DMAS: Mandatory Managed LTSS Enrollment Delayed; CCC Won’t be Extended

Published in September 17, 2015 Issue

This week the Department of Medical Assistance Services (DMAS) announced significant changes in its plans for managed Medicaid Long Term Support Services (MTLSS).  At the DMAS Board meeting on September 15, Director Cindi Jones announced that the agency will not move forward with previously announced plans to mandate a Medicaid managed care product for CCC-eligibles in 2016 for those individuals who had opted-out of the program (this was termed Phase 1 of the expansion of managed long term care). DMAS has also said it is no longer planning to extend the Commonwealth Coordinated Care (CCC) program beyond December 2017.

Sept 11 2014 CCC Map

CCC Updates: Uniformity for Claims and DMAS Signals Intent to Extend the CCC

Published in September 10, 2015 Issue

MMPs Will Be Applying More Uniformity to CCC Claims:  The three Medicare/Medicaid Plans (MMPs) are collectively working on guidance to nursing facility providers to achieve more uniformity and clarity on billing under the CCC program.  There have been several billing issues primarily since the switch to RUGs-based billing back in November.  VHCA has been working with the Department of Medical Assistance Services (DMAS) and the MMPs for the past several months on various claims processing concerns, most recently through the formation of a claims processing workgroup involving VHCA members.

Transition to ICD-10 Less Than One Month Away

Published in September 3, 2015 Issue

October 1 is the effective date for the transition from the International Classification of Diseases (ICD) version 9 to version 10.  For service dates on or after October 1, 2015, usage of ICD-9 coding will result in claims processing denials and/or delays for both Medicaid and Medicare services, according to the Department of Medical Assistance Services (DMAS) and the Centers for Medicare and Medicaid Services (CMS).

NOTICE Act Requires Medicare Beneficiaries to Be Informed of Hospital Status

Published in August 13, 2015 Issue

Congress has passed and President Barack Obama has signed the Notice of Observation Treatment and Implication for Care Eligibility (NOTICE) Act (H.R. 876). The new law, which will take effect next year, will require hospitals to notify Medicare beneficiaries of their outpatient status within 36 hours of service inception or at discharge (if sooner). Outpatient status affects a patient’s ability to receive Medicare coverage for post-acute care in a skilled nursing center.

Crossover Claims Fixed, According to the Department of Medical Assistance Services (DMAS)

Published in April 2, 2015 Issue

In early March, DMAS announced that crossover claims for nursing facility services with dates of service on or after November 1, 2014 were not processing correctly.  Specifically, Edit 364 (Primary Carrier Payment Equals/Exceeds VMAP'S) was not posting for claims where the Medicare paid amount exceeded the DMAS allowed amount.  DMAS has announced that they “implemented the fix on March 29, 2015 to correct the crossover claim issue causing nursing facility services to be paid incorrectly. Affected claims will be reprocessed beginning April 1, 2015. The corrected claims will be available on the April 10, 2015 remittance advice. Questions about this issue may be sent to NFPayment@dmas.virginia.gov.”

OIG Releases 2015 Work Plan

Published in November 20, 2014 Issue

The American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) has reported that the US Department of Health and Human Services (HHS), Office of Inspector General (OIG), has released its 2015 Work Plan.

Upcoming AHCA/NCAL Webinars

Published in October 30, 2014 Issue

The American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) has scheduled two webinars specifically for Independent Owners (IO). 

Medicare Appeals Backlog Cleared, According to KEPRO

Published in September 11, 2014 Issue

As previously reported in this publication, the transition to KEPRO under the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) contract had led to multiple concerns from the field primarily around the timeliness of Notice of Medicare Non-Coverage (NOMNC) appeals and the obvious implications for both facilities and patients in terms of potential financial liability for services.  KEPRO reported significant backlogs in appeals processing, and VHCA, through the the AHCA (American Health Care Association), was working with the Centers for Medicare and Medicaid Services (CMS) and KEPRO to rectify the situation.

Update on CMS Guidance on Part D and Hospice Drug Coverage

Published in July 24, 2014 Issue

On July 18th the Centers for Medicare and Medicaid Services (CMS) released interim guidance intended to address the highly problematic May 1st Guidance on Part D and hospice drug coverage.   The updated CMS guidance responds to the March 10, 2014, CMS memorandum to Part D Plan Sponsors and Medicare Hospice Providers entitled, "Part D Payment for Drugs for Beneficiaries Enrolled in Hospice – Final 2014 Guidance".   The guidance, based on a 2012 Office of the Inspector General report, identifies that Medicare is likely paying for Medicare-financed medications twice both through the Part D Prescription Drug Plans’ (PDP) capitation payments and through the hospice per diem.  The guidance became effective on May 1, 2014.   In brief, the guidance caused significant confusion among PDPs, hospice providers, pharmacies, consultant pharmacists, and skilled nursing center providers (SNF).  The results of this confusion were based on:

Access 2014 PEPPER Reports Now

Published in July 17, 2014 Issue

As reported previously, the 2014 release of the Program for Evaluating Payment Patterns Electronic Report (PEPPER) for skilled nursing facilities (SNFs) has been available for download through the secure access page since May 5, 2014. As of June 30th, however, only 7,363 (49%) of the 14,961 SNF PEPPERs have been accessed.

billing

REGISTRATION STILL AVAILABLE - LTC Billing and Claims Management Workshops in TWO LOCATIONS

Published in July 17, 2014 Issue

The Long Term Care Billing and Claims Management Workshop, presented by Mary Lynn Wright, Revenue Cycle Consultant with The Wright Group, LLC, is a one-day course developed to provide a comprehensive review of third-party claims management for the long term care setting.  The program, scheduled July 22nd in Roanoke and July 23rd in Williamsburg, will provide attendees with the knowledge necessary to achieve a high rate of clean claim submission while decreasing risk of denials.  Payers addressed in this session are: Medicare A/B, Traditional Virginia Medicaid, managed care, and the transition to Commonwealth Coordinated Care (CCC) for dual eligible beneficiaries.  With CCC fully launched in Tidewater and coming to the rest of the Demonstration regions in the next few months, claims/billing procedures are evolving on a daily basis.  This workshop will provide up to the minute information that will assist you in working with the Medicare Medicaid Plans (MMPs) to get paid timely for the services you provide to CCC. 

CMS to Pilot “Settlement Conference Facilitation” for Part B Claims Appeals

Published in July 10, 2014 Issue

The Centers for Medicare & Medicaid Services (CMS) has just announced a new pilot, Settlement Conference Facilitation, which it hopes will alleviate some of the significant backlog of Medicare Part B claims being appealed to the Administrative law Judge (ALJ) level.  Settlement Conference Facilitation is an alternate dispute resolution process, designed to bring providers and CMS together to negotiate and settle some Medicare Part B disputes (e.g., only those appeals of Medicare Part B Qualified Independent Contractor (QIC) disputes) with the help of a settlement conference facilitator.  The facilitator will be an employee of the Office of Medicare Hearings and Appeals (OMHA), who will use mediation principles to help the parties come to a “mutually agreeable resolution.”  The facilitator will not make official determinations on the merits of the claims; but instead will help all the parties “see the relative strengths and weaknesses of their positions.”  If a resolution can be reached, a settlement document will be drafted to reflect the agreement, and the document will be signed by all the parties.  As part of the agreement, any provider requests for an ALJ hearing for the claims covered by the settlement will be dismissed.  To obtain more information and learn about eligibility and the process to request Settlement Conference Facilitation, go to the Department of Health and Human Services (HHS)/OMHA website

AHCA Medicare Rate Tool Available for 2015 Proposed Rule

Published in May 8, 2014 Issue

On May 1, 2014, the Centers for Medicare and Medicaid Services (CMS) released its proposed rule for the skilled nursing facility ( SNF) Prospective Payment System (PPS), indicating Medicare rates for the coming fiscal year. CMS is proposing a 2.0% increase, estimated to increase overall SNF payments by $750 million nationally.

CMS Announces Proposed Rule for SNF PPS

Published in May 2, 2014 Issue

Yesterday, the Centers for Medicare and Medicaid Services (CMS) released the proposed rule for the SNF Prospective Payment System. CMS is proposing a 2.0% increase, estimated to be $750 million for the profession. There are several aspects to this proposed rule that look positive. (A fact sheet is available on the CMS website.)  This rule reflects the third year in a row of market basket increases, and an increase from last year's 1.3% market basket update.  The key provisions in the SNF PPS proposed rule that could have a direct impact on the long term and post-acute care profession are highlighted below.

Commonwealth Coordinated Care Update

Published in May 2, 2014 Issue

Member facilities located in the Tidewater area of the Commonwealth are reporting the receipt of letters addressed to their residents announcing that they will soon be enrolled in one of three Medicare-Medicaid Plans (MMPs) and that their long term care services and supports will transfer to the Commonwealth Coordinated Care (CCC) program effective July 1, 2014.  The receipt of these passive enrollment 60-day letters is raising a number of questions from VHCA member facilities as they struggle with how to respond to questions from their residents.

Commonwealth Coordinated Care Update

Published in April 25, 2014 Issue

Beginning this week, individuals with full Medicare and Medicaid benefits in the Tidewater Region of the Commonwealth Coordinated Care (CCC) program will receive letters announcing that effective July 1, 2014 they will be assigned to one of three Medicare-Medicaid Plans (MMPs). The letter from the Virginia Department of Medical Assistance Services (DMAS) indicates that their traditional coverage provided through the Medicare and Medicaid programs will cease as of that date unless they choose to opt-out of the CCC. 

Commonwealth Coordinated Care Update

Published in April 3, 2014 Issue

Earlier this week, the Department of Medical Assistance Services (DMAS) released its April 2014 update covering the rollout of the Commonwealth Coordinated Care (CCC) program.  As of March 31st, a total of 1,417 individuals voluntarily enrolled in CCC in the Tidewater and Richmond/Central regions.  These voluntary enrollments represent 3.5% of the total Dual Eligible beneficiaries that reside in the two CCC regions.  Of the 1,417 voluntary enrollments, DMAS has indicated that only 14 beneficiaries are receiving services in nursing facilities.  Coverage for those who enrolled prior to March 26th began April 1, 2014. 

CMS Issues Advance Copy of SOM Chapter 7 Revisions

Published in April 3, 2014 Issue

In a March 28, 2014 Survey & Certification Memo to State Agency Directors (S&C -14-18-NH,) the Centers for Medicare and Medicaid Services (CMS) provides an Advance Copy of Chapter 7 of the State Operations Manual (SOM) which has been revised to incorporate the following provisions of Section 6111 of the Patient Protection and Affordable Care Act (the Affordable Care Act).

Commonwealth Coordinated Care Update

Published in March 28, 2014 Issue

Earlier this week, a second Commonwealth Coordinated Care (CCC) town hall meeting was held in Fredericksburg.  These meetings are intended to provide information about Virginia’s dual eligible financial alignment demonstration to both beneficiaries and providers, including nursing facilities.  Representatives from the Department of Medical Assistances Services (DMAS) report that approximately 1,500 individuals have initiated the process to enroll in the CCC voluntarily.  As of March 19, DMAS reported that only 14 dual eligible beneficiaries residing in nursing facilities in the Tidewater and Central/Richmond CCC regions had initiated voluntary enrollment efforts.

Commonwealth Coordinated Care Update

Published in March 21, 2014 Issue

An issue identified recently that may have significant implications for dual eligible resident populations in nursing facilities focuses on a provision in the three-way contract between the Centers for Medicare and Medicaid Services (CMS), the Department of Medical Assistance Services (DMAS) and the three contracted health plans (Medicare-Medicaid Plans or MMPs) that stipulates that beneficiaries with other insurance coverage are not eligible to participate in the Commonwealth Coordinated Care (CCC) program.  It is not uncommon for nursing facility residents to have Medicare supplemental insurance policies.  DMAS has indicated that traditional Medigap and Tricare policies indeed meet these criteria.  One primary concern related to this provision is that DMAS and its enrollment broker MAXIMUS do not maintain records that identify which dual eligible beneficiaries have supplemental insurance in effect.  Facilities are encouraged to identify residents with this type of coverage and communicate and clarify the CCC participation restriction to residents, resident’s families or their representatives with this coverage.

Commonwealth Coordinated Care Update with Initial Medicaid Payment Rates

Published in March 13, 2014 Issue

Despite the fact that there are significant and important ongoing discussions between VHCA, the three contracted Medicare-Medicaid Plans (MMPs) and the Department of Medical Assistance Services (DMAS) to address a range of operational issues, DMAS is continuing its efforts to launch the Commonwealth Coordinated Care (CCC) program in accordance with their enrollment timetable for each of five CCC regions.  These discussions focus on three key areas: service authorizations, claims processing and payment determination (treatment of Medicare bad debts and Medicaid patient pay components), and care coordination. There is no formal mechanism for reporting the status of providers, including nursing facilities, that have contracted with Anthem HealthKeepers, Humana and Virginia Premier. It is our understanding that all three MMPs continue to work aggressively to negotiate and execute provider agreements.

DMAS Townhall Meeting Concerning the CCC Scheduled for March 5th in Virginia Beach

Published in February 20, 2014 Issue

The Department of Medicare and Medicaid Services (DMAS) is holding a Townhall meeting concerning the Commonwealth Coordinated Care Program (CCC) in Virginia Beach on March 5, 2014.  Click link for details.  Future Townhall meetings are also being scheduled in all CCC regions.  DMAS will provide additional information to these events when they are finalized.  Anyone who would like more information about Townhalls or would like to partner with DMAS to host a Townhall in your region, please contact DMAS at CCC@dmas.virginia.gov.

Medicare Recovery Audit Program Update

Published in February 20, 2014 Issue

After learning last week at the Administrative Law Judge (ALJ) Forum that a significant increase in the number of audits in the Recovery Audit (RA) program over the last several years is a major factor in the two plus year backup at the ALJ level, the Centers for Medicare and Medicaid Services (CMS) announced on its website that it is “pausing” RA audits in preparation for the procurement of new RA contracts and to “allow CMS to continue to refine and improve the Medicare RA Program.”  To obtain a complete copy of the announcement click here.

Commonwealth Coordinated Care Update

Published in February 6, 2014 Issue

As a follow-up to a December 2013 meeting of VHCA’s ad-hoc managed care committee, association staff recently met with the Department of Medical Assistance Services (DMAS) to address a number of issues identified by the committee.  An outcome from the January meeting with DMAS was DMAS’ agreement to host a series of additional meetings with all three contracted MCOs and VHCA member representatives to try and work through key operational concerns that must be resolved prior to the Commonwealth Coordinated Care (CCC) launch.  To date, two workgroup meetings have been held focusing on a number of issues including authorizations, preauthorizations, reauthorizations, patient pay, Medicare bad debt, and claims submission and testing. Additional meetings will take place through February and possibly into March to wrap up discussions on these topics as well as to address the overall process surrounding care coordination and the transition/discharge planning process.

Minimum Wage Initiative Tied to Services Provided to VA Patients

Published in January 30, 2014 Issue

On Tuesday, President Obama issued an executive action regarding the minimum wage increase for new federal contract workers.  In advance of this week’s State of the Union address, the White House released some details about the executive action that would raise the minimum wage from $7.25 to $10.10 for new federal contract workers by 2015.  It is important to note that this executive action does not impact Medicare or Medicaid providers, as it is a long-standing policy that such providers are not "federal contractors."  It is also important to note that if long term care facilities serve VA patients, those facilities are considered to be federal contractors, and thus, this executive action may apply.

DMAS Reports Medicaid Billing Concern

Published in January 23, 2014 Issue

The Department of Medical Assistance Services (DMAS) reports that it is experiencing an increase in complaints related to hospitals not being able to receive payment for services rendered due to some nursing facilities failure to adjust the admission date on their claims when a resident returns from the hospital. When nursing facilities leave the original admission date on submitted claims, it causes an edit to set within the DMAS claims processing system and the hospital is not paid.  This issue can create large outstanding balances for hospitals.

Observation Stays in the National Spotlight

Published in January 15, 2014 Issue

In a press release issued Friday, January 10th, the American Health Care Association and the National Center for Assisted Living (AHCA/NCAL) brought light to the recent media attention garnered by the complex issue of observation stays.  The press release links to two media segments focused on the issue: a recent episode of NBC's Nightly News and an op-ed piece published in The Hill.

2014 Medicare Part B Fee Schedule

Published in January 9, 2014 Issue

The 2014 therapy fees for each CPT/HCPCS Code in each geographic area are now available courtesy of Tony Marshall with the Florida Health Care Association.  This Excel document has four worksheets containing the following information:

Commonwealth Coordinated Care Update

Published in January 9, 2014 Issue

Earlier this week, the Department of Medical Assistance Services (DMAS) released a Commonwealth Coordinated Care (CCC) update.  The launch dates for the CCC, Virginia’s dual eligible demonstration, have been revised slightly from previous communications.  DMAS indicates a one-month delay from the original dates due to the extended time required to finalize the three-way contract.  With this adjustment, the timeline for passive enrollment has been shifted accordingly to allow for a gradual implementation.  As a result, services for beneficiaries passively (automatically) enrolled in the Tidewater Region will begin July 1 and the service start date for Central Virginia beneficiaries will shift to August 1.  Following is the revised enrollment timetable for each region in the Commonwealth:

Commonwealth Coordinated Care Update

Published in December 19, 2013 Issue

On December 17th, members of the VHCA’s Ad-Hoc Managed Care Committee met with representatives of all three health plans that have been selected by the Department of Medical Assistance Services (DMAS) and the Centers for Medicare and Medicaid Services (CMS) to participate in Virginia’s Commonwealth Coordinated Care program (CCC or dual demonstration). The meeting was structured to allow the committee to meet with the three managed care organizations (MCOs) separately for purposes of discussing the status of efforts by each health plan to address a range of operational issues that are considered essential to the successful coordination of activities and communications between MCOs and nursing facilities.

Commonwealth Coordinated Care Update

Published in December 12, 2013 Issue

As communicated yesterday in a broadcast email to our members, the Department of Medical Assistance Services (DMAS) provided the final three-way contract dated December 4, 2013 to VHCA earlier this week.  The three-way contract is the key legal agreement between the federal Centers for Medicare and Medicaid Services (CMS), DMAS and each individual participating health plan necessary to form the Commonwealth Coordinated Care (CCC or dual demonstration) program.

Commonwealth Coordinated Care - Virginia's Dual Demonstration

Published in November 14, 2013 Issue

Earlier this week we sent out an email to nursing facility administrators and corporate offices announcing the availability of a side-by-side comparison of key provisions and observations related to each of the managed care contract templates approved by the Department of Medical Assistance Services for the three MCOs that have been selected to participate in the Commonwealth Coordinated Care program (CCC).

Commonwealth Coordinated Care Program

Published in November 6, 2013 Issue

We continue to encourage our members to consider delaying the execution of contracts with MCOs especially in light of the fact that the “three-way contract”, the core agreement between the Centers for Medicare and Medicaid Services (CMS), DMAS and each of the MCOs, has not been finalized and the blended payments to MCOs have not been formally established.  One additional key element that we understand will be addressed in the three-way contracts is the provision for prompt payment as it relates to MCO payments to providers.  While there are no guarantees, we anticipate that the three-way contracts may be finalized over the next two to four weeks.

CMS Announced 2014 Medicare Deductible and Co-Insurance Amounts

Published in November 1, 2013 Issue

Earlier this week, the Centers for Medicare and Medicaid Services (CMS) announced the 2014 rates for Part A deductibles and co-insurance payments for Medicare beneficiaries receiving care in a hospital inpatient setting or skilled nursing facility. The following table summarizes the updates:

Commonwealth Coordinated Care Update

Published in November 1, 2013 Issue

VHCA has been informed by the Department of Medical Assistance Services (DMAS) that all three managed care organization (MCO) contract templates for the Commonwealth Coordinated Care program (CCC or the dual demonstration) have been approved.   As described by DMAS, each of the three MCOs (Virginia Premier, Humana, and Anthem HealthKeepers) may now begin talking with individual nursing facilities regarding participation in the CCC program.

Commonwealth Coordinated Care: DMAS Approves Humana Provider Agreements

Published in October 23, 2013 Issue

Late last week, the Department of Medical Assistance Services (DMAS) announced that they had approved templates of Humana’s provider participation agreements under the Commonwealth Coordinated Care (CCC or dual demonstration) program.  This approval included the nursing facility contract.  After discussion with DMAS staff, it appears that the Department has approved two Humana documents, a base contract titled “Ancillary Provider Contract” and a separate Nursing Facility Addendum.  According to DMAS, both documents will be sent to nursing facilities within the five CCC regions that currently do not have a contract with Humana.  Nursing facility providers who currently have a contract with Humana will only be sent the Nursing Facility Addendum.  We are pleased to report that based upon our initial review of the contracts, it appears that Humana has agreed to pay providers no less than the established Medicaid and Medicare rates paid to nursing facilities. 

Save the Date: November AHCA Webinar on Medicare-Medicaid Demonstrations

Published in October 17, 2013 Issue

Critical phases of the Medicare-Medicaid Coordination Demonstration such as three-way contracts and open enrollment periods are currently in place in select states.  Additional states, including Virginia are expected to roll out similar coordination demonstrations.

Commonwealth Coordinated Care Update and the Future of Medicaid Payment

Published in October 17, 2013 Issue

As we reported last month, in late September the Department of Medical Assistance Services (DMAS) announced in an email message that the agency had approved provider agreements submitted by Virginia Premier Health Plan, Inc. including the plan’s nursing facility agreement.  The message also indicated that DMAS had approved all agreements submitted by HealthKeepers (Anthem/WellPoint) except for the nursing facility agreement.  Finally, the Department indicated that none of the provider agreements submitted by Humana have been approved at this time.  Virginia Premier officials stressed that the approved plan will serve as a template for individual provider agreements and provides the flexibility to incorporate contact provisions that foster innovative and effective approaches for care coordination.

OIG Releases Medicare RAC and CMS Action Report

Published in October 10, 2013 Issue

The US Department of Health and Human Services, Office of Inspector General (OIG) has called on the Centers for Medicare & Medicaid Services (CMS) to strengthen activities to prevent improper Medicare payments, including enhancements to the Recovery Audit Contractor (RAC) program.  According to the OIG report, RACs identified only half of all claims they reviewed in FYs 2010 and 2011 as having resulted in improper payments totaling $1.3 billion. While CMS took corrective actions to address the majority of identified vulnerabilities, the agency did not evaluate the effectiveness of those actions, however, so high levels of improper payments may continue. The OIG report also raised concerns about CMS failure to act on all referrals of potential fraud that it received from RACs, along with gaps in CMS evaluations of RAC performance on contract requirements. OIG recommends that CMS address identified vulnerabilities; ensure that RACs refer all appropriate cases of potential fraud; take appropriate action on RAC referrals of potential fraud and enhance RAC performance evaluation. CMS generally concurred with the OIG recommendations.  To obtain a copy of the full report, click here.

OIG Releases Medicare Appeals Process Information

Published in October 10, 2013 Issue

The US Health and Human Services, Office of Inspector General (OIG) has released a report, The First Level of the Medicare Appeals Process, 2008-2012: Volume, Outcomes, and Timeliness, focusing on the redetermination phase of the Medicare appeals process for Part A and B claims.  According to the study, Medicare Administrative Contractors (MACs) processed 2.9 million redeterminations, which involved 3.7 million claims, showing an increase of 33 percent since 2008.  Although 80 percent of all redeterminations in 2012 involved Part B services, redeterminations involving Part A services have risen more rapidly.  In fact, the OIG report says that between 2008 and 2012, the redeterminations handled by MACs have seen a 148 percent increase in Medicare Part A claims.  The majority of this increase comes from appeals from Medicare recovery audit contractors (RACs).  As the number of Part A appeals exploded, those providers appealing these claims have seen their chances at a favorable decision at the redetermination level go down.

Commonwealth Coordinated Care Update

Published in September 26, 2013 Issue

On September 24th, the Department of Medical Assistance Services (DMAS) announced in an email message that the agency had approved provider agreements submitted by Virginia Premier Health Plan, Inc. including the plan’s nursing facility agreement.  The message also indicated that DMAS had approved all agreements submitted by HealthKeepers (Anthem/WellPoint) except for the nursing facility agreement.  Finally, the Department indicated that none of the provider agreements submitted by Humana have been approved at this time.  VHCA has obtained a copy of the Virginia Premier agreement and is now reviewing the document.  Virginia Premier officials stress that the approved plan will serve as a template for individual provider agreements and provides the flexibility to incorporate contact provisions that foster innovative and effective approaches for care coordination.

UPDATE: Commonwealth Coordinated Care

Published in September 6, 2013 Issue

As a reminder to our members and due to its significance, we’re repeating portions of a CareConnection article published on August 1st.  Department of Medical Assistance Services (DMAS) and the Centers for Medicare and Medicaid Services (CMS) continue to move forward with the development and implementation of Virginia’s demonstration for a blended Medicare-Medicaid program for dual eligibles – now known as Commonwealth Coordinated Care (CCC).

Update: MCO Provider Agreements

Published in August 9, 2013 Issue

Commonwealth Coordinated Care

Last week, the Virginia Health Care Association was informed verbally by leadership of the Department of Medical Assistance Services (DMAS) that all proposed provider agreements between health plans and nursing facilities under Virginia’s Commonwealth Coordinated Care program must be submitted by the managed care organization (MCO) to DMAS for review and approval prior to execution.  VHCA’s Managed Care Committee is working with DMAS to ensure that provider agreements contain essential provisions that will allow facilities to provide post-acute and long term care services to dual eligible beneficiaries free of unnecessary administrative oversight and require health plans to pay providers fairly and promptly for those services.

UPDATE: Commonwealth Coordinated Care

Published in August 1, 2013 Issue

On July 31st, representatives from the Department of Medical Assistance Services (DMAS) presented an update to members of the Commonwealth Coordinated Care Advisory Committee.  DMAS and the Centers for Medicare and Medicaid Services (CMS) are moving forward with the development and implementation of Virginia’s demonstration for a blended Medicare-Medicaid program for dual eligibles – now known as Commonwealth Coordinated Care (CCC).

CMS Issues 2014 PPS Final Rule

Published in August 1, 2013 Issue

The Centers for Medicare and Medicaid Services announced on July 31st that Medicare payment rates for skilled nursing facilities in fiscal 2014 will rise by 1.3 percent, or a total of $470 million higher than in fiscal 2013.  The 2014 final rule updates the payment rates used under the prospective payment system for skilled nursing facilities (SNFs) for fiscal year 2014.  In addition, it revises and rebases the SNF market basket, revises and updates the labor related share, and makes certain technical and conforming revisions in the regulations text. This final rule also includes a policy for reporting the SNF market basket forecast error in certain limited circumstances and adds a new item to the Minimum Data Set (MDS), Version 3.0 for reporting the number of distinct therapy days. Finally, this final rule adopts a change to the diagnosis code used to determine which residents will receive the AIDS add-on payment, effective for services provided on or after the October 1, 2014 implementation date for conversion to ICD-10-CM.

CMS Issues Final Rule for Hospice in Nursing Centers

Published in August 1, 2013 Issue

On June 27, 2013, the final rule Medicare and Medicaid Programs; Requirements for Long Term Care Facilities; Hospice Services was published in the Federal Register. The Final Rule revises skilled nursing facility (SNF)/nursing facility (NF) requirements for arranging provision of hospice care and primarily focuses on the information that must be contained in an agreement for hospice services between a hospice and nursing center.  Facilities must be in compliance by August 26, 2013 according to the preamble of the regulation, “This final rule sets forth requirements consistent with requirements in the June 5, 2008 final rule (73 FR 32088) titled ‘‘Medicare and Medicaid Program: Hospice Conditions of Participation.’’  This final rule also supports current LTC requirements that protect a resident’s right to a dignified existence, self-determination, and communication with, and access to, persons and services inside and outside the facility.”

UPDATE: OIG Advisory on Checking LEIE for Exclusions

Published in August 1, 2013 Issue

In the July 24th CareConnection we published an article on the Health & Human Services Office of Inspector General’s (OIG) Updated Special Advisory Bulletin on the Effect of Exclusion from Participation in Federal Health Care Programs, issued May 8, 2013.  This updated Special Advisory Bulletin describes the scope and effect of the legal prohibition on payment by Federal health care programs for items or services furnished (1) by an excluded person or (2) at the medical direction or on the prescription of an excluded person.

PEPPER Reminder

Published in August 1, 2013 Issue

In July, Center for Medicare and Medicaid Services (CMS) contractor TMF Health Quality Institute [HQI] informed the American Health Care Association that HQI was sending out, via regular mail, the attached postcard to all 15,000+ SNFs. 

Commonwealth Coordinated Care: MCO Contracting

Published in July 3, 2013 Issue

Due to the significant potential impact for our members, we are repeating this article from last week's CareConnection.  The Department of Medical Assistance Services (DMAS) along with the Centers for Medicare and Medicaid Services (CMS) recently announced that they have selected three managed care organizations (MCOs or health plans) to participate in Virginia's dual demonstration - Commonwealth Coordinated Care.  The awardees are Anthem HealthKeepers, Humana and Virginia Premier.  Each of these three health plans will compete in all five demonstration regions.  A 10-day protest period is now underway to allow unsuccessful health plans to appeal the DMAS/CMS decision.

DMAS Announces MCO Awardees for Commonwealth Coordinated Care

Published in June 28, 2013 Issue

Late today, we received information from the Department of Medical Assistance Services (DMAS) that the agency, in conjunction with the Centers for Medicare and Medicaid Services (CMS), has selected three managed care organizations (MCOs or health plans) to participate in Virginia’s dual demonstration – Commonwealth Coordinated Care.  The awardees are Anthem HealthKeepers, Humana and Virginia Premier.  Each of these three health plans will compete in all demonstration five regions.  A ten-day protest period now begins to allow unsuccessful health plans to appeal the DMAS/CMS decision.

Palmetto Webinar: SNF Required Notices - Expedited Determinations, ABNs and NEMBs

Published in June 28, 2013 Issue

Palmetto GBA is offering a recorded webinar addressing SNF Required Notices for Expedited Determinations, Advanced Beneficiary Notices (ABNs) and Notice of Exclusion from Medicare Benefits (NEMBs).  This webinar discusses the different types of Skilled Nursing Facility (SNF) Medicare required notices. This program is designed to cover a range of notification requirements from the generic and detailed notices under the expedited determinations process to the Advanced Beneficiary Notice (ABN) and Notice of Exclusion from Medicare Benefits (NEMB).  After attending this course, SNF Medicare providers will be well versed in all the required Medicare notices.

AHCA Responds to Ways and Means Medicare Reform Hearing

Published in June 19, 2013 Issue

The American Health Care Association (AHCA) issued the following statement last week from President and CEO Mark Parkinson in conjunction with the House Committee on Ways and Means, Subcommittee on Health hearing on the President’s and other bipartisan proposals to reform Medicare Post-Acute Care Payments:

CMS Revises Guidance Related to Improving Care for Persons with Dementia and Reducing Antipsychotic Drug Use in Nursing Facilities

Published in June 5, 2013 Issue

The Centers for Medicare & Medicaid Services (CMS) has released two new Survey and Certification Memos revising guidance on care for persons with dementia, consistent with the goals of the Partnership to Improve Dementia Care in Nursing Homes to, “optimize quality of life and function of residents in America’s nursing homes by improving approaches to meeting the health, psychosocial and behavioral health needs of all residents, especially those with dementia.”  The new guidance emphasizes the need to individualize care and treatment approaches and to ensure that antipsychotic medications are used only when a clear and appropriate clinical indication exists.

Medicaid Testing New Rug Grouper

Published in June 5, 2013 Issue

Last week, the Department of Medical Assistance Services (DMAS) announced via a communication included in each Medicaid-participating nursing facility’s GoFileRoom that it is evaluating a new version of the Resource Utilization Group (RUG).  The RUG-IV grouper was first available on October 1, 2010.  The Medicaid version of this grouper contains 48 RUG categories.  The evaluation of the Medicaid RUG-IV 48 group version is one component of work now underway to develop, and possibly implement, a new price-based Medicaid payment methodology in Virginia.

RAI Manual Update

Published in May 30, 2013 Issue

The RAI Manual v1.10 posted on May 20, 2013 by the Centers for Medicare & Medicaid Services (CMS) omitted six sections: Chapter 3 - Section F; Chapter 3 - Section J; Chapter 3 - Section S title page; Appendix D; Appendix F title page; and Appendix H title page.  The re-posting of RAI Manual v1.10 on May 29, 2013, now includes these six sections.

Observation Status Coalition Heads to Capitol Hill

Published in May 22, 2013 Issue

The American Health Care Association (AHCA) and the Observation Status Coalition recently headed to Capitol Hill as a group to meet with members of Congress and its staff to raise the issue of Medicare beneficiaries’ access to skilled nursing facility (SNF) care being constrained by the increased use of extended hospital stays in observation status.  Specifically, the group is advocating for the Improving Access to Medicare Coverage Act of 2013 (S. 569/H.R. 1179), which aims to ease access to skilled nursing care for Medicare beneficiaries following a hospital stay.  The coalition brought with it a fact sheet signed by a dozen organizations including AHCA/NCAL.  AHCA staff has been hitting the Hill since the bill was introduced in March and welcomes the opportunity to work in a coalition with others interested in advancing the legislation. The coalition will continue to meet with key Congressional offices to garner support for the Improving Access to Medicare Coverage Act.

CMS & Virginia Announce Dual Demonstration MOU

Published in May 22, 2013 Issue

On May 21st, the Centers for Medicare & Medicaid Services (CMS) and the Virginia Department of Medical Assistance Services (DMAS) announced that they will establish a Federal-State partnership to implement the Commonwealth Coordinated Care program (also referred to as the Dual Demonstration) to better serve individuals eligible for both Medicare and Medicaid (dual eligibles).  The Federal-State partnership will include a three-way contract with managed care organizations (MCOs) that will provide integrated benefits to Medicare-Medicaid Enrollees in the targeted geographic area(s).  The Demonstration will begin on February 1, 2014 and will continue until December 31, 2017, unless terminated earlier in accordance with provisions of the executed Memorandum of Understanding (MOU).  The demonstration is intended to test a payment and service delivery model to lessen the fragmentation and improve coordination of services for Medicare-Medicaid Enrollees, enhance quality of care, and reduce costs for both the Commonwealth and the federal government.

Palmetto GBA Offers Part A SNF Required Notices Webinar

Published in May 15, 2013 Issue

On Wednesday, May 22nd from 10:00 AM - 11:30 AM, Palmetto GBA will offer a no-charge webinar to all J11 providers.   

Dual Demonstration Update

Published in May 9, 2013 Issue

Virginia providers are paying increasing attention to the status of the proposed Medicare/Medicaid financial alignment demonstration (the Dual Demonstration).   Despite the belief that the Centers for Medicare and Medicaid Services (CMS) would issue a Memorandum of Understanding (MOU) to the Commonwealth in April, the federal agency has not yet added Virginia to the short list of states with approved MOUs.  Senior leadership at the Department of Medical Assistance Services (DMAS) believes the release of the MOU to be imminent.

Skilled Nursing Profession Responds to CMS Proposed Payment Rule

Published in May 9, 2013 Issue

Recently, the American Health Care Association (AHCA) issued a statement from President and CEO Mark Parkinson in response to the release of the Skilled Nursing Prospective Payment System (SNF PPS) Proposed Rule for FY2014 by the Centers for Medicare and Medicaid Services (CMS):

Updated Medicare Projections Indicate Additional Cuts Unnecessary

Published in May 1, 2013 Issue

Payments to Medicare providers, including skilled nursing facilities, will not have to be cut this year, the Centers for Medicare and Medicaid (CMS) has announced.  In a memo to CMS’ Acting Administrator Marilyn Tavenner, the agency’s Acting Chief Actuary Paul Spitalnic indicated that projections for Medicare’s per capita growth rate were within targeted spending rates laid out in President Obama’s health care reforms.

Dual Eligible Financial Alignment Demonstration: DMAS Issues RFP to MCOs

Published in April 17, 2013 Issue

The Department of Medical Assistance Services (DMAS or the Department) formally issued a Request for Proposals (RFP) on April 10th from managed care plans (plans or MCOs) to enter into risk-based contracts for the capitated model under the Medicare-Medicaid Financial Alignment Demonstration (the Demonstration).

CMS Clarifies Medicare Coverage of Maintenance Therapy

Published in April 17, 2013 Issue

As previously reported, on January 24, 2013, the U. S. District Court for the District of Vermont approved a settlement agreement in the case of Jimmo v. Sebelius, in which the plaintiffs alleged that Medicare contractors were inappropriately applying an “Improvement Standard” in making claims determinations for Medicare coverage involving skilled care (e.g., the skilled nursing facility (SNF), home health (HH), and outpatient therapy (OPT) benefits). The settlement agreement sets forth a series of specific steps for the Centers for Medicare & Medicaid Services (CMS) to undertake, including issuing clarifications to existing program guidance and new educational material on this subject.

Final 2014 Rate Announcement for Medicare Advantage Plans

Published in April 4, 2013 Issue

Earlier this week, the Centers for Medicare and Medicaid Services (CMS) announced the changes to Medicare Advantage (MA) Plan payment rates for 2014. In total, CMS will raise payments to MA plans by 3.3%, a drastic turn away from the 2.2% rate cut it proposed in an advance notice in February. There are two primary drivers of this reversal: First, public pushback to the proposed cuts resulted in many Members of Congress writing letters to CMS acting administrator Marilyn Tavenner, urging the agency to reconsider its position. And second, more importantly, in the final rate announcement CMS readjusted its methodology for calculating the growth rate by assuming that the Sustainable Growth Rate (SGR) formula (the 27% cut to payments that threaten physicians every year) will be either replaced or temporarily avoided, as it has been every year for the past decade. This assumption had a significant impact on CMS’ projections.

Dual Demonstration Update

Published in March 25, 2013 Issue

During a recent meeting with representatives of managed care organizations, staff of the Department of Medical Assistance Services (DMAS) shared some news and their updated regional implementation timing expectations with respect to Virginia’s proposed Medicare/Medicaid Financial Alignment Demonstration (Dhttp://www.vhca.org/IlluminAgeApps/whatsnewApp/files/5CD65A34C.pdfual Demonstration). 

Final Rule Published on Notice of Facility Closure

Published in March 25, 2013 Issue

On March 19th the Centers for Medicare & Medicaid Services (CMS) published the Final Rule on Requirements for Long-Term Care Facilities related to “Notice of Facility Closure” in the Federal Register with an effective date of April 18, 2013.   This rule adopts technical changes to the interim final rule, published on February 18, 2011, that implemented Section 6113 of the Affordable Care Act (ACA), requiring that individuals serving as Administrators of a SNF or NF provide written notification of impending closure and plan for relocation of residents at least 60 days prior to the closure or, if the Secretary terminates the facility’s participation in Medicare or Medicaid, not later than the date the Secretary determines appropriate.  The full text of the rule can be found here.  

VHCA Submits Comments to CMS: Dual Demonstration Proposal

Published in June 29, 2012 Issue

Earlier this week, the Virginia Health Care Association (VHCA) submitted written comments to the Centers for Medicare and Medicaid Services (CMS) related to a proposal submitted by the Department of Medical Assistance Services (DMAS) for a blended payment demonstration for dual eligible beneficiaries that, if approved, would provide capitated combined Medicare and Medicaid funding to managed care organizations (MCOs).  These MCOs would in turn, contract with providers, including nursing facilities, for the delivery of coordinated services to individuals with both Medicare and Medicaid benefits. The comments, developed in conjunction with the association’s ad-hoc committee on managed care, are available here (member log-in required).

 

FINAL CALL: Virginia’s Dual Demonstration Comment Period Ends June 30th

Published in June 22, 2012 Issue

The Virginia Health Care Association (VHCA) encourages all members to forward comments, questions and suggestions to the association related to the proposed Medicare/Medicaid Alignment Demonstration as we work to finalize comments that will be submitted to the Centers for Medicare and Medicaid Services (CMS).  The official end of the comment period is Saturday, June 30th.  VHCA plans to submit written comments on Wednesday, June 27th.  A draft of the association’s comments is available for your information and review.

Nursing Home Quality Improvement Questionnaire Announced

Published in June 22, 2012 Issue

The American Health Care Association (AHCA) has asked affiliates to assist the Centers for Medicare & Medicaid Services (CMS) in announcing a Nursing Home Quality Improvement Questionnaire that will be administered this summer by a CMS contractor.   The collection of this information is part of the CMS advancement of Quality Assurance and Performance Improvement (QAPI) in nursing homes.   The contractor will identify a representative sample of 4,200 nursing homes that will receive an invitation to complete the questionnaire.  The goal of the questionnaire is to identify the quality systems and processes nursing homes currently have in place, as well as assess the extent to which these systems and processes function to help nursing homes recognize and address quality issues. This information will help CMS and the contractors refine the QAPI components. Members are encouraged to participate if selected.  An Information Sheet describes the questionnaire as well as some of the other initiatives under way.

Virginia Dual Demonstration: CMS Comment Period Ends June 30th

Published in June 15, 2012 Issue

The Virginia Health Care Association (VHCA) encourages all members to forward comments, questions and suggestions to the association related to the proposed Medicare/Medicaid Alignment Demonstration as we work to finalize comments that will be submitted to the Centers for Medicare and Medicaid (CMS) on or before June 30th.

CMS Region III to Host ACO Webinar

Published in February 3, 2012 Issue

The Philadelphia Regional Office of the Centers for Medicare & Medicaid Services will be hosting an Open Door Forum (ODF) call and webinar for Region III providers on Wednesday, February 8, 2012 from 12:00 noon to 2:00 pm to present an overview regarding the Medicare Shared Savings Program (MSSP)/Accountable Care Organizations (ACOs), and the final rule. The presentation will conclude with a question and answer period regarding the program and final rule.

MedPAC Approves Harsh SNF Payment Recommendations

Published in January 20,2012 Issue

The Medicare Payment Advisory Commission (MedPAC) voted earlier this week to recommend that the way skilled nursing providers (SNF) are paid by the government be drastically modified.  In a move consistent with recent years, MedPAC also voted to recommend that providers receive no Medicare inflationary pay increase in Federal fiscal year 2013.

Congress

ACT NOW: Tell Congress to Oppose Reductions to Nursing Facility Bad Debt Reimbursement Take Action!

Published in January 13,2012 Issue

As Congress returns to work in the new year, their priority is to resolve the payroll tax cut controversy, provide a doc fix, and possibly extend the therapy cap exceptions process.  A Conference Committee has been created to address these issues. They have been given a deadline of March 1 to decide what to fix, for how long, and how to pay for it.

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Chart Highlights Virginia Impact of Medicare SNF Payment Cuts

Published in March 14, 2013 Issue

Based upon new national data published by several organizations, we’ve pulled together recent cuts to Medicare Skilled Nursing Facility Prospective Payment System (SNF PPS) rates for Virginia and developed a chart that may be helpful for our members as they speak with both national and state-level elected officials.  Data analysis by Avalere Health LLC developed for the Alliance for Quality Nursing Home Care and by the American Health Care Association focusing on known cuts from 2010 forward was used to create the chart.

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Sequestration Looms

Published in February 20, 2013 Issue

All indications point to sequestration cuts going into effect on March 1st.  Skilled nursing facilities should do budget and cash flow planning now to prepare for the impact on reimbursement.  Sequestration will involve a two percent cut in Medicare payments, effective for services provided on or after April 1, 2013.  While there is little formal or practical guidance available to providers, it is our understanding that facilities should continue to bill at the FY2013 rates.  Any adjustments to reimbursement will be made by the Medicare Administrative Contractor (MAC) Palmetto GBA.

Important Update: Virginia's Proposed Medicare/Medicaid Financial Alignment Demonstration for Dual Eligibles

Published in January 31, 2013 Issue

The Virginia Department of Medical Assistance Services (DMAS) submitted a proposal in late May 2012 to the Centers for Medicare and Medicaid Services (CMS) to implement a three-year pilot which would combine Medicare and Medicaid funding for dual eligible beneficiaries.  All health care services provided to these individuals would be coordinated through, and payment made by, health plans (managed care organizations or MCOs) in each of the designated geographic areas comprising the Demonstration.

2013 Part B Fee Schedule

Published in January 31, 2013 Issue

This information is being made available to VHCA members through the generosity of Tony Marshall with the Florida Health Care Association.

The 2013 therapy fees for each CPT/HCPCS Code in each geographic area are provided in the linked Excel spreadsheetThis document has four worksheets containing the following information:

  1. The 2013 Medicare Part B Fee Schedule (Part B Fees) for Outpatient Rehabilitation for each Carrier and Locality.
  2. The 2013 Medicare Part B MPPR Fee Schedule (MPPR) for “Always Therapy” Services (25% MPPR Factor for January 1, 2013 through March 31, 2013).
  3. The 2013 Medicare Part B MPPR Fee Schedule (MPPR 04012013) for “Always Therapy” Services (50% MPPR Factor Effective April 1, 2013).
  4. The 2013 Relative Value Units (RVUs) for each Outpatient Rehabilitation Therapy Code.
  5. The 2013 Geographic Practice Cost Indices (GPCI) by Medicare Carrier and Locality.

Post Election: All Eyes on Washington

Published in November 13, 2012 Issue

Medicare cuts will be harmful to residents and providers, according to a new ad campaign unveiled this week by the American Health Care Association (AHCA).  Launched on Monday, AHCA’s week-long ad blitz brings the sector’s concerns with possible Medicare funding cuts directly to the nation's lawmakers.

CMS Clarifies Guidance on Medication Errors and Pharmacy Services

Published in November 7, 2012 Issue

On November 2, 2012, CMS (the Centers for Medicare & Medicaid Services) distributed a Survey & Certification Memo (S&C: 13-02) providing guidance on three specific topics related to medication errors and pharmacy services.

  • Medication Errors: Potential medication errors related to medication administration via feeding tube and administration timing for metered dose inhalers and proton pump inhibitors and survey implications.
  • Medication Administration Practices: The practice of “borrowing” medications and issues related to diversion, control, reconciliation and disposal of medications, including fentanyl patches.
  • Medication Regimen Reviews for Stays under 30 days and/or Changes in Condition: The need for pharmacist medication regimen reviews when a resident experiences a change in condition and/or for residents admitted for less than 30 days.

The clarification provides specific Guidance to surveyors for deficiency citations.  The S & C memo notes that additional tags are provided as “links” for the surveyors.  In Virginia medication administration [technique, error, and administration] are consistently being cited under multiple tags, including F332; F333; F281; F425, etc.  The Guidance is effective immediately.

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Medicare & Medicaid Information Notice

Published in October 31, 2012 Issue

In recent months we have become aware of several facilities that were surveyed and cited because they did not have information related to Medicare and Medicaid benefits and coverage for nursing facility services prominently displayed to comply with guidance on F-156:

§483.10(b)(10) -- The facility must prominently display in the facility written information, and provide to residents and applicants for admission oral and written information about how to apply for and use Medicare and Medicaid benefits, and how to receive refunds for previous payments covered by such benefits.

Since information on how to apply for Medicare and Medicaid benefits is not covered in the Resident Rights poster and there does not appear to be a commercial poster that would meet the requirement, VHCA and VANHA have developed a sample document as written information that facilities can “prominently display” in their buildings which satisfies the requirement in the F156 guidance.  The Office of Licensure And Certification has reviewed the sample document and agrees that it satisfies the intent of the law.  The sample document posted on our website is an 8½ x 11.  If you wish to receive an 11 x 17 poster, contact Kathy Robertson in the VHCA office at 804.212.1700 or via email.  Please be sure your facility prominently posts the information in a location where it can be easily viewed. 

OIG Releases 2013 Work Plan

Published in October 31, 2012 Issue

The Department of Health and Human Services’ (HHS), Office of Inspector General (OIG) has released its annual Work Plan for 2013.  The Work Plan focuses on seven different areas including:  Medicare Part A and Part B; Medicare Part C and Part D; Medicaid Reviews; Legal and Investigative Activities Related to Medicare and Medicaid; Public Health Review; Human Services Reviews; and Other HHS-related reviews.  In each area, the Work Plan identifies compliance risk areas that subject Medicare and Medicaid providers to audit and enforcement initiatives.  Under Medicare Part A and Part B, SNFs are specifically targeted and OIG plans follow-up reports in the following areas:  Adverse Events in Post-Acute Care; Quality of Care Requirements; State Agency Verification of Corrections; Oversight of Poorly Performing Facilities; Use of Antipsychotic Drugs; Questionable Billing Patterns for Part B Services; and Oversight of the Minimum Data Set.  Overall, OIG will continue its trend to focus its efforts on reviewing potential areas to discover fraud, quality issues and costs.  To obtain a copy of the complete OIG Work Plan for 2013, click here.  OIG also has just released a video on its Work Plan for 2013.

Court Case Settlement May Broaden Skilled Services

Published in October 24, 2012 Issue

The post-acute and long term care sector is closely following Medicare’s decision to start paying nursing facility, home care and physical therapy bills for some patients who were previously denied coverage.  Historically, Medicare regulations eliminated coverage of skilled nursing and home care services if patients were not shown to be improving. The care in question might have been physical therapy for stroke victims, home nurse visits for those with Alzheimer’s or post-hospital nursing facility care for diabetics.  Once their health status no longer reflected improvement or started deteriorating, Medicare would stop paying.

Behavioral Issues Survey Coming This Week

Published in October 17, 2012 Issue

Over the past year, VHCA has seen an increase in multiple survey citations, including abuse and safety, related to resident behaviors. We are now challenged with a CMS national initiative to reduce the use of antipsychotic drugs in nursing home residents by 15% by the end of 2012, based on the CMS claim that too many residents with dementia are receiving antipsychotic medications inappropriately. There has also been an increase in inquiries about the limited availability of mental health services for residents with behaviors and the costs associated with providing care to respond to the behaviors and to protect other residents and staff. VHCA created a Behavior Management Workgroup to explore opportunities for providing additional resources to our members to assist them in successfully addressing resident behavioral issues within their organizations.

CMS Releases Revised Surveyor Guidance and Updates to Appendix P

Published in October 11, 2012 Issue

The Centers for Medicare and Medicaid Services (CMS) recently posted advance copies of revised surveyor guidance and updates to Appendix P of the State Operations Manual. The changes to Appendix P are to be implemented no later than December 1st and include Survey Protocols for LTC Facilities revised for the traditional survey process.  Tasks 1 - 5 C reflect changes for the following:

  • Minimum Data Set (MDS) 3.0;
  • New Quality Measures (QM) Reports;
  • Sampling and reviewing residents receiving psychopharmacological medications, specifically antipsychotic medications.

LATER TODAY: CMS Special Open Door Forum on Manual Medical Review of Therapy Claims

Published in September 26, 2012 Issue

Wednesday, September 26, 2012

3:00pm – 4:00pm Eastern Time

The purpose of this Special Open Door Forum (ODF) is to provide an opportunity for providers to ask questions about the mandated manual medical review of therapy services from October 1-December 31, 2012 that was enacted by the Middle Class Tax Relief and Job Creation Act of 2012.  

During this Special Open Door Forum, CMS will discuss therapy documentation requirements.  CMS requests providers’ participation who order or provide therapy services nationally.

Dual Demonstration Update: MCO to Meet with VHCA Committee

Published in September 26, 2012 Issue

Following up on last week’s news related to outreach efforts by managed care organizations (MCOs) as part of their planning for possible participation in Virginia’s proposed Medicare/Medicaid payment alignment pilots (Dual Demonstration), this week we had a request from Virginia Premier, a health plan affiliated with Virginia Commonwealth University, to meet for purposes of sharing information and perspectives related to facility-based long term care services.

MCOs Begin Dual Demonstration Dialogue with Nursing Facilities

Published in September 20, 2012 Issue

Earlier this week, we received word from a member facility in Northern Virginia that they were visited by representatives of a managed care organization (MCO) to discuss the facility’s participation in the MCO’s Dual Demonstration network should they be awarded a contract by the Centers for Medicare and Medicaid Services (CMS) and the Virginia Department of Medical Assistance Services (DMAS).  As previously reported, Virginia is one of 26 states seeking CMS approval to implement a three-year pilot which would combine Medicare and Medicaid funding for dual eligible beneficiaries.  All health care services provided to these individuals would be coordinated through, and payment made by, MCOs in each of four designated geographic areas comprising the Demonstration.  Under the proposal, 164 of 267 Virginia Medicaid-participating nursing facilities (61.4%) are located in one of the four pilot areas.  Beneficiaries would be automatically enrolled effective January 1, 2014.

AHCA Comments on Observation Stay Proposed Rule

Published in September 5, 2012 Issue

AHCA expressed appreciation to CMS for the renewed interest in the plight of beneficiaries denied Medicare coverage for post-acute care because the time they spent in the hospital was in an observation stay. The comments acknowledged that CMS is faced with many problems regarding proper categorization of medical services provided within the four walls of a hospital. In order to cope with and address these problems, CMS has over the years developed policies regarding hospital "transfers," three-day windows, inpatient only stays and more.

CMS Removes ZPIC Prepayment Review

Published in August 29, 2012 Issue

Zone Program Integrity Contractor (ZPIC) evaluations have been occurring throughout the country, including Virginia.  A high number of evaluations have been focused on facilities in Florida. Over the past few months, the American Health Care Association (AHCA) has been working with the Florida Health Care Association (FHCA) to communicate to the Centers for Medicare and Medicaid Services (CMS) concerns with several aspects of the evaluation process, including the prepayment review audits conducted by Medicare Administrative Contractors (MACs), as instructed by ZPICs.  AHCA and FHCA recently had a joint conference call with CMS Administrator Marilyn Tavenner and reiterated concerns with the ZPIC encouraged MAC prepayment audits, as well as concerns with the general lack of transparency and communication between the ZPICs and providers. 

CMS Releases Schedule for Manual Medical Review Phase-In

Published in August 29, 2012 Issue

The Middle Class Tax Relief and Job Creation (MCTRJC) Act of 2012 extended the Medicare Part B outpatient therapy cap exceptions process through December 31, 2012.  Through the exceptions process, providers may receive payment for therapy services above the $1,880 cap on outpatient therapy (OT), and the $1,880 cap on physical therapy (PT) and speech language pathology (SLP) services combined, when they are reasonable and medically necessary, require the specialized skills of medical professionals, and are justified by supporting documentation in the patient’s medical record. The MCTRJC Act also required that providers submit a request for an exception for therapy services above the threshold of $3,700 for OT, and $3,700 for PT and SLP services combined. These requests for exceptions will be manually medically reviewed. Providers will be required to submit requests for exceptions to the threshold in advance of furnishing therapy services above the threshold.

Palmetto Announces Part A/B 2012 Fall Tour Workshop Series

Published in August 29, 2012 Issue

Palmetto GBA has announced its 2012 Fall Tour Workshop series.  Providers are invited to join as they discuss Medicare coverage and billing updates, as well as clinical and documentation information affecting the Medicare provider community. The target audience includes Part A hospital and skilled nursing facility (SNF) providers and all Part B provider specialties.

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Compliance Program Alert

Published in August 22, 2012 Issue

Written by Martin A. Donlan, Jr., Esquire

Nursing homes now face audits by Medicare and Medicaid recovery audit contractors (“RACs”) (overpayment auditors), Medicare and Medicaid integrity contractors (fraud auditors), as well as standard Medicare and Medicaid cost report and utilization review auditors such as PHBV Partners, LLP (formerly, Clifton Gunderson, LLP) who are ever more aggressive than in the past.  These auditors rely upon their successful retraction of payments for their continued contracting, not to mention that some receive direct incentive payments.  Accordingly, the scrutiny of your medical and billing records will now be more intense. 

Federal Benefit Paper Checks Switching To Electronic Direct Deposit by March 1, 2013

Published in August 22, 2012 Issue

The Treasury Department is phasing out paper check payments and requiring federal benefit recipients to receive payments electronically. Residents can choose to get their payments by direct deposit to a bank or credit union account or to a Direct Express® Debit MasterCard® card account.

2013 Medicare SNF Rate Calculation Model Available

Published in August 15, 2012 Issue

The updated federal fiscal year 2013 Medicare Skilled Nursing Facility RUGs IV payment rates will be implemented on October 1, 2012.  Associate member Walker-Phillips Healthcare Consulting, a certified public accounting and healthcare consulting firm that focuses on Medicare and Medicaid payment and related services to long term care facilities is making available their RUGs IV rate calculation model.

CMS Announces SNF Payment Increase

Published in July 31, 2012 Issue

The Centers for Medicare and Medicaid Services (CMS) will increase Skilled Nursing Facility (SNF) Medicare payments by 1.8% in fiscal year 2013. In a notice published on July 27th, CMS indicated that the cumulative $670 million pay hike will take effect on October 1, 2012.

DMAS Holds Dual Demonstration Care Coordination Workgroup Meeting

Published in July 31, 2012 Issue

The Virginia Department of Medical Assistance Services (DMAS) held a workgroup meeting in Richmond on Friday, July 27th intended to begin a discussion about issues related to service coordination within the proposed Dual Eligible Demonstration. The workgroup members included advocates, managed care organizations that have expressed an interest in participating in the Demonstration, public and governmental agency representatives and providers.  Provider groups represented on the workgroup included nursing facilities, hospitals, home care and hospice, PACE centers, adult day care centers and personal care providers.  Physicians were not represented on the workgroup.

CMS Releases 5010 Implementation Reminder

Published in July 25, 2012 Issue

In June, the Centers for Medicare & Medicaid Services (CMS) released an updated and revised document in MLN Matters regarding the enforcement of the Health Insurance Portability and Accountability Act (HIPAA) 5010 transaction standards that became effective July 1, 2012.  As providers know, Medicare (in most instances) requires the use of electronic claims in order for providers to receive Medicare payments; providers must now submit these claims electronically using the Accredited Standards Committee Version 5010.  This MLN Matters document reminds long term care providers that the implementation of HIPAA 5010 presents substantial changes in the content of the data that providers submit with claims, as well as the data available to providers in response to electronic inquiries.  The implementation requires changes to the software systems and perhaps procedures that providers use for billing Medicare and other payers.  Most of these changes have already been implemented by provider’s vendors.  To obtain a copy of the document, click here.

OIG Report On Medicare Payment for Prescription Drugs for Beneficiaries in Hospice Released

Published in July 13, 2012 Issue

The OIG has just issued a report, Medicare Could Be Paying Twice for Prescription Drugs for Beneficiaries in Hospice (A-06-10-00059)06-28-2012), on Medicare payment for hospice drugs.   While it may not appear to be pertinent to SNFs on its face, the report illustrates the OIG focus and scrutiny on hospice.   SNFs  who are also hospice providers may want to review the report as well as SNFs who contract with hospice provider.  The Executive Summary includes the following information.

CMS Posts Proposed Rule Addressing Bad Debt Reimbursement Reduction

Published in July 6, 2012 Issue

The federal government requires that beneficiaries who receive care in a skilled nursing facility (SNF) must pay their Medicare co-pay on the 21st day of a Medicare-qualified stay. These beneficiaries are either seniors solely on Medicare, or seniors who qualify for both Medicare and Medicaid, known as dual eligibles. Very rarely are these beneficiaries financially able to cover the co-pay. In particular, dual eligibles, by definition underprivileged, account for more than 90 percent of the bad debt incurred in SNFs. This leaves a gaping hole for SNFs that must recover the costs of providing care to these vulnerable seniors.

New Five-Star Ratings for Individual Facilities

Published in June 29, 2012 Issue

The American Health Care Association (AHCA) has notified us that as of last week nursing facilities were able to access their new Five-Star rating and quality measure information via the CASPER on-line reporting system.  The Centers for Medicare & Medicaid Services (CMS) announced that they anticipate releasing this information publicly via Nursing Home Compare  on July 19th.  Changes to the Nursing Home Compare website that facilities and consumers will see as of that date include updates to the look, feel and some functionalities as well as new information, including:

Congress Requests Review of Medicare Oversight Efforts

Published in June 29, 2012 Issue

Members of the Senate Finance, the House Energy and Commerce and the House Ways and Means Committees – those with jurisdiction over Medicare in the United States Congress and with responsibility for oversight of the Centers for Medicare & Medicaid Services (CMS) and the federal health care programs administered by CMS have requested that the Government Accountability Office (GAO) conduct a study regarding coordination of the various audits that are being conducted in the Medicare program.

DMAS Submits Modified Dual Eligible Proposal to CMS

Published in June 1, 2012 Issue

On May 31st, the Department of Medical Assistance Services (DMAS) submitted its proposal to the Centers for Medicare and Medicaid Services (CMS) to implement a Dual Eligible Integration Demonstration in Virginia.  Based upon communications between VHCA’s Ad-hoc Medicaid Managed Care Committee and DMAS, the Department incorporated two key changes requested by VHCA in their final proposal.  The proposal now contains a provision that managed care organizations (MCOs) must enter into provider contract with any willing nursing facility that has a Medicaid provider agreement in place.  Additionally, under the Demonstration, MCOs must pay no less than the equivalent fee for service Medicaid rate payment as determined by DMAS.

CMS Pilot Overview for Staffing Payroll Participants

Published in May 24, 2012 Issue

The Centers for Medicare & Medicaid Services (CMS) is seeking nursing homes to participate in the Payroll Based Nursing Home Staffing Data Collection (PBNHSDC) Pilot.  This pilot is testing a method to measure staffing turnover, retention and levels quarterly from payroll data.  CMS intends to implement this data collection process nationally in late 2013 or early 2014. 

CMS Issues Update on the Use of Physician Assistants to Perform SNF Level of Care Certifications and Recertifications

Published in May 11, 2012 Issue

Change Request (CR) 7701 implements Section 3108 of the Affordable Care Act. This section adds physician assistants to the list of practitioners who can perform SNF level of care certifications and recertifications. Performing this function is a requirement for Medicare coverage of Skilled Nursing Facilities (SNF) services under Part A.

AHCA Optimistic About SNF Rate Increase

Published in April 26, 2012 Issue

We’re passing along some information provided yesterday, April 25th, by American Health Care Association (AHCA) President Mark Parkinson.

With respect to Medicare payment to skilled nursing facilities, rather than a proposed rule, the Centers for Medicare and Medicaid Services (CMS) will be issuing an Update Notice for the SNF Prospective Payment System (PPS) for FY 2013. The agency plans to publish this notice on or before July 31, 2012. This indicates that there will be no policy changes that would have required a Proposed Rule and a comment period.  Instead, the market basket update, along with a subtraction from the required productivity adjustment, will be announced.

Initial Observations on the DMAS Dual Eligible Demonstration Draft Proposal

Published in April 20, 2012 Issue

The Virginia Department of Medical Assistance Services (DMAS) posted its Dual Eligible Demonstration draft proposal to the Center for Medicare and Medicaid Innovation (CMS) as scheduled on April 13th.

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VHCA and DMAS Meet to Discuss Dual Eligible Payment Demonstrations

Published in April 13, 2012 Issue

The Virginia Health Care Association’s Ad-Hoc Committee on Managed Care held its initial meeting on Wednesday, April 4, 2012 in the association’s office in Richmond.  For this meeting, committee members were joined by Cindi Jones, Director of the Department of Medical Assistance Services (DMAS) and other senior staff from the Department. 

Free ZPIC Webinar in April

Published in April 13, 2012 Issue

Mark your calendar!  Reed Smith attorneys Scot Hasselman and Rahul Narula are speaking at an upcoming American Health Care Association Zone Program Integrity Contractors (ZPIC) Webinar, Navigating ZPIC Audits: Challenges and Solutions for LTC Providers, on April 24, 2012, 2:00 PM, ET.  Currently, ZPICs are conducting audits in healthcare facilities across the U.S., including SNFs. ZPICs replaced CMS’ Program Safeguard Contractors (PSCs), and are investigating potential fraud in the Medicare program by instituting both post- and pre-payment audits to review the integrity of the claims. ZPIC contracts include work for all Medicare claim types including Part A, Home Health, Hospice, Part B, Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS), Managed Care (Part C), Prescription Drug (Part D) and Medicare and Medicaid Data Matching. While ZPIC audits are similar in many ways to other Medicare audits currently being performed nationwide; they differ in one important aspect – they are not random. If a LTC provider is contacted by a ZPIC; the auditor already suspects coding and billing irregularities. Please click here to register for the webinar and to learn more about ZPIC audits and how to prepare for these audits.

Medicare Recovery Auditor Webinars Beginning Next Week

Published in March 30, 2012 Issue

The American Health Care Association (AHCA), along with the Centers for Medicare & Medicaid Services (CMS) and Recovery Auditors (RA) (previously known as Recovery Auditor Contractors [RACs]), are hosting four separate webinars, entitled “Medicare Recovery Auditor (RA)/SNF Update,” to provide relevant information on the Medicare RA program.  As you know, the Medicare RA program was made permanent under the Tax Relief and Health Care Act of 2006, and required all 50 states to implement the program no later than December 31, 2010.  Under the RA program, each RA is responsible for one fourth of the US and is accountable for identifying both Medicare overpayments and underpayments for the federal government. RAs are paid on a contingency basis depending upon how many overpayments they identify. We hope these RA webinars help providers to better understand, prepare and avoid program audits.

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DMAS Holds Initial Dual Eligible Stakeholder Meetings

Published in March 23, 2012 Issue

On Wednesday, March 21st the Department of Medical Assistance Services (DMAS or the Department) held the first in a series of meetings intended to gain stakeholder involvement and support for its proposed plan to integrate care for Medicare-Medicaid enrollees or dual eligibles.  Two sessions were held on the 21st – a two-hour general information session followed by a meeting focused on issues related to nursing facilities and hospitals.

AHCA to Host Medicare RA Program Update Webinars

Published in March 23, 2012 Issue

Mark your calendar!  The American Health Care Association (AHCA), along with the Centers for Medicare and Medicaid Services (CMS) and Recovery Auditors (RA) (previously known as Recovery Auditor Contractors [RACs]), are hosting four separate webinars, entitled “Medicare Recovery Auditor (RA)/SNF Update,” to provide relevant information on the Medicare RA program.  As you know, the Medicare RA program was made permanent under the Tax Relief and Health Care Act of 2006, and required all 50 states to implement the program no later than December 31, 2010.  Under the RA program, each RA is responsible for one fourth of the US and is accountable for identifying both Medicare overpayments and underpayments for the federal government.  RAs are paid on a contingency basis depending upon how many overpayments they identify.  We hope these RA webinars help providers to better understand, prepare and avoid program audits.

CMS Announces Initiative to Reduce Avoidable Hospitalizations among Nursing Facility Residents

Published in March 23, 2012 Issue

This new effort aims to improve the quality of care for people residing in nursing facilities. The Centers for Medicare & Medicaid Services (CMS) is currently accepting applications to participate in this initiative.

CMS will support organizations that will partner with nursing facilities to implement evidence-based interventions that both improve care and lower costs.  The initiative is focused on long-stay nursing facility residents who are enrolled in the Medicare and Medicaid programs, with the goal of reducing avoidable inpatient hospitalizations. This initiative supports the Partnership for Patients' (http://innovation.cms.gov/initiatives/Partnership-for-Patients/index.html) goal of reducing hospital readmission rates by 20% by the end of 2013.



Medicare CMS-855 A Application Process

Published in March 16, 2012 Issue

In a communication last week from the Centers for Medicare and Medicaid Services (CMS) to the American Health Care Association (AHCA), CMS outlines a number of measures being taken to address noted deficiencies in the Medicare CMS-855 A process.  AHCA’s earlier request for CMS action focused on the following areas:

  • Improve the Medicare CMS-855 A application process by creating separate Medicare forms for changes of ownership and information for initial enrollments,
  • Host webinars for Medicare Administrative Contractors  (MACs) and providers with easy to follow instructions from one source,
  • Improve the overall Medicare enrollment process by requiring the MACs to follow a consistent set of guidelines and to require them to follow CMS guidance,
  • Require the MACs to confirm application receipt; provide a contact person, and create an Internet-based electronic filing and tracking tool.


MDS 3.0 Quality Measure Manual

Published in March 16, 2012 Issue

The Centers for Medicare & Medicaid Services recently posted the MDS 3.0 Quality Measures User’s Manual (v 5.0 03-01-2012) on their website.  The measures, recommended by the NQF Steering Committee for the Development of MDS 3.0 Quality Measures (QMs), were tested by CMS contractor RTI International. Chapter I of the manual includes the QM Sample, Record Selection Methodology and definitions for long and short-stay. Chapter 2 addresses the specifics of each of the  MDS 3.0 measures identifying the numeration and denominator and any exclusions and covariates. The last section, Appendices A-E include the Technical Details, Parameters Used for Each Quarter, Episode and Stay Determination, Measures Withdrawn from NQF Submission, and the Surveyor Quality Measures.



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Update on DMAS Dual Eligible Integration Pilots

Published in March 9, 2012 Issue

Cindi Jones, Director of the Department of Medical Assistance Services (DMAS), recently announced that Virginia plans to move forward with three geographic pilot programs designed to better coordinate the care provided to Medicare-Medicaid enrollees.  It is our understanding that DMAS intends to pursue managed care pilot programs in the Northern Virginia, Richmond/Charlottesville and Tidewater regions of the Commonwealth.  Under the pilot programs, long term care services provided to dual eligible (Medicare-Medicaid) enrollees would likely be coordinated and paid for by managed care organizations who have been awarded a three-way contract between the Center for Medicare and Medicaid Services (CMS), DMAS and the health plan.  According to Ms. Jones, DMAS is planning to pursue pilot programs that would automatically enroll all dual eligible beneficiaries within the designated geographic regions and that an opt-out provision would likely be available.

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DMAS Moving Forward With Dual Eligible Integration Pilots

Published in March 2, 2012 Issue

During last week’s VHCA/VCAL Legislative Conference in Richmond, Cindi Jones, Director of the Department of Medical Assistance Services (DMAS), announced to attendees that Virginia plans to move forward with three geographic pilot programs designed to better coordinate the care provided to Medicare-Medicaid enrollees.  According to information provided by the American Health Care Association (AHCA), 23 states are either planning for some form of Medicaid managed care for long term care services or have already implemented managed care programs.

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Conference Committee Actions Impact Medicare Payment

Published in February 17, 2012 Issue

We are reproducing yesterday’s letter from American Health Care Association (AHCA) President Mark Parkinson addressing actions of the Conference Committee.

We Need Your Voice!

Published in January 27, 2012 Issue

To echo the old quote that just showing up is a significant part of achieving success, we need all members to be in Richmond next month to meet with legislators in person and to describe for them the real world consequences of trying to deliver high quality long term care services while Medicaid payment rates are facing a fifth consecutive year of cuts.  Your voice is critical!  

ACTION Needed: Tell Congress to Oppose Reductions to Nursing Facility Bad Debt Reimbursement

Published in January 27, 2012 Issue

With the full Congress back in Washington, House and Senate Conferees are meeting daily to resolve the payroll tax cut controversy, provide a doc fix, and possibly extend the therapy cap exceptions process. With the March 1 deadline getting closer with each passing day, we must weigh in on the impact of the current Medicare bad debt payment policy on our profession.