Commonwealth Coordinated Care (CCC) Update

Things have not been moving as quickly as we would like in regards to CCC issue resolution, despite the Virginia Health Care Association’s (VHCA) efforts.   However, we did want to provide an update on where things stand, as we have received some responses to various issues:

CCC Interaction Issues with Medicare Fee-For-Service (FFS)

We finally received a response to a list of interaction issues between CCC and Medicare FFS, primarily in the case of folks who move out of CCC into FFS, and how the Centers for Medicare and Medicaid Services (CMS) will view the services/level of care when they revert to FFS under Medicare.  Specifically, we asked:

VHCA Question 1:  A CCC beneficiary opts-out and becomes Medicare FFS on the first of the next month, but are receiving skilled level services without a hospitalization – how will Medicare FFS treat that claim?

CMS Answer 1:  Chapter 4 of the Medicare Managed Care Manual (section 10.2.1) addresses the 3-day stay issue from a Medicare Advantage perspective: “If the enrollee is in a SNF in December in an MA that does not require a prior qualifying 3-day hospital stay and then joined Original Medicare on January 1, the stay continues to be considered a covered stay (if medically required).” The same guidance applies for demonstrations under the capitated financial alignment model.

VHCA Question 2:  We would like to know from CMS if the three-way contract has exempted the Duals program from the federal Preadmission Screening and Resident Review (PASRR) requirements, and if not, how other states are addressing the practical implementation issue.

CMS Answer 2:  CMS has not waived any of the federally required screenings under PASRR as part of the Virginia demonstration (or any of the capitated financial alignment demonstrations). We have not heard of any related challenges in other states.

VHCA Question 3:  It is unclear how Medicare FFS intends to account for skilled service days relative to the 100 day cap and wait period for additional days.  Similarly, facilities are unclear how to count days under the Duals program for coinsurance purposes, again, when the beneficiary is in and out of the Duals and FFS due to the open opt-out allowances required by CMS.  We would like formal guidance from CMS on this issue.

CMS Answer 3:  We are still in the process of confirming the answer to this question with our colleagues internally and will follow-up separately.

VHCA Question 4:  We would like CMS to reconsider its stance on not providing Medicare claims history to the Medicaid agency and the Medicare/Medicaid Plans (MMPs).  Because the Medicaid agency does not have this information, the “intelligent assignment” logic cannot consider existing physician relationships in MMP assignment.

CMS Answer 4:  There seems to have been some miscommunication regarding CMS’ position on this issue. We currently have mechanisms in place for states and, more recently, for MMPs to request and receive historic Medicare claims data and have been in communication with DMAS and the VA MMPs with respect to using the data for these purposes.

We will communicate the answer to Question 3 when we receive it, and have some follow-up necessary with DMAS in regards to Question 4 and Question 2, which relate to the pre-screening requirements generally, not just the federal PASRR requirement.

Authorization Concerns

We continue to hear from our membership regarding authorizations for Medicare services under CCC – specifically, retroactive denial of skilled care (the 7-day authorization issue) and delayed authorizations generally.  We have also heard from several folks that it is taking inordinate amounts of staff time to track down authorizations (5 hours on the phone, for example).  We were supposed to have a meeting with DMAS to discuss these concerns last week, but it has been rescheduled twice and is now scheduled for December 16th.  

DMAS did provide information obtained from the MMPs which essentially showed that Anthem was the only MMP with significant denials of skilled level services.  According to the DMAS data, Virginia Premier had not denied any skilled care during the 7 day authorization period and Humana only had four (4) denials with 300 authorizations.  Anthem, however, had 129 approvals and 26 denials (17 percent denial).   It is unclear what period of time this data covers.  
As you know, the CCC contains an administrative appeals process available when there is disagreement on a service denial.

Payment Concerns

We communicated last week that Humana had informed us that their patient pay processing issue had finally been resolved and they would be communicating with you all regarding reconciling previous claims.  That communication generated some additional comments from folks regarding incorrect CCC payment relative to the November 1 changes to individual RUGs-based payment.  Please let us know what problems you are experiencing with CCC payments, now that most providers have submitted bills under the new November 1 rates.

Also in regards to the November 1 rates, we are in an on-going conversation with DMS regarding the limitation of payment to charges.  You may recall in a previous communication that DMAS was not pursuing this policy under the November 1 methodology.  The concern was that high intensity RUGs payment could exceed the private room rate in some facilities, thereby capping payment to that room rate.  This was not the intention of DMAS, nor was it considered in the rate development; therefore, DMAS is not applying it to payment going forward.

The question then arose regarding the MMPs approach under CCC.  Obviously, we expect them to follow DMAS’ lead on FFS.  DMAS has confirmed that two of the MMPs, Humana and Va Premier, have followed DMAS’ lead and are not applying the charges logic to limit payment.  However, Anthem currently has applied the logic and DMAS is in discussion with Anthem regarding this issue.  It is not clear if the limitation has occurred in practice, but obviously, we would like to know if/when it does.  In the meantime, we are pursuing resolution to this issue with Anthem through DMAS.