treatment’ for COPD is the only way the patient can be comfortable?

The second patient is very clear.  If I had choice to continue to receive a medication that kept me free from pain and alert or elect the hospice benefit which relied on narcotics, I would not elect the hospice benefit. But, what if the patient met the eligibility requirements for the hospice benefit?  Are they stuck with a drug problem they cannot afford?

This is going to amount to a lot of patients who need care returning to home health if they are lucky enough to have a skill.  Those who do not have needs that warrant skilled home health services will be left out in the cold.

If you think I am merely creating drama or resorting to my favorite sport of Alarming Providers, read the quotes below from the December letter from CMS ‘clarifying’ their position regarding hospice meds and Medicare Part D.

“…..the original intent of the Medicare Hospice Benefit was to have a Medicare benefit available that provided virtually all-inclusive care for terminally ill individuals, provided pain relief and symptom management, and offered the opportunity to die with dignity and comfort in one’s own home rather than in an institutional setting.”

“Thus, when we refer to “pain and symptom relief”, or “palliation and management of the terminal illness and related conditions”, this encompasses all medical supplies and drugs needed to manage all the patient’s health conditions related to the terminal prognosis, to minimize symptoms and maximize comfort and quality of life. The focus is not limited to pain medications or a narrow definition of palliative care, but is broad and holistic.” Now they decide to be holistic?  December of 2013? 

“Sometimes a beneficiary requests a certain medication that a hospice can’t or won’t provide because it’s not reasonable and necessary for the palliation and management of the terminal illness and related conditions . The cost of  such a medication,which is not reasonable and necessary for the management of the terminal illness or related conditions,would be a beneficiary liability.”

The letter goes on to state that the hospice provider must give the patient an ABN and the patient can appeal the process. Does anyone else see the flaw in that process?

Review last week’s post about the indefinite leave of absence by the Administrative Law Judges.  While it is true that beneficiaries can still appeal, the life span of the average hospice patient is less than 25% of the average wait time for an ALJ hearing.

I guess the ‘holistic’ part only includes physical, spiritual and emotional needs.  Financial needs are bequeathed to the survivors – you know, so they will have a reason to go living on after the death of a loved one.

What a fun year this is going to be,

Elizabeth Hogue–Bearer of Good News


One of the industry’s patron Saints, Elizabeth Hogue has shared an interesting article involving the ability of hospitals to pay for ‘transition’ services.  On planet Julianne, all the best business deals benefit all parties involved.  This is one where hospitals, patients and home care agencies can all benefit.  Much thanks to Elizabeth for being so generous with her information.

OIG Allows Hospitals to Pay for Care Transition Services

by Elizabeth Hogue, Esq.

Hospitals are increasingly aware of the need to prevent readmissions. Although there is limited data regarding what works and what does not, it appears that certain types of care transition services; such as follow-up regarding prescription medications, appointments with physicians following discharge, etc.; may be helpful. The Office of the Inspector General (OIG) of the U.S. Department of Health and Human Services addressed the issue of the provision of these services to hospitals in Advisory Opinion No. 13-10, issued on August 9, 2013. The Opinion addresses the issue of whether a wholly-owned subsidiary of a major pharmaceutical manufacturer can assist hospitals to better coordinate care, help patients adhere to their hospital discharge plans, and avoid preventable hospital readmissions.

Specifically, the vendor will sell hospitals a package of services designed to help them avoid payment reductions associated with excess hospital readmissions. The services will be marketed to hospitals directly and through group purchasing organizations authorized to act as purchasing agents for hospitals. Agreements to purchase the services will be in writing, signed by both the vendor and hospitals, and have a term of not less than one year. The Agreement will also spell out all of the services that the vendor will provide to hospitals. The vendor will charge hospitals standard fees at fair market value. In other words, agreements between the vendor and hospitals will meet the requirements of the personal services and management contracts safe harbor or exception under the federal anti-kickback statute.

Hospitals will be able to purchase services from the vendor on a patient-by-patient basis that they expect will help reduce preventable readmission rates. Discharge planners/case managers will identify patients who may benefit from services offered by the vendor. If patients elect to receive the services, discharge planners/case managers will enter their discharge plans into the vendor’s software system.

Participating patients will have access for a twelve-hour period each day to a patient liaison who will help them understand and follow their discharge plans. For the remaining twelve-hour period each day then patient liaisons are unavailable, participating patients will be automatically transferred to a twenty-four-hour nurse hotline. Patient liaisons, who are not necessarily clinicians, will contact participating patients within forty-eight hours of discharge to ensure that they understand and will follow discharge plans.

Thereafter, patient liaisons will contact participating patients daily or at intervals selected by contracting hospitals to administer questionnaires about participating patients’ health and compliance with discharge plans. Participating patients may also answer questionnaires on the internet or through telephone interactive voice response systems. Patient liaisons will ask participating patients about medication compliance, remind them about refills, and add newly-prescribed medication to their electronic health records. Patient liaisons may also assist participating patients with various tasks, such as scheduling follow-up appointments, reminding them about scheduled appointments or helping them obtain transportation at participating patients’ own cost, providing participating patients with unbranded educational materials intended for general audiences, and providing updates to participating patients’ caregivers and primary care providers. Reports will be provided to hospitals regarding patients’ medication adherence, post-discharge physician appointment completion, readmission rates, demographics, readmitting hospitals, and secondary diagnoses.

Fees charged by the vendor for these services will include an initial flat fee for implementation services. The vendor will also charge a per-patient annual fee. Hospitals may also request additional services for which the vendor would charge separate or additional fees, based on an hourly basis plus expenses and a reasonable profit margin.

The OIG reviewed the above and concluded that the proposed arrangement is unlikely to violate the federal anti-kickback statute or to trigger the imposition of civil money penalties for the following reasons:

  • The arrangement is unlikely to lead to increased costs or overutilization of federal reimbursable services.
  • The proposed arrangement is unlikely to interfere with clinical decision making.
  • The vendor will implement a number of safeguards to prevent the proposed arrangement from being used to increase drug sales by the parent pharmaceutical company.
  • The proposed arrangement is unlikely to result in inappropriate patient steering.
  • Participating patients will designate providers, practitioners, and suppliers that he/she wishes to receive information associated with the services provided by vendor.
  • The proposed arrangements will not involve providing any rewards or incentives to participating patients that would likely influence their selection of providers, practitioners, or suppliers.

Based upon this Advisory Opinion, it appears that hospitals may pay outside vendors for services related to care transitions so long as the criteria described above are met. As long as the same safeguards are in place, hospitals may pay post-acute providers for the same types of services.

Readmission rates must be reduced and controlled. Hospitals must engage in activities to accomplish this goal and clearly need capable partners.

Data Submission


Have you submitted your OASIS data?  All of it?  Have you looked at your validation reports in great detail to ensure that there was not one fatal error that may have been overlooked?

What about your HHCAHPS data?  Have you been diligent about submitting it?  If your agency had less than 60 patients from March 31 through April 1, have you submitted an exemption request on the HHCAHPS website?

If you are not 100 percent sure about these answers, it might be a really good time to find out and ensure that  you have met your data submission requirements.  You will be penalized if your OASIS and/or HHCAHPS data isn’t submitted.

The penalty sounds modest enough – 2 percent.  But unless you are really good at doing business or really bad at taking care of patients, that 2 percent could be anywhere from 20 to 50 percent of your margin.  If you are really good at taking care of patients and mediocre in the business area, this modest 2% could devastate you.

The Medicare Guidance, which can be found here, reads:

In calendar year 2007 and each subsequent year, if a home health agency does not submit required quality data, their payment rates for the year are reduced by 2 percentage points.

Notice the reference to the year 2007?  The actual reg has been in effect even longer than that and only a couple of agencies here and there were penalized.  The Office of the Inspector General took notice of that earlier in the year and penalties are on the way.  The  Medicare Administrative Contractors (MAC’s – formerly FI’s also known as Palmetto, Pinnacle, etc.) have received these instructions straight from CMS:

Each fall, Medicare contractors with home health workloads will receive a technical direction letter (TDL) which provides a list of HHAs that have not submitted the required OASIS and/or HHCAHPS data during the established timeframes. These Medicare contractors shall review their paid claims history for claims which have:

  • a provider on the (naughty) list
  • Dates of service from July of the previous year
  • Beneficiaries over 18

Here’s the part that is really good:

If the contractor finds any such claims, the contractor shall notify the HHAs that they have been identified as not being in compliance with the requirement of submitting quality data and are scheduled to have Medicare payments to their agency reduced by 2%.

I have yet to see where a threshold for compliance has been set.  It does not say if the majority of data was submitted or if 90 percent of the data was received.

It also doesn’t say how they are going to identify the providers.  Will they look for gaps longer than 3o days between submissions?

My experience is not reassuring.  Agencies have received deficiency notices for late submissions but there have a number of times over the past few years when no data was submitted.  Nothing has been received when no data was submitted.

In one agency, a young lady had indeed submitted the data and placed the validation reports in a binder just as she was told.  Her instructions should have included reading the reports.  Every single assessment had been rejected for a period of six months.

Several times in several different agencies, the person responsible for data submission left employment.  When they did, nobody picked up the relatively insignificant task of transmitting data.

If I were an administrator or a Director, you can prevent disaster by:

  • Requiring OASIS data to be submitted every two weeks.  It is not unheard of that uploading data is difficult and time consuming
  • Require written confirmation that the task was done.
  • If you use outlook, put a recurring reminder with an email that goes out two days before data is to be uploaded.  That way, if you forget about all this a year from now and the person uploading the data leaves, you will get a bounced email
  • Actually look at validation reports and ensure they are being addressed.
  • A system of verifying with your HHCAHPS vendor that submission of data has occurred according to your contract.

If you are a field nurse or someone else who doesn’t deal with OASIS transmission, don’t hesitate to bring a copy of this to the people who do to remind them of the importance of it.  If they are offended, walk it off as my son’s coaches used to say.  I can pretty much guarantee that you will not get a raise next year if your agency takes a 2 percent hit.

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