Kristin Rowan, Author at The Rowan Report

Home Care Patient Dies in Care: Aide Arrested

by Kristin Rowan | Oct 10, 2024 | Clinical, Regulatory

by Kristin Rowan, Editor

Elderly Patient Needs 24-hour Care

In Polk County, FL, an 86-year old man, identified only as Mr. Anderson, was hopsitalized and diagnosed with congestive heart failure. In addition to receiving care from Good Shepherd Hospice, his family hired round-the-clock care through Assisting Hands. The home health aides were caring for Mr. Anderson in 12-hour shifts.

Night Shift

Beatrice Taylor arrived for her night shift at 9 p.m. She noted that Mr. Anderson and his wife were already in bed, but not sleeping. Shortly after the day aide left, Taylor fell asleep on the couch in the living room of the patient’s home. Company policy states she was responsible for the patient’s care and should not have been sleeping.

An Avoidable Tragedy

Taylor was awakened by a “thump” coming from the bedroom. She entered the bedroom to investigate and found Mr. Anderson lying on his side, on the floor, with his head wedged between the nightstand and the bed. Taylor told investigators that she tried to help him back into the bed. He told her not to touch him, so she left him there and went back to sleep on the couch. She did not call 911, as was the policy of Assisting Hands in the event of an emergency. Nor did she call her agency or anyone else to assist.

Four Hours Later

Taylor woke up somewhere between 3:45 a.m. and 4:53 a.m. that morning. At some point, she called her parents and had a 36 minute conversation. During that conversation, she decided to check on the patient and found him still on the floor, but now unresponsive. It was her parents who suggested she call 911.

Contrary to both her parents’ urging and her employer’s policy, Taylor still did not call 911. Instead, she called Assisting Hands and left a message through the company portal. Taylor finally called 911 at 5:37 a.m., more than four and a half hours after Mr. Anderson fell.

The implanted pacemaker found during autopsy showed that Mr. Anderson was still allive at 1:oo a.m. when Taylor initially found him. The autopsy also concluded that he would have survived if Taylor had called 911 right away. His official cause of death was positional asphyxia with pre-existing health conditions listed as contributory causes.

Not actual image from story

Company Policies Broken

During the course of their investigation, detectives reviewed the Assisting Hands employee policies. That investigation uncovered several policies that Taylor violated:

If a patient falls, home aides are required to seek help which may entail calling 9-1-1. Home aides must notify the company as soon as the patient is safe
Home aides are not permitted to sleep during their assigned shift unless it is a “live in” shift
Home aides are required to submit care notes using the company portal throughout their shift to ensure assigned services are being followed appropriately.

The 911 call that Taylor placed at 5:37 a.m. should have been placed at 1:00 a.m.
Assisting Hands confirmed to detectives that this was not a “live in” shift
No information was provided as to whether Taylor submitted care notes during the shift.

Arrested Development

Taylor worked for Assisting Hands for eight months, but did not show up for her shift following the incident with Mr. Anderson. Assisting Hands has since terminated her employment. She was a licensed home health aide, but does not have a medical license, nor is she a nurse.

Taylor was arrested by detectives and made several statements about her innocence. She insisted she had done nothing wrong saying she, “didn’t kill that man.” A paramedic who responded to her 911 call overheard Taylor on the phone say, “he was old anyway so what does it matter.” Taylor remains in custody at the Polk County Jail and is being held without bond.

Polk County Sheriff

“The complete disregard for Mr. Anderson’s life by the person who was employed by his family is completely outrageous, and egregious. I believe someone who was not even being paid to look after this elderly man would have immediately dialed 9-1-1 under these circumstances. Her behavior and attitude are simply deplorable. Mr. Anderson’s family members are in our prayers.”

Grady Judd

Sheriff, Polk County Sheriff's Office

Risk Fall

In 2021, more than 38,000 older adults died from falls. This is the leading cause of injury death for adults aged 65 and older. The death rate increased 41% between 2012 and 2021. You can read more about the risk of falling and what one company is doing to help prevent falls in our accompanying article this week, an interview with Dr. Ann Wells of InnovAge.

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Kristin Rowan has been working at Healthcare at Home: The Rowan Report since 2008. She has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in event planning, sales, and marketing strategy. She has recently taken on the role of Editor of The Rowan Report and will add her voice to current Home Care topics as well as marketing tips for home care agencies. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

National PACE Awareness and National Fall Prevention Month

by Kristin Rowan | Oct 10, 2024 | Advocacy, Clinical

by Kristin Rowan, Editor

New Fall Prevention Study: An Interview with Dr. Ann Wells

Fall Prevention Month

September was National Fall Prevention month. Accidental falls are the number one cause of injury and death among adults over the age of 65. Fall Prevention month attempts to raise awareness on preventing falls, reducing the risk of falls, and helping older adults live without the fear of falling. The National Council on Aging also promotes advocacy on behalf of fall prevention funding and offers training and other materials to help prevent falls. Read our complimentary article this week about a nurse charged in the death of a patient who fell here.

National PACE Awareness Month

September was also PACE Awareness Month. The Program of All-Inclusive Care for the Elderly )PACE) is a Medicare and Medicaid program that helps seniors with long-term care needs to live independently and age in place. The program includes an interdisciplinary team of professionals working together to coordinate care. There is no co-pay, deductible, or coverage gap and the amount paid each month doesn’t change, no matter what care services the patient needs. All Medicare and Medicaid services are covered as well as medically-necessary care and services that are not typically covered. Coverage includes prescription drugs, doctor care, transportation, home care, checkups, hospital visits, and nursing home stays when necessary. Access more information about PACE here.

InnovAge has been tapped to participate in a fall prevention study. The study is conducted by LeaHD, a research and training center established in partnership with Brown University, Boston University, and University of Pittsburgh in the Center on Health Services Training and Research. The Rowan Report sat down with Dr. Ann Wells, Chief Quality and Population Health Officer of InnovAge. Dr. Wells said of the study, “[it] will help us better understand the multi-faceted factors contributing to falls among seniors and develop intervention strategies tailored to their unique needs.”

Dr. Ann Wells, Chief Quality and Population Health Officer

Rowan Report:

Dr. Wells, thank you for taking the time to speak with me today. Why don’t we start with a little background on you. How did you come to be involved in elder care and PACE programs?

Dr. Ann Wells:

By trade, I am in internal medicine doctor, focused on the geriatric population. I have spend 20 years in medical leadership working in population health. Population health is the approach to healthcare that evaluates and improves outcomes in subgroups with similar needs and the populations as a whole through team care and analytics. Through my work in medical leadership and population health, I was approached by InnovAge to be part of their leadership team.

RR:

You mentioned the PACE program. What do you think is the key difference, or differences, between PACE programs and other types of senior care?

Ann:

The PACE model is health care’s best kept secret and we don’t want it to be a secret anymore. Most patients and families don’t want institutional care. 86% of seniors value remaining in the communities in which they live.

In order to qualify for PACE programs, the patient has to qualify for nursing home levels of care. The program delivers services designed to help them stay in the community. PACE leverages an 11-member interdisciplinary team that includes a primary care provider, a registered nurse, a driver, a master-level social worker, PT, OT, a dietician, a PACE center manager, a home care coordinator, and a personal care attendant. The team coordinates care for medication, medical care and transportation with wrap-around social support and in-home support to help with bathing, shopping, and dressing. They also coordinate specialty care, make appointments with contracted specialists, provides transportation and a chaperone if needed, sends medical records in advance of the appointment, and gets notes back from the specialist.

Participants can come to a center for primary care, PT, or OT. They can also enjoy the center for socialization and activities. Patients provide permission to talk to each caregiver to make sure they are getting the care they need. Almost 90% of patients are dual-eligible. Roughly 10% are Medicaid only. The small remainder are Medicare only and pay the difference out of pocket.

RR:

There is a lot of information about the PACE program that I didn’t know before. Thank you for that. Can you tell us a little about InnovAge?

Ann:

InnovAge is the largest provider of the PACE program based on number of participants. They are both a delivery arm and a health plan. InnovAge administers care from 20 centers in six states.

RR:

And what your role is as Chief Quality and Population Health Officer?

Ann:

The Clinical Value Initiative aims to ensure the company is managing revenue and participant expenses including risk adjustments, ensuring the most accurate risk score, resource management, payment integrity or a claims audit process, and network optimization. Through these initiatives, the average inpatient rate for hospital admissions was 5.5% and the average time from enrollment to placement in a nursing home is three years. These initiatives and the PACE program are reducing hospitalizations for participants and keeping patients in their homes and in their communities longer.

RR:

September was National Fall Prevention Month. The number of injuries and deaths due to falls among seniors over age 65 is staggering. But, InnovAge, using the PACE model, has reduced falls. How does that program work?

Ann:

Any fall that has a major fracture is very difficult to recover from. InnovAge leverages the STEADI program. Stopping Elderly Accidents, Deaths, and Injuries (STEADI). This program includes screening, assessing, and intervening.

Screening

All participants are asked intake questions to screen for risk. Have you fallen in the last year? Do you have a fear of falling? Statistically, once a patient has fallen once, the risk is much higher for another fall.

Assessing

At enrollment, and again yearly, the patient receives an in-home assessment with an environmental safety evaluation. We look at things like lighting, rugs, grip bars, ramps, a non-slip rug in the bathroom. PACE arranges for installation and payment for any items they might need to lower the risk of falls. OT & PT conduct yearly evaluations as well. Do they need a walker? Do they have proper footwear? Have they had a recent eye screening and do they have glasses? They also evaluate leg strength and balance. If there is a deficit, the patient can do PT at the center.

In addition to the in-home assessment, we conduct a root cause analysis if there is a fall to determine why they fell and what they need to prevent a future fall. Clinical pharmacists also evaluate medicine regiments and optimize medications to reduce or eliminate side effects and improve safety.

Intervention

When there is a patient at high risk for a fall, due to any of the factors we find in the screening and assessment, we employ some intervention. PERS units, emergency alert pendants and wristwatches, are provided for high-risk patients. Units with fall detection and emergency activation buttons place automatic calls to a call center. The call center will try to contact the patient and send an ambulance if they can’t be reached or need assistance.

RR:

InnovAge has recently been selected to participate in a national study for the prevention of falls. Tell us about that study and how InnovAge will participate.

Ann:

LeaHD approached InnovAge to help improve their training for chronic care. InnovAge has a population that aligns with their research. The research topic is to evaluate whether they can predict risk of falling with new enrollees. From there, we will assess whether we can create more tailored interventions to lower risk. The hope is that the study will inform us, as an industry, what we should be asking a new patient to determine their actual risk of falling. In turn, the study will inform caregivers on how they can identify high risk patients and prevent future falls.

RR:

What is the timeline and goal of the study?

Ann:

The study will run for one year, starting in October, 2024. There is a data scientist working on the project who will conduct and write the study. We are hoping to publish sometime in 2026. The goal is finding interventions; gaining insight on which systems can be executed to reduce the risk.

RR:

That sounds fascinating. I can’t wait to read the results of the study. Is there anything else about InnovAge that you’d like to share?

Ann:

Just that our mission is to help seniors live independently in the community and to advocate for the PACE model of care. We are excited to have three new centers – one in California and two in Florida. The goal is to spread the PACE model and grow the individual centers. InnovAge is the largest provider of PACE based on number of patients enrolled. We are dedicated to expanding and serving more seniors across the country.

RR:

Thank you, Dr. Wells for your time and your insight. It’s been a pleasure talking with you. Please stay in touch and keep The Rowan Report updated on the progress of your study.

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CMS Ransomware Attack: Breach of PII

by Kristin Rowan | Sep 27, 2024 | Admin, Breaking News, CMS, Regulatory

by Kristin Rowan, Editor

CMS Ransomware Attack

In mid-2023, a planned file transfer went awry when Clop claimed to have breached hundreds of companies that they later listed on a data leak site. Among the companies listed were Shell, UnitedHealthcare Student Resources, The University of Georgia, and Putnam Investments. Also compromised were government entities including the U.S. Department of Energy. According to Clop, data from military sources, children’s hospitals, and other .gov sites was also copied. The ransomware group alleges they deleted all information from government, military, and children’s hospital sites.

Unfortunately, there is no way to confirm whether all that information was indeed deleted. Earlier this year, Change Healthcare suffered a similar widespread breach that caused massive payment delays for months. CMS provided guidance during those delays.

Underreporting of Attack

Many of the companies impacted by this attack chose to disclose the breach rather than negotiate with the ransomware attackers to retrieve the stolen data. When Bleeping Computer reached out to those companies immediately following the attacks, a number of them indicated that only a small number of people were effected and that no financial or identifiable information had been stolen. It seems, now, though that not all companies involved in the attack were on the initial list.

Wisconsin Physicians Service (WPS) health insurance corporation was among the companies not listed when news of this attack was first published. WPS provides Medicare administrative services to CMS, including handling Medicare Part A/B claims. In the first week of September, nearly 3-1/2 months after the attack, CMS and WPS started notifying beneficiaries whose protected health information (PHI) or other personally identifiable information (PII) may have been stolen during the attack.

1,000,000 Notifications

On July 28, 2023, CMS estimated 612,000 Medicare beneficiaries may have had PHI and/or PII exposed in the breach. That number has increased to almost 1 million. CMS and WPS are sending notifications to more than 950,000 people whose information has been compromised. The letter explains further:

May 31, 2023, MOVEit disclosed the breach to the public and released a patch.

June 2, 2023, WPS notified CMS of a data breach that occurred sometime between May 27 and May 31, 2023.

According to WPS, they applied the patch but did not observe any evidence of any files having been copied.

July 28, 2023 CMS sends an initial letter to beneficiaries whose information may have been affected.

May 2024, WPS acted on new information that led them to discover copied files from before the patch was deployed.

Of the portion of breached files that WPS studied, none were found to have personal information.

June 8, 2024, a different portion of the files showed personal information was contained in those files. This information includes:

Name
Social Security Number or Individual Taxpayer Identification Number
Date of Birth
Mailing Address
Gender
Hospital Account Number
Dates of Service
Medicare Beneficiary Identifier (MBI) and/or Health Insurance Claim Number

Note: in the initial letter sent to beneficiaries in July of 2023, CMS also listed Healthcare Provider, Prescription Information, Insurance Claims, Policy Information, Subscriber Information, Health Benefits, and Enrollment Information as possibly having been leaked. These items were removed from the list in the September 2024 version of the same letter.

For those who received this notification, CMS and WPS offered a complimentary year of credit monitoring from Experian. CMS also advised members to request their free credit report from each of the credit reporting companies.

The letter also informed members that they would soon receive a new Medicare card with a new Medicare Number. 946,801 people received this notice.

CMS Ransomware Attack Victims Not Notified

On September 24, 2024, Bleeping Computer reported that on the same day CMS sent more than 900,000 letters to members, they also reported to the Department of Health and Human Services that the total number of people with information stolen was 3,112,815. CMS explains the difference by saying the larger number includes Medicare beneficiaries, people who are deceased, and people who were covered by other providers but whose information was included in WPS data collection used for provider audits in their role as Medicare Administrative Contractors (MACs).

New MBIs and What it Means For You

According to a blog post dated September 26, 2024 from SimiTree, starting in mid-October, CMS will issue new Medicare cards with new Medicare Beneficiary Identifiers to the 946,801 Medicare beneficiaries who were previously identified as at risk and were notified of the breach. This may cause undue delays and other issues for home health and hospice providers.

Claim Rejection

If these beneficiaries use their existing MBI after the new one has been issued, providers could see rejections on NOAs, NOEs, OASIS submissions, and claims.

Urgent Reverification

Providers will need to reverify eligibility and update patient records in their EMR systems. Because providers were not notified of which beneficiaries were impacted, agencies will need to verify MBIs for every Medicare patient.

Possible Disruption

The full impact of reassigning MBIs to nearly 1 million Medicare beneficiaries is not yet known. Medicare has not clarified what will happen with claim processing for patients whose MBIs change during the claim processing for active patients. There are possibilities for delayed processing, delayed payments, and incorrect denial of services or payments due to the volume of MBIs changing at once.

How to Prepare

Our friends at SimiTree have some suggestions for how home health and hospice providers can prepare in advance for the MBI change coming around October 15-16, 2024.

Take Immediate Action – start reverifying eligibility for all Medicare patients now
Update Systems – ensure your EMR and other solutions in your tech stack are updated and ready to handle the changes
Train your Staff – make sure everyone on your team knows this change is coming and teach them new verification procedures so their patients aren’t left without care

CMS has not issued a statement about the impact of the MBI changes, but this story is ongoing and we will continue to monitor and report on any updates from WPS and CMS as well as look for additional information on the changes expected with the new MBIs.

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Another One Bites the Dust

by Kristin Rowan | Sep 20, 2024 | CMS, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Essentia Drops Medicare Advantage

Essentia Health is an integrated health system with locations in Minnesota, North Dakota and Wisconsin. The health system offers 285 different services across more than 1,700 locations. They employ more than 2,700 doctors. Essentia also includes 14 hospitals, emergency care, same-day care for mental health crises, and multiple specialties.

This is all to say that Essentia Health is not a small player. They contract with the largest payers in the industry.

Re-Evaluation

Recently, the health system began re-evaluating its participation in some Medicare Advantage plans. According to the chief medical officer for population health at Essentia, Cathy Cantor, M.D., M.B.A., too often deny or delay care. Cantor said in a statement:

“This was not a decision we made lightly. The frequent denials and associated delays negatively impact our ability to provide the timely and appropriate care our patients deserve. This is the right thing to do for the people we are honored to serve.”

Essentia informed patients that they will no longer be an in-network provider for MA plans through UnitedHealthcare (UHC) or Humana beginning January 1, 2025. The health system claims that UHC and Humana delay and deny approval of care at more than twice the rate of other Medicare Advantage plans. They are encouraging its patients to choose a different plan during open enrollment that is in-network with Essentia.

UHC Responds

UnitedHealthcare responded to the press release that Essentia issued. According to their statement, the two parties extended their contract just this past July. Negotiations included a number of items on which they agreed to collaborate, but Medicare Advantage was not specified among them.

“Essentia Health didn’t raise concerns regarding its participation in our Medicare Advantage network until last week. We have since met with Essentia on Sept. 9 and are committed to working with the health system to explore solutions with the goal of renewing our relationship. We hope Essentia shares our commitment toward reaching an agreement.”

Following Suit

Essentia’s departure from Medicare Advantage is just one in a recent mass exodus.

Sanford Health of South Dakota ended its Humana MA participation due to “ongoing challenges and concerns that negatively effect patients including ongoing denials of coverage and delays in accessing care.”

HealthPartners out of Minnesota announced over the summer that “UnitedHealthcare delays and denies approval of payment for MA claims at an exceptionally high rate…up to 10 times higher than other insurers…. After over a year of being unable to persuade UnitedHealthcare to change their practices, we’ve determined that we can no longer participate in the UnitedHealthcare Medicare Advantage network.”

Mercy, the official medical provider of the St. Louis Cardinals, announced its year-end departure from the Anthem Blue Cross Blue Shield network. This includes all Medicare Advantage, ACA marketplace, and managed Medicaid plans. They cited administrative tasks that create a barrier to timely, appropriate patient care. Mercy also complained that Anthem has raised its rates for patients and employers, increased its profits, and still has not raised reimbursement rates to providers. Like Essentia, Mercy is encouraging its patients to consider whether the health care plan they choose during open enrollment will list Mercy as one of its in-network providers.

Final Thoughts

CMS reimbursement rates, Medicare Advantage denials, payment delays, and other interruptions are impeding patient care. As Tim mentions in his editorial this week, we are in an election year and we urge you to research how each party might impact our industry.

If more providers and payors continue to drop Medicare Advantage from their offerings, will we see more patients returning to traditional Medicare plans with an affordable Medicare Supplement or MediGap coverage? One can only hope!

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Hospice Fraud Oversight

by Kristin Rowan | Sep 12, 2024 | Admin, CMS, Hospice, Regulatory

by Kristin Rowan, Editor

CMS Oversight in Fraud-Ridden States

In 2023, The Centers for Medicare and Medicaid Services (CMS) cited research suggesting that hospices profit from fraud far too often. CMS has identified cases of hospices certifying benficiaries who are not terminally ill, providing little to no services, and still billing CMS. Four states have had rapid growth in fraudulent hospices: Arizona, California, Nevada, and Texas.

Churn-and-Burn

Some of the registered hospices had non-operational addresses. This information led to an investigation that resulted in evidence of the fraud dubbed “Churn and Burn.” This scheme involves registering a new hospice and billing for services until there is an audit or the agency maxes out on yearly payments. Then, the hospice closes, keeps the money, registers for a new Medicare billing number, and starts all over again.

Program Integrity Strategy

As a result of the findings of this research, CMS put more effort behing the hospice program integrity strategy to find and address fraudulent activity. Part of the strategy was unannounced visits to hospices nationwide. Hospices not active at listed addresses were deactivated and Medicare billing privileges were revoked. Of the more than 7,000 hospices visited, 400 had potential administrative action pending.

Enhanced Oversight

In the four states identified as having higher instances of fraud, CMS implemented a provisional period of enhanced oversight. During the provisional period, CMS conducted a medical review prior to payment for hospices in these states that have identified problems.

Nationwide Pilot Project

In addition to the provisional period for the four identified states, CMS started a pilot project to review hospice claims after a patient’s intitial 90 days of hospice care. This pilot project was not limited to the four states, but was implemented nationwide. CMS launched the program to help inform medical reviews in determining whether hospices are submitting claims for eligible patients.

Regulatory Changes

CMS also proposed some regulatory changes to combat hospice fraud. Some of these regulatory changes were initially suggested by hospice providers. The proposals include:

- Prohibiting the transfer of Medicare billing privileges of a new hospice for 36 months
- Clarifying the definition of “Managing Employee” to include the administrator and medical director of a hospice
- Implementing a Special Focus Program to increase oversight on poor-performing hospices that have ongoing health and safety deficiencies
- Adding criminal background checks for owners when they initially enroll for Medicare billing privileges.

Prepayment Review Expanded

CMS has just announced that they will expand the prepayment review process in the four states beginning in September, 2024. Information from CMS is limited and states that prepayment review volume will start low to protect compliant hospices, but will increase if a hospice is found to be non-compliant. Consequences for non-compliance includes delays in payment, extended review, or additional administrative actions.

According to preliminary information we received from a hospice consultant, the expanded program puts all new hospices or hospices with ownership changes into prepayment review even if they have not had identified problems.

We have reached out to both CMS and some of our expert hospice consultants to get more information and will update this story as information becomes available.

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NHPCO and NAHC Announce New Name and Website

by Kristin Rowan | Sep 12, 2024 | Advocacy, Breaking News, Regulatory

by Kristin Rowan, Editor

The Alliance

Since the announcement that the National Hospice and Palliative Care Organization and the National Association for Home Care and Hospice would merge, the default name for the combined entities has been “The Alliance.” NAHC President Bill Dombi and Interim NHPCO CEO Ben Marcantonio, along with a transition board and other members have been working since August of 2023 on the merger. In June of 2024, the two organizations signed an official affiliation agreement.

Alliance Updates

In the last year, the two organizations have spoken about the work they’ve been doing to create the new affiliation. They jointly hosted a town hall to answer questions, and Bill Dombi has spoken at state and national association meetings about the merger. On August 26, 2024, The Alliance named its inaugural CEO, Dr. Steven Landers.

National Association for Care at Home (NACH)

Our industry loves its acronyms and this one rolls off the tongue like we’ve been using it for years. Although, we may all need to perfect the German guttural sound to differentiate it from NAHC.

In a press release on Sept. 5, 2024, the two associations officially announced that The National Alliance for Care at Home (NACH) is the new name of the combined organizations. Along with this announcement, The Alliance has also launched its new logo (below) and new website at www.AllianceForCareAtHome.org.

From The Alliance

Statements from both organizations outline the path forward and the mission and vision for the new affiliation:

- The National Alliance for Care at Home will Combine the Strengths of the Two Largest National Organizations Representing Healthcare Providers Delivering Care Primarily in Homes
- The Alliance Will Provide Unparalleled Resources and Representation to Support the Care-at-Home Community
- This Alliance will be the leading authority on transforming care in the home. We will implement that mission under a new name that welcomes providers across the care continuum to join – the National Alliance for Care at Home
- The Alliance will be your advocate, your resource, and your network to help you reach your goals

The new logo for NACH is, according to the press release, both an homage to the past and a symbol for the future. It creates a visual representation of both NAHC and NHPCO. The star shape of the logo is representative of the stars on the American flag, part of the NAHC logo. The visual aesthetic of the logo is reminiscent of the lotus flower from the NHPCO logo. The individual sections of the logo represent people holding hands, the visual representation of the coming together of types of care. The white space in the middle is meant to symbolize a house or home.

The logo is based on guidance from a workgroup comprised of members from both organizations, whose input has helped shape the Alliance brand.

About Us

This press release also included a new boilerplate, describing the National Association for Care at Home, rather than two separate descriptions of each organization. This is probably still a temporary description, as it mentions that they are still in the process of combining operations and Communications Officers from both separate organizations are listed as press contacts.

More to Come

Despite the announcement of the new CEO and the new name, the merger is far from over. There are logistical and operational hurdles still to overcome, a new board to enstate, the combining of assets and competencies, and a restructuring of existing employees. We will continue to report on press releases coming from NACH.

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HHA to pay Nearly $4 Million after False Claims Act Violations

by Kristin Rowan | Aug 23, 2024 | Regulatory

by Kristin Rowan, Editor

False Claims Act Violations

According to allegations in U.S. es rel. Jones v Intrepid U.S.A. Healthcare Inc. and U.S. es rel. Rigney v Intrepid U.S.A. Inc., Intrepid U.S.A. Inc. (Intrepid) violated the False Claims Act multiple times over five years.

Intrepid is based in Texas and includes more than 80 Personal Care, Home Health, Palliative Care, and Hospice Care agencies across 18 states. Intrepid describes their services as “concierge medical home healthcare, hospice at home, private duty home care, and independent living support.”

Whistleblowers

Whistleblowers filed Civil cases against Intrepid under the whistleblower provisions of the False Claims Act. A former travel nurse and a former Director of Quality and Improvement for Intrepid filed the first case. A former Director of Clinical Excellence and Integrity and a former Regional Manager of Clinical Excellence for Intrepid filed the second. Under the False Claims Act, a private party can file an action against a company on behalf of the United States. Should there be a settlement or resolution, the filing party(ies) receive a portion of any recovery.

Allegations

Each of the cases addresses different lines of business for Intrepid. The first case alleges that Intrepid knowingly submitted home healthcare Medicare claims for patients who did not qualify for the home healthcare benefit, or where services did not qualify for reimbursement. The second case alleges that Intrepid knowlingly submitted Medicare claims for patience who did not qualify for the hospice benefit.

More Allegations

Additionally, the United States claims that from 2016 to 2021, Intrepid submitted claims for services that were not reasonable or medically necessary, services provided by untrained staff, and services that were never provided at all. Separately, the United States alleges that Intrepid admitted patients who were ineligible for hospice benefits because they were not terminally ill and continued providing services to patients who should have been discharged because they no longer met the requirements to qualify for the hospice benefits.

Settlement

The Justice Department’s Civil Division, Commercial Litigation Branch, Fraud Section, the U.S. Attorney’s Office for the Western District of Kentucky and U.S. Attorney’s Office for the District of Minnesota worked together to investigate and resolve these matters. According to the Department of Justice report, no liability or admission of guilt was determined and the settlement resolved allegations only.

Repeat Offender

It seems this is not the first run-in with the law that Intrepid U.S.A. has faced.

2014: a class action suit alleged unpaid wages.

2019: Intrepid settled a class action suit where employees alleged unpaid overtime.

2021: William Buchanan filed a civil right – employment discrimination suit against Intrepid in Indiana.

Intrepid in Minnesota and North Carolina faced similar Medicare fraud charges as well.

Not Alone

Intrepid U.S.A. Inc. is not the only home health or hospice agency to face these types of allegations.

Evolution Health LLC

In July, 2024, Guardian Health Care, Inc., Gem City Home Care LLC, and Care Connection of Cincinnati LLC, together with their parent company Evolution Health LLC, settled a False Claims Act case in which the Companies were accused of providing illegal kickbacks to ALFs and physicians in exchange for referrals. That settlement totaled almost $4.5 million dollars.

Halo Home Healthcare

Similarly, in June, 2024, the former owner of Halo Home Healthcare pled guilty to billing more than $8.5 million in fraudulent claims to Medicare, Medicaid, and Veterans Affairs from 2015 to 2021. Halo Home Healthcare hired more than 50 employees with criminal backgrounds that should have excluded them from providing home health services, one of whom was charged with a quadruple murder during their employment at Halo. The former owner also hid her ownership of the company because she had been convicted in 2013 of passing forged and fraudulent prescriptions for oxycodone and hydrocodone.

Atlantic Home Health Care

In January, 2024, Atlantic Home Health Care was accused of falsely billing the Energy Employees Occupational Illness Compensation Program. The claim alleges Atlantic charged for in-home nursing and personal care when employees weren’t providing services and paying kickbacks for patient referrals. The Arizona-based company paid almost $10 million to resolve that case.

Speak Up, Speak Out

Fraudulent billing, up-coding, and other illegal acts from home health and hospice agencies put additional strain on the already stretched CMS budget for reimbursement. The millions of dollars recovered just this calendar year is just a portion of fraudulent claims filed. Whistleblower laws protect employees from retaliation by their employers. Fraudulent practices that send money directly to an agency without benefitting a patient hurts the whole industry. The only way the Department of Justice can address and stop these billing practices and keep that money going directly to patient care is with the help of whistleblowers.

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HHVBP Model Payments Begin January 1, 2025

by Kristin Rowan | Aug 23, 2024 | Admin, CMS, Regulatory

by Kristin Rowan, Editor

Background on the HHVBP Model

The Home Health Value Based Purchasing (HHVBP) Model, implemented by CMS in 2016, began in nine states. The goal is “to provide incentives for better quality care, to study new quality and efficiency measures, and to enhance the reporting process.” It may also provide new avenues for payment models.

According to the CMS website, the original HHVBP Model, launched in nine states, improved an average of 4.6 percent HHA performance scores and saved Medicare $141 million. Additionally, the model lowered unplanned hospitalizations for acute care and reduced skilled nursing facility (SNF) stays.

HHVBP Model Expansion

From the initial study, CMS surmised that expanding the model would increase performance, increase savings, and further reduce hospitalizations and SNF stays. Early in 2021, CMS announced the nationwide expansion of the HHVBP Model.

The expanded model started on January 1, 2022. In its first expansion year, CMS provided training and allowed HHAs time to adjust practices based on HHVBP expectations and requirements. During the transition year, HHA performance did not risk future payment rates.

HHVBP Model Performance Year

January 1, 2023 marked the beginning of the performance year, in which all HHA results would impact future payments. CMS will adjust fee-for-service payments based on performance relative to other HHAs. CMS groups HHAs into cohorts determined by beneficiary count the previous year. Cohorts include large- and small-volume for agencies above and below 60 unique HHCAHPS eligible beneficiaries, respectively.

Using data already reported by HHAs through the Home Health Quality Reporting Program (HH QRP) and HHCAHPS surveys, CMS compares an HHAs data to similar agencies. Based on this comparison, CMS adjusts future payments between -5% and 5% for fee-for-service payments.

Interim Performance Report

The Interim Performance Report (IPR) is a quarterly report with performance data for all HHAs participating in the HHVBP Model. Active HHAs that were Medicare certified before January 1, 2022, are eligible for payment adjustment, and meet the minimum threshold of data for at least one quality measure receive the reports. Reports are available at iQIES. Registration on the portal is required.

CMS publishes new reports every quarter and eligible HHAs should receive an email when a new report is available.

Points System

Payment adjustments for the next calendar year are based on an HHAs performance in the last report. For CY 2025, payment adjustments will use the Final Annual Performance Report, published 30 days prior to each payment year.

The process to determine your HHAs ranking in relations to the other HHAs in your cohort can be confusing and has many steps. Payment adjustments are based on “Care Points”, which are calculated on a weighted scale, using the higher of the agency’s earned achievement points or improvement points. An HHA must have at least 20 quality stays for claims-based measures and at least 40 surveys for the HHCAHPS survey-based measure.

Achievement Points

Achievement points are earned by scoring above the median performance on each quality measure (better than half of the agencies in your cohort) and dividing that by the difference between your score and the top 10 percent in your cohort.

Improvement Points

Improvement points are calculated using an HHAs prior year performance measure, current measure and the mean score of the top 10 percent of agencies in your cohort.

Care Points

Care points are the higher of Achievement Points or Improvement Points for each quality measure. Each quality measure is weighted differently in each category of OASIS-based Measures, Claims-based Measures, and Survey-based Measures.

The higher of each agency’s achievement and improvement scores is multiplied by its assigned weight to calculate the weighted score within each measure. Each measure then has its own weight. OASIS- and Claims-based measures each count for 35% of the total score while Survey-based measures make up 30% of the final score.

The HHA score is measured against all HHAs in the cohort to determine your rank. Where your weighted points fall in comparison with the rest of your cohort determines whether your next payment cycle will go up or down by as much as 5 percent.

Public Reporting

Your scores will not only be used to determine your payment increase or decrease. These reports will be made public as well. CMS will publicly report each quality measure’s benchmark and achievement threshold. For every HHA that qualifies for a payment adjustment, CMS will also publish:

- - Measure results and improvement thresholds
  - Total Performance Score and Percentile Ranking
  - Payment adjustment percentage

Scoring well on the Achievement and Improvement markers for each measure may offer an HHA an opportunity to gain more referrals, recruit talented clinicians, and gain a reputation for quality care.

On the other hand, scoring low may hurt an agency irreparably. HHAs who think there is an error in the initial reporting can submit a recalculation request within 15 days of the publishing of a preview report. Based on CMS’s decision, HHAs have 15 days to submit a reconsideration request if they submitted a recalculation request and are not happy with the decision. If the HHA is still not in agreement with the decision of the reconsideration request, they have seven days to submit a request for administrative review.

Next Steps

According to the information we can find on CMS, these reports will be published quarterly. Logically, then, the recalculation requests can also be submitted quarterly along with reconsideration and administrative review requests. We will continue to follow this and provide updated deadlines to submit requests as we find them.

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Medicare Advantage Predatory Marketing

by Kristin Rowan | Aug 16, 2024 | CMS, Editorial, Marketing, Medicare Advantage, Regulatory

by Kristin Rowan, Editor

Leading Associations Attempt to Curb Medicare Advantage Marketing Practices that Prey on the Unsuspecting

For some time now, we’ve been reporting on the marketing practices that Medicare Advantage uses to lure new members. And, it’s working, as more than 50% of eligible patients are now on Medicare Advantage plans. From federal lawsuits to fraud, to upcoding, Medicare Advantage has made headlines more often than almost any other topic in the industry in the last few years. A joint move last week by two national associations may bring the issue to a head once and for all.

The National PACE Association (NPA) and LeadingAge wrote to the Centers for Medicare and Medicaid Services (CMS) urging them to employ stricter oversight on Medicare Advantage marketing practices. The letter, dated July 25, 2024, cited the impact of these marketing tactics on adults served by Programs for All-Inclusive Care for the Elderly (PACE). They called the marketing “aggressive and misleading” and called upon CMS to protect PACE beneficiaries from harm.

One of the selling points in the marketing of Medicare Advantage is the supplemental benefits. Medicare Advantage plans are allocated nearly $64 billion dollars to pay for dental, vision, gym memberships, and other benefits that are not available with traditional Medicare. However, the government has no idea where this money is going, who is using it, and what it’s for. Limited available data suggests that a very low number of Medicare Advantage enrollees are using these supplemental benefits. The rest of the money just sits with the payers at taxpayer expense.

The false promise of cash benefits draw even more of this population away from traditional Medicare and into Medicare Advantage plans. Cash benefits from MA plans are only available to dual eligible members. What they don’t tell you, though, is that if you are dual eligible and you switch from Medicare to Medicare Advantage, you are subject to prior authorization rules, care denials, and smaller networks, meaning you may lose your physician when you switch plans. Some of those cash benefits are restricted to use in particular stores. For example, Aetna restricts the use of cash benefits to stores owned by CVS Health. If there isn’t a CVS Health near you, the cash benefits can’t be used.

PACE Programs

Programs of All-Inclusive Care for the Elderly (PACE) are typically traditional Medicare and Medicaid joint programs that provide medical and social services in home and community-based care settings. The programs cover prescriptions, dental care, emergency services, home care, meals services, primary care providers, nurses, social workers, and more. The program’s goal is to keep patients at home or in their communities and get the health care they need. There is no out-of-pocket costs to these programs for dual eligible members. Medicare only members have a monthly premium and prescription drug (Part D) premium. There are no additional deductibles or copayments for any service or level of care.

Bait and Switch

The marketing messages from Medicare Advantage are pulling PACE eligible members into dual MA and Medicaid plans, which significantly reduce the level of care, access to care, and continuity of care. The MA/Medicaid programs also have higher out-of-pocket costs to members, despite having no monthly premium. Research shows that Medicare Advantage is targeting healthier individuals who will use the provided benefits less often and that when Medicare Advantage patients become sicker, they switch back to traditional Medicare plans if they can.

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PACE LeadingAge MA Reform The financial and health implications of uninformed disenrollment from PACE to conventional MA plans are significant. The needs of PACE beneficiaries, most of whom have multiple complex medical conditions, cognitive or functional impairments – or all three – are not comprehensively addressed by MA plans. The loss of PACE services is harmful and, in some cases, can be life-threatening.

Katie Smith Sloan

president and CEO, LeadingAge

Dire Need for Change

In their letter to CMS, NPA and LeadingAge called for the following changes to be made:

Require MA plans to explain, clearly and without embellishment, all out-of-pocket costs and network/coverage limitations. using easy to understand terms
When a member disenrolls from a PACE program, additional steps should be taken to ensure the disenrollment is voluntary and that the member is fully informed of the differences in coverage before leaving the PACE program.
Increased leniency in re-enrolling in PACE programs after leaving a Medicare Advantage program by allowing re-enrollment mid-month.
Require MA brokers, when providing comparative benefit information of their current coverage (e.g., PACE) to an alternate MA plan, to also inform them, in plain language, if the new plan does not cover or coordinate their Medicaid benefits; and any benefits the individual would “lose” under the new plan (e.g., transportation to groceries).

Pace LeadingAge MA Reform We share CMS’ stated desire that people have access to accurate and complete information when they make health care choices. We have numerous examples of vulnerable seniors being induced to enroll in MA plans without being fully-informed of what they are giving up when they enroll.

Shawn Bloom

president and CEO, National PACE Association

The Rowan Report reached out to LeadingAge to see if CMS has responded to their letter.

Updates will be provided when we have them.

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Sources:

https://prospect.org/health/2024-05-30-medicare-advantage-64-billion-supplemental-benefits/

https://leadingage.org/associations-urge-tougher-enforcement-of-anti-predatory-medicare-advantage-marketing-practices/

Product Review: AI Comes to Data Analytics

by Kristin Rowan | Aug 16, 2024 | Product Review

by Kristin Rowan, Editor

Artificial Intelligence has existed in basic forms for many years and has recently advanced to include augmented intelligence and generative intelligence. The Rowan Report has provided several examples of quality AI usage and even more examples of AI applications that are fraudulent, improperly applied, and/or poorly executed. As we continue our journey of AI discovery, we are seeing more companies researching how to effectively use AI to enhance existing software solutions as well as new solutions entirely based on AI. We’ve reviewed AI software for point of referral, talk to text documentation, employee recruitment and retention, and now data analytics.

The Rowan Report recently met the founder of a data analytics AI software solution, Skyra.ai. “Our goal is to advance the industry to be technology forward,” said Skyra founder Mickel Mirchandani, “we imagined a future were technology empowers home care agencies to focus on what matters – serving patients.”

Data Analytics: From What to Why

Care at Home agencies have no shortage of access to reports through various tech solutions. Hours worked and earnings from payroll reporting, average length of visit and number of patients per week from EMR and EVV reports, average daily census, employee turnover rate, and the list goes on. These reports are useful in telling us what is happening within our agency, with our staff, and with our partners. Once you have this information, what do you do with it? Does it tell you why your top clinician saw five fewer clients last week? Does it explain the decrease in referrals from area hospitals and physicians? Can the reports tell you whether the recent trends will continue? Why are these things happening in your agency? And what’s more, how do I fix them?

Give Your Home Health Agency a Much-Needed Tune-Up

Like the warning light on your dashboard, data is meaningless until it is diagnosed. That warning light that tells you your referral numbers dropped last week might indicate new competition in your area, a drop in confidence in your agency by hospitals and physicians, too many NTUCs on your scorecard, or simply a glitch in paperwork or your website. The data tells you the numbers have dropped. Skyra.ai tells you why.

Skyra is a data analytics solution that connects to your EMR, payroll, accounts payable, scheduling, and quite literally almost any other piece of your tech stack that has useful data you want to see.

With a standard dashboard containing the most relevant and popular queries, and the ability to create custom insights, Skyra makes understanding the volumes of data collected simple and easy. Once you understand the “why” behind the numbers, you can make adjustments in your operating, scheduling, ordering, and operations to improve the overall health of your agency.

Features

Standard Dashboard
Insights for each Team (Sales, Executive, Clinical)
Two-Month Data Trends
Custom Insights Page
Pinned Query that refreshes itself daily
Understands multiple languages
Zero Percent Hallucination
HIPAA Compliant with multiple security layers applied vertically and horizontally

“Ask Sky” – the Generative AI assistant you can tap into for custom insights into your agency
Compliance Monitor to avoid payment penalties by ensuring accuracy and timeliness of submissions
Control Tower for key metrics and alerts

Platform Agnostic

Data analytics is difficult enough without using multiple tech solutions. Even worse is when you’ve decided that a particular solution no longer works for your agency and you find yourself shopping for a new payroll, scheduling, or EMR solution. How do you preserve the years of data from your legacy systems without interruption?

Skyra.ai’s unique process stores all your data as though it comes from the same source, in the same language. Switching from solution to solution is a seamless process that keeps your data intact and reduces the opportunity cost of changing systems.

Future Plans

The team at Skyra is not content with one of the most advanced AI applications in the space. With a recently redesigned website, and new partners, Skyra is now looking to the future. Look for a two-way communication solution over a secured system with encrypted messages. The messaging system will connect caregivers to patients, patients to care teams, and caregivers, to care teams. The solution will reduce triage costs, reduce rehospitalizations rates, assist with marketing efforts, and increase CHAP scores. Skra Connect will launch sometime in 2025.

But, first, Skyra is focusing its development efforts on an application for sales teams and marketers. An alternative to a traditional CRM that requires large amounts of useless data input and doesn’t help close a deal, Skyra’s sales solution will provide a CRM solution that sales people actually want to use and will free up their time to spend on customer-facing activities.

The Rowan Report will provide a separate review of each of these new products as they become available.

Overall Impression

A Familiar Problem

Skyra.ai found Mickel tells a familiar story about the idea for his solution. Familiar, at least, to those of us who grew up in the 80s. When our favorite band released new songs, we ran to the nearest music retail store to buy a cassette tape. If your favorite song on the tape was track 3, you know the pains of fast forwarding and rewinding to get the tape to the perfect spot at the beginning of the song, only to have to do it all over again when the song ends. Today, we ask “Alexa” or “Siri” or “Google” to play our favorite song and it starts at exactly the right second every time. Mickel strove to make accessing and understand data as easy as asking Alexa to play your favorite song. Ask Sky removes the fast forward and rewind buttons and lets you understand your data faster.

A Consolidated Solution

As a small business, and even as an individual, I know how many applications I have to log in to daily to see my business analytics and personal information. Skyra houses all of your business information in one place for easy access and provides an open-ended query so each agency gets the information they need most to help the agency operate at its fullest potential. The possibilities that will exist as the AI technology advances is near endless.

As we have mentioned before, there are a lot of misuses for artificial intelligence, and a lot of misunderstanding. Now, it seems, we have found at least one more company doing AI well.

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