Cyberattack Interrupts Pharmacy Operations

Admin

by Kristin Rowan | Mar 6, 2024 | Admin, CMS, Regulatory, Vendor Watch

By Kristin Rowan, Editor

**March 6, 2024 Update** As the previously reported cyberattack on Change Healthcare continues, the US Department of Health and Human Services issued a statement on March 5, 2024 outlining immediate steps CMS is taking to assist providers. CMS is strongly encouraging Medicaid and CHIP plans to waive or relax prior authorization requirements. They’ve also urged providers to offer advance funding to providers.

According to feedback from NAHC members, the impact of this cyberattack on home health and hospice providers has remained minimal. However, for those experiencing delays in claims processing and payments, some providers are unable to meet payroll or pay for patient care items.

**February 29, 2024 UPDATE** We’ve just been contacted by a home care agency out of Charlotte, NC who told us, “For our home care agency we can’t submit claims for VA clients (ChangeHealthcare [sic] has been totally taken off line), and we aren’t having remittance records from Optum feed through ChangeHealthcare [sic] to Wellsky.”

February 28, 2024

The news broke last week that another cyberattack is impacting healthcare. This time, it is Change Healthcare, a division of UnitedHealth Group, that processes insurance claims and pharmacy requests for more than 340,000 physicians and 60,000 pharmacies. In response to this attack, UnitedHealth Group separated and isolated the effected systems, causing delays in claim payments and backlog pharmacy orders.

The attack was first reported on February 21, 2024 and the outage is still ongoing. Former FBI cyber official and current adviser for cybersecurity and risk at the American Hospital Association warns that the longer this outage persists, the worse it will get and it will start to impact patient care. UnitedHealth Group claims that fewer than 100 pharmacy orders and claims have been interrupted across its insurance and pharmacy plans. But, at least on health insurer is claiming a 40% drop in claims since the system went down.

Source of the Attack

Initially, UnitedHealth Group blamed an unknown “nation state” for the cyberattack. The FBI found no evidence of this and has since named Blackcat ransomware gang culpable in the attack. Blackcat ransomware gang has attacked numerous hospitals and the FBI seized their website and servers in December, 2023. Blackcat accessed the Change Healthcare system through vulnerabilities in the ConnectWise ScreenConnect remote desktop and access software.

Implications

The American Hospital Association has urged all healthcare organizations that work with Optum, Change Healthcare, and UnitedHealth Group to weigh the risk of the connection to Change Healthcare against the possible clinical and business disruptions cased by severing that connection.

Health-ISAC anticipates additional cyberattack victims in the coming days. ConnectWise has alerted its users to the remote code execution flaw and has urged all users to update immediately to prevent attacks.

Point of View

This is not the only story this week about UnitedHealth Group. Backlogged pharmacy orders, healthcare claims, and payments, add further credence to the Antitrust probe filed this week by the Justice Department, investigating UnitedHealth and Optum. Should one healthcare group have this much influence over insurance, physicians, pharmacies, and home care?

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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.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only.

editor@homecaretechreport.com

Sources:

Fox. February 22, 2024. Change Healthcare Experiencing a Cyberattack. Retrieved from: https://www.healthcareitnews.com/news/change-healthcare-experiencing-cyberattack

Fox. February 27, 2024. Change Healthcare Cyberattack Still Impacting Pharmacies, as H-ISAC Issues Alert. Retrieved from: https://www.healthcareitnews.com/news/change-healthcare-cyberattack-still-impacting-pharmacies-h-isac-issues-alert

Pashankar & Tozzi. February 28, 2024. Change Healthcare Cyberattack is Still Disrupting Pharmacies, Other Providers. Retrieved from: https://finance.yahoo.com/news/change-healthcare-cyberattack-still-disrupting-211913516.html

Satter & Bing. February 26, 2024. US Pharmacy Outage Triggered by ‘Blackcat’ Ransomware at UnitedHealth unit, Sources Say. Retrieved from: https://www.reuters.com/technology/cybersecurity/cyber-security-outage-change-healthcare-continues-sixth-straight-day-2024-02-26/

Justice Department Launches Antitrust Probe Against UnitedHealth Group

Admin

by Kristin Rowan | Feb 28, 2024 | Admin, Regulatory

by Kristin Rowan, Editor

DOJ Blocks Acquisition

History

The Biden administration has recently increased its efforts at antitrust enforcement against some of the largest companies in the U.S. These include Apple, Amazon.com, Live Nation Entertainment, and Alphabet’s Google unit. The enforcement of antitrust laws would restrain monopolies in the U.S. Thus far, the Justice Department has had questionable success in stopping mergers, but continues its crusade on monopolies. The administration has stated the the healthcare industry is a priority in its antitrust efforts.

The Wall Street Journal reported on February 27, 2024, that a new Antitrust investigation has been launched into UnitedHealth. This is not the first antitrust action against UnitedHealth Group. In 2022, the Justice Department sued to block UnitedHealth’s plan to buy Change Healthcare. That lawsuit was unsuccessful.

Current Action

According to the WSJ, The Justice Department has spent the last few weeks interviewing industry representatives in markets where UnitedHealth operates.

Investigators asked about relationship between UnitedHealth and Optum, the health-services arm of the company, which owns physician groups, surgery centers, and pharmacy-benefit managers. They specifically asked about the effects on the doctor-group acquisitions on rivals and consumers.

UnitedHealth has been under scrutiny for some time by the Justice Department. They have twice asked for information about the planned merger with Amedisys, a home health company. UnitedHealth is also facing a private antitrust lawsuit by a hospital system in California, siting strong-arm tactics to exert control over its affiliated physician groups and primary-care doctors.

Additional Inquiries

The DOJ isn’t stopping at antitrust probes. A concurrent investigation is looking into UnitedHealth’s Medicare billing issues, including documentation of patients’ illnesses. The more health conditions a patient has, the higher the Medicare payments. The DOJ is looking into “aggressive documentation” practices by UnitedHealth doctors and other healthcare providers.

Additionally, the merger between UnitedHealthcare and Optum medical groups could violate federal rules that cap the amount a health-insurance company retains from premiums. Health insurance plans should keep 15-20 percent of premiums for administrative costs, with the balance spent on patient care or sent as a rebate back to customers. Because UnitedHealthcare keeps their percentage of premiums and collects additional money from Optum, they may be well above the federal cap.

Response

UnitedHealth has denied any antitrust claims, stating that United Health and Optum don’t favor one another, and routinely work with competitors. UnitedHealth Chief Executive Andrew Witty testified that Optum has an “arm’s length relationship” with United Healthcare.

In an ongoing investigative series about CareMount/Optum, The Examiner News reporter Adam Stone, spoke with an anonymous insider who said, “If they are stopped before they become a monopoly, than that’s great, but they are headed down that road.” That same source has reported massive layoffs, mostly among C-suite executives, in the wake of the antitrust “document preservation notice” from the DOJ.

We will continue following the antitrust lawsuit and the objection to the merger with Amedisys.

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Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news, and speaker on Artificial Intelligence and Lone Worker Safety and state and national conferences.

She also runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. 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 The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Sources:

Mathews & Michaels. February 27, 2024. U.S. Opens United Health Antitrust Probe. Retrieved from: https://www.wsj.com/health/healthcare/u-s-launches-antitrust-investigation-of-healthcare-giant-unitedhealth-ff5a00d2?st=30zpi0dw9hktzlj&reflink=desktopwebshare_permalink

Stone. February 26, 2024. Justice Department Probing UnitedHealth/Optum Over Antittrust Concerns; Local Layoffs Enacted, More Forecast. Retrieved from: https://www.theexaminernews.com/justice-department-probing-unitedhealth-optum-over-antitrust-concerns-local-layoffs-enacted-more-forecast/

Acute Hospital Care at Home

Clinical

by Kristin Rowan | Feb 21, 2024 | Clinical, Regulatory

By Kristin Rowan, Editor

Federal Waiver Program

In 2020, CMS launched a hospital care at home program to help increase patient capacity during the height of the Covid-19 pandemic. The study included 300 hospitals and thousands of patients receiving care in their home using a hospital at home waiver. Outcomes of the study showed that patients had greater ability to stand up and move around at home than would have had in a hospital and that in-home caregivers were better able to educate patients on home to care for themselves once they were able to see the social determinants of care in the home. CMS also reports only 7.2% of patients were required to be transferred to a hospital.

Hospital Study

Mass General Brigham conducted its own study alongside CMS and analyzing outcomes of diverse patients, including socially vulnerable and medically complex patients. The findings of their national analysis showed that within 30 days of discharge, 2.6% of patients used a SNF, 3.2% died, and 15.6% were readmitted. Findings were consistent among all groups, including those who generally have worse outcomes: patients of Black and Latine race and ethnicity, dual-eligible patients, and patients with disabilities.

Health System Study

In April of 2020, Kaiser Permanente conducted an 18-month study on the scalability of “Advanced Care at Home” (ACAH). The patients all required hospital-level care and were first admitted to the program through the emergency department. Some were admitted to the hospital, and some were instead admitted to the Kaiser ACAH program, where a team of nurses, physicians, nurse practitioners, and a pharmacist developed a care plan.

This study increased its daily census from 7.2 per day to 12.7 per day at the end of study. The average episode of care decreased from 7.43 days to 5.46 days and readmission rates dropped from 11.52 percent to 9.24 percent. These patients were less likely to experience delirium than patients admitted to traditional hospital settings. The researchers noted the limitation of the study as being too small to develop precise comparisons.

Limitations of Acute Hospital Care at Home

Currently, the only patients eligible for AHCaH are those who have been evaluated in a hospital or emergency department. Kaiser has extended this to patients seen in their own urgent care offices in areas where they don’t own a hospital. Kaiser has served a few thousand patients through this program, but they estimate there are more than 1.1 million eligible patients. Rural patients who don’t live near a hospital or emergency department have the same trouble accessing AHCaH that they do accessing hospital and physician care now.

The CMS waiver for AHCaH has been extended through December 2024. Beyond that, it is unclear how hospital care at home will be reimbursed. Some providers have offered hospital care at home to risk-based patients in a VBC model. Not all eligible patients will qualify for the waiver or VBC reimbursement. Without specific provisions from CMS to reimburse hospital care at home for all Medicare and Medicaid patients and coverage from private insurance, the hospital at home program will remain limited.

The current model for AHCaH includes technology support for the patient using a tablet, smartphone, or other device. This requires that the patient have a broadband internet connection in the home, which eliminates eligibility for rural patients who are already underserved.

Final Thoughts

There is a lot of support for Hospital Care at Home among providers, health systems, and consumer insurance companies. Support for home health, hospice, palliative care, and supportive home care has not been as strong. As these larger players start to see the cost and outcome benefits of care in the home, a few things may happen.

First, hospitals, payers, and physician groups may start to recognize the value of care at home and be more open to creating referral partnerships with care at home agencies. Home care is a small percentage of total care reimbursed by Medicare and Medicaid and we could see that increase.

Conversely, these providers may realize that care at home is lucrative and will extend their own AHCaH models to include post-acute and hospice care, cutting out home care agencies altogether. Care teams are constructed around a Hospital Care at Home patient. Including a post-acute nurse who is familiar with the patient history would provide additional continuity of care.

Either way, I see the support for the Hospital Care at Home program as beneficial to home health. Branches of health care that were previously averse to extending patient care into the home are now supporting it. Increased adoption of telehealth and other technology platforms increase the possibilities for integrating with home health and hospice providers. Interoperability between Hospital Care at Home and Post-Acute Care at Home may finally become a reality.

We will continue to report on the AHCaH waiver as the deadline to renew comes closer.

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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.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com

Sources:

CMS (2024) Acute Hospital Care at Home Data Release Fact Sheet. Retrieved from: https://www.cms.gov/newsroom/fact-sheets/acute-hospital-care-home-data-release-fact-sheet#:~:text=In%20response%20to%20challenges%20faced,inpatient%2Dlevel%20care%20at%20home.

Mass General Brigham (2024) Study of National Data Demonstrates the Value of Acute Hospital Care at Home. Retrieved from: https://www.massgeneralbrigham.org/en/about/newsroom/press-releases/study-of-national-data-demonstrates-the-value-of-acute-hospital-care-at-home#:~:text=In%20addition%2C%20within%2030%20days,and%20have%20fewer%20adverse%20events.%E2%80%9D

mHealth Intelligence (2023) Kaiser Permanente Study Shows Scalability of Hospital-at-Home model

Family Caregiver Tax Credit Bill

CMS

by Kristin Rowan | Feb 14, 2024 | CMS, Regulatory

By Kristin Rowan, Editor

Republican and Democratic leaders joined forces to introduce the Credit for Caring Act (S. 3702, H.R. 7165) in support of family caregivers across the country. Family caregivers are those who are caring for a family member but are not nurses or employees of any home care agency. They are not eligible for Medicare or Medicaid payments, nor is there an employer paying them for the endless hours of support they provide. Family caregivers are often under a lot of emotional and financial stress. Some have full-time jobs in addition to the care provide. Others are caring for more than one family member, sometimes in different homes.

The Credit for Caring Act, a bipartisan effort to recognize the personal cost to family caregivers with a $5,000 federal tax credit for eligible working family caregivers. As is generally the case with government intercession, the “eligible” part will exclude many family caregivers. From Congress.gov:

“This bill allows an eligible caregiver a tax credit of up to $5,000 for 30% of the cost of long-term care expenses that exceed $2,000 in a taxable year. The bill defines eligible caregiver as an individual who has earned income for the taxable year in excess of $7,500 and pays or incurs expenses for providing care to a spouse or other dependent relative with long-term care needs.”

The bill also includes the caveat that eligible caregivers must incur qualified expenses, limited to goods, services, and supports. The language excludes the time and energy a family caregiver expends, essentially limiting the tax credit to repayment of money paid out of pocket for care that should have been covered by Medicare, Medicaid, or private health insurance, but isn’t. The cost of a direct care giver is included in eligible expenses, but doesn’t consider the family caregiver to be one.

As I break down the math in my head, I come up with this:

A tax credit of $5,000 is received if the caregiver has spent $16,600 in the previous year (5,000/.3). This leaves a total out of pocket amount of $11,100. Supportive home care services average $30/hour. $16,660 is equivalent to 555 hours of non-medical home care. That’s roughly 10 hours per week or 1-1/2 hours per day. This doesn’t include the costs for DME, doctor visits, lost wages from time off work, medication, or any of the other eligible expenses included in the bill.

This is getting us one step closer to paying for supportive in-home care and palliative care services, but I don’t think it goes far enough. An under-served, under-paid population who makes $7,500 per year cannot afford $16,000 in out-of-pocket expenses in order to qualify for the maximum tax credit. Once this bill is (hopefully) passed, we should move on to including additional services in the Medicare/Medicaid reimbursement model. The Rowan Report joins NAHC in its support of the Credit for Caring Act and urges you to reach out to your representatives to urge them to support the passing of the bill.

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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.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com

Read the article and statement from NAHC here

Read the full text of the bills: H.R. 3321 and S. 3702

Find your Senator here

Find your Representative here

Get Closer to Bonus Pay with the Net Promoter Score

Admin

by Kristin Rowan | Feb 7, 2024 | Admin, Marketing, Regulatory

by Kristin Rowan, Editor

Medicare Advantage has multiple measures of success for payment bumps and bonuses. Rehospitalization rates has long been the most important measure of how well a care at home agency is performing, but there are additional measures that can help or hurt your agency. One that is gaining a lot of traction with MA and can impact your agency’s ability to survive is the overall patient experience. Measuring the patient experience can be subjective, but a great marketing tool to use is the Net Promoter Score (NPS). NPS is a calculation of patient responses regarding their likelihood to recommend you to others. A NPS score of “0” means that, overall, your clients are not going to speak positively or negatively about you; there just isn’t anything outstanding enough to bother saying anything. Anything above zero is better than nothing, but 30 and above is ideal.

During January’s HomeCare 100 Winter Conference, Tim Craig moderated the panel, “The MA Member Experience and Why it Matters” with a panel of experts. He posed this question to the audience:

“How well do home care providers perform when it comes to delivering on patient experience?”

Rating care provider performance on a scale of 1-5, the responses during the panel were somewhat surprising

47% of those who responded rated the delivery on patient experience 3
43% said 4
6% responded 2
A mere 4% responded 5
There were no responses of 1

If we turn these answers into a Net Promoter Score, we get -6. If caregivers, administrators, and providers don’t believe we’re doing a good job, how can we expect our clients, patients, and families to be happy with the care they receive?

Statistics

Patient experience and complaint measures count higher toward star rating than they have before
CAHPS Scores have changed weight from 1.5 to 4 since 2021
Star Ratings Determine Bonus Eligibility and Amount – starts at 4 stars and above
Number of plans that have a 4.0 or higher star rating dropped from 64% to 43%
Disenrollment is on the rise from 10% in 2017 to 17% in 2021

Net Promoter Score

Glen Moller, CEO of Upward Health, whose net promoter score is a whopping 86, said:
“The Member Experience has always been important. What has changed is the way we manage it, given the implication of the CAHPS rating, you can’t be a 4 star without high CAHPS scores.” Moller improved his patient experience with internal surveys to get actionable intel and asking open-ended questions. Look at change and innovation and how that could be disruptive to members. Member experience is at the center of all the other measures. No matter what benefits you’re offering, embed member experience measures at every step of the process.

Because your star rating directly impacts your ability to receive bonuses and because experience-related metrics are increasingly weighted in determining star ratings, you should be looking at the member experience more closely in all of your process. You should also be measuring the member experience and looking at ways to improve it.

Ways to measure ME

• HHCAHPS
• Quality of Patient Care Ratings
• Word of Mouth
• Net Promoter Score
• Glassdoor
• YelpCalculating a Net Promoter Score can be challenging, especially when trying to get older or infirmed patients to answer a survey. For the most accurate NPS, send a single question survey to all of your current and past customers asking them to rate, on a scale of 1 to 10, “How likely are you to recommend us to a friend or family member.” If you aren’t able to do this, you can still calculate a rough NPS using your other measures. You can use your Google and Yelp reviews with a simple formula: % of promoters – % of detractors = NPS. Three stars and below are detractors; four and five stars are promoters.The NPS score is more about comparative to the usual experience rather then the actual experience. A high score from a customer doesn’t necessarily meant it’s “great”, only that it’s much better than what they’re used to or what they expected.

The NPS is not the only measure of customer experience. To get the whole picture, use all the data you have to find out what interventions should be done and implement them. Whether the change is in training your staff, updating your scheduling process, using AI to help communicate directly with patients and families, or simply streamlining your website for a better user experience, you can improve your chances for higher ratings and bigger bonuses in a few easy steps.

I won’t often insert a shameless plug into an article, but if increasing patient satisfaction and member experience can help your agency survive the CMS pay cuts, and you need help with getting a NPS, understanding how to measure your patient experience, or getting online reviews, please contact me for more information. My marketing agency is happy to help get you started.

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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.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com

Caregiver Charged with Death of a Patient

Admin

by Elizabeth E. Hogue, Esq. | Feb 7, 2024 | Admin, Regulatory

by Elizabeth E. Hogue, Esq.

A caregiver in Wyoming who is charged with causing the death of her mother has been jailed based on allegations that she committed aggravated assault and battery; deliberate abuse of a vulnerable adult; and intentionally and maliciously killing another human being, commonly known as 2nd degree murder. The defendant, Edwina Leman, cared for her mother, Mary Davis, beginning in June of 2022. At the time of the events described below, Davis was a hospice patient.

On December 28, 2023, Leman’s son heard her yelling at her mother. At some point, he heard an audible “thump” and Davis began to scream. The son then entered the bathroom and found Leman pulling roughly on her mother’s leg, even though Davis was screaming that it hurt. According to Leman’s son, Leman then told her mother “not to be dramatic” and called her “Marygina,” a derogatory name the caregiver had previously called Davis on multiple occasions.

Leman claimed that she was removing her mother’s clothing “more forcibly than necessary when she fell.” She also said that Davis became very frail and fragile during the time the patient lived with her. Leman admitted that she had a temper and had “thumped or swatted” her mother on the head at various times in the past.

Leman’s husband and son said that they saw the caregiver engage in a pattern of physical and verbal abuse toward Davis. The caregiver screamed at her mother and sometimes called her names. Leman’s husband said he saw his wife hit the patient on the head and push her while she was walking with her walker. Leman said that she also pushed Davis when she was not using her walker, which caused her to fall to the ground. The coroner’s report said that Davis died of complications of a displaced fracture of her femur.

A sad story indeed! We read it and weep!

This case is a reminder for all types of providers who render services to patients in their homes to be alert to any signs of abuse or neglect, and to take action to protect patients who are subject to abuse or neglect. Action by providers should include reports to adult protective services. Providers may respond to this recommendation by saying that adult protective services rarely takes action based on their reports. Providers must remember, however, that reports to adult protective services are required in many states. In addition, it is important to establish a record of abuse and neglect even if authorities do not take action. Better to err, if necessary, on the side of protecting patients.

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

Cigna Divests Medicare Business

Regulatory

by Kristin Rowan | Feb 7, 2024 | Regulatory

by Kristin Rowan, Editor,

On Wednesday, January 31, Cigna and HCSC signed an agreement to sell all of Cigna’s Medicare business — including traditional Medicare, supplemental benefits, Medicare Part D offerings, and CareAllies, a value-based care management subsidiary. — to HCSC, a Blue Cross / Blue Shield partner with operations in Illinois, Texas, New Mexico, Oklahoma and Montana. The $3.3 billion deal will quadruple the size of HCSC’s Medicare Advantage population, which numbered 217,623 as of this month.

Medicare Advantage had not been a significant business for Cigna. CEO David Cordani explained that it required resources disproportionate to its size in the company. With 19 million insurance customers, Cigna had a little over a half million in its MA business, a little under a half million Medicare supplement members, and 2.5 million in Part D.

It had previously been reported that Cigna believed divesting its Medicare business would make its merger with Humana more acceptable to regulators. The company completed its HCSC deal even though negotiations with Humana had already broken down. Though inked today, the deal is not expected to close until the first quarter of 2025.

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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.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com

Why Every Provider Must Establish and Maintain a Fraud and Abuse Compliance Program

Admin

by Elizabeth E. Hogue, Esq. | Jan 31, 2024 | Admin, Regulatory, Waste Fraud and Abuse

by Elizabeth E Hogue, Esq.

Providers may have heard or read about the importance of Fraud and Abuse Compliance Plans in their organizations. Despite the wealth of available information about Compliance Plans, many providers continue to express uncertainty about their value. Here are some of the questions providers commonly ask about Compliance Plans:

Why should we have a Fraud and Abuse Compliance Plan?

First, the Office of Inspector General (OIG) of the U.S. Department of Health and Human Services has clearly stated that, consistent with the Affordable Care Act (ACA) as described below, all providers are now expected to have current Compliance Plans that are fully implemented.

As a practical matter, when providers establish and maintain Compliance Plans, it clearly discourages regulators from pursuing allegations of fraud and abuse violations.

Technically speaking, the Federal Sentencing Guidelines make it clear that establishment and implementation of Compliance Plans is considered to be a mitigating factor. That is, if accusations of criminal conduct are made, the consequences may be substantially less severe because of a properly implemented Compliance Plan.

In addition, providers with Compliance Plans are more likely to avoid fraud and abuse. This is because Plans routinely establish an obligation on the part of every employee to report possible instances of fraud and abuse, and Plans include training for all employees.

Compliance Plans may help to prevent qui tam or so-called “whistleblower” lawsuits by private individuals, rather than by government enforcers, who believe that they have identified instances of fraud and abuse. There are significant incentives to bring these legal actions since whistleblowers receive a share of monies recovered because of their efforts. Some whistleblowers have received millions of dollars. Compliance Plans make it clear that employees have an obligation to bring any potential fraud and abuse issues to the attention of their employers first. Compliance Plans provide a clear path to resolve fraud and abuse issues internally.

In addition, the federal Affordable Care Act (ACA) requires providers to have Compliance Plans. In short, it’s the law!

Finally, the Deficit Reduction Act (DRA) requires providers who receive more than $5 million in monies from state Medicaid Programs per year to implement policies and procedures, provide education to employees, and put information in their employee handbooks about fraud and abuse compliance. These requirements can be met through implementation of Fraud and Abuse Compliance Plans.

We don’t receive reimbursement from the Medicare or Medicaid Programs. Do we still need a Compliance Plan?

Statutes and regulations governing fraud and abuse also apply to providers who receive payments from any federal and state healthcare programs, including Medicaid, Medicaid waiver and other federal and state health care programs, such as TriCare and the VA. Many private insurers have followed the federal government’s lead in terms of fraud and abuse enforcement. Therefore, providers that don’t receive reimbursement from the Medicare Program must have compliance plans, too.

We hear that the OIG of the U.S. Department for Health and Human Services has provided guidance for various segments of the healthcare industry regarding Compliance Plans.

Specifically, the OIG has already published guidance for clinical laboratories, hospitals, home health agencies, hospices, physicians’ practices, third-party billing companies, and home medical equipment companies. Should we just use the model guidance that is applicable to us?

The answer is, “No!” Guidance from the OIG is not a model Compliance Plan. Guidance from the OIG consists of general guidelines and does not constitute valid Compliance Plans. In addition, the OIG has made it clear that Plans must be customized for each organization.

We have read that, before implementing Compliance Plans, providers must conduct expensive internal audits that can take many months to complete. Is this true?

While beginning the compliance process with an extensive internal audit is certainly one way to proceed, it is not the only viable way to work toward compliance. It is equally valid to begin with Compliance Plans that are customized for the organization and include training for all employees about fraud and abuse, and Compliance Plans. Then all staff members can subsequently participate in internal compliance activities, including audits, with a process in place to handle any issues that arise as a result of the audits.

We have all sorts of policies and procedures in our organization. Why do we need something else called a Compliance Plan?

Compliance Plans are specific types of documents that routinely address fraud and abuse issues that providers do not usually cover in internal policies and procedures. In addition, providers may not gain benefits under the Federal Sentencing Guidelines described in paragraph one (1) above if there is no formal document called a Compliance Plan.

We just spent a lot of money to become accredited or reaccredited. Doesn’t certification mean that we are in compliance?

On the contrary, Compliance Plans appropriately address potential fraud and abuse issues. They also include mechanisms for helping to ensure compliance, such as processes for identification and correction of potential problems that are not addressed during the certification process. In other words, organizations may be accredited, but fail to meet applicable compliance standards for fraud and abuse.

Will the fact that our organization has a Compliance Plan make any difference regarding the outcome of fraud and abuse investigations and the imposition of Corporate Integrity Agreements (CIA’s)?

Yes, it may make a considerable difference, based on statements from the OIG. If providers have Compliance Plans in place during investigations that are current and fully implemented, the OIG may be less aggressive in pursuing potential violations. Enforcers are likely to ask for information about Compliance Plans and related policies and procedures. Enforcers are now also likely to ask providers to show them how much money they have spent on fraud and abuse compliance activities!

When the OIG discovers problems with fraud and abuse in organizations, providers are usually asked to develop and implement a Corporate Integrity Agreement (CIA). The OIG often requires CIA’s to include a process for stringent monitoring by the OIG on a continuous basis. These monitoring activities can be extremely burdensome to providers in terms of both time and money. Providers with valid Compliance Plans may not be asked to develop and implement CIA’s.

Now is the time for all providers to recognize and act upon the need to establish and maintain Compliance Plans. “Working on it” is no longer good enough.

No portion of this material may be reproduced in any form without the advance written permission of the author.

NAHC Fights for Home Health on Capitol Hill

Admin

by Kristin Rowan | Jan 31, 2024 | Admin, CMS, Regulatory

By Kristin Rowan, Editor

The National Association for Home Care and Hospice joined other advocacy groups this month on Capitol Hill to fight against the looming pay cuts from CMS. Some members of Congress joined the fight for “common sense policies” to expand access to care in the home for Americans.

Rep. Adrian Smith (R-NE-3), who spoke at the event, decried moves against home health, saying “there are cuts looming that are not based on reality” and “we want to make sure reimbursement policies are reflective of the actual realities.” Smith is also the representative who introduce the “Homecare for Seniors Act,” H.R. 1795, which would allow the use of Health Savings Accounts (HSAs) to be used for home care.

Rep. Terri Sewell (D-AL-7) has a personal connection to home care and spoke about how her mother cared for her father through a series of strokes he suffered. She expressed strong opinions about payment reductions that could see home health lose as much as $20 billion dollars over the next ten years. Sewell called the idea “frightening” and said, “I am a big fan of making sure that my constituents have access to quality, affordable health care.”

The Medicare program has admitted that home health is not just a bringing of great care and not just a more cost effective way to provide care, but is a service that provides dynamic value. Care in the home has decreased overall costs by $3.2 billion dollars just in the small segment of value-based payment model test cases. Patients who receive care in the home are re-admitted to the hospital 37% less frequently than those who do not and are 43% less likely to die than patients who do not receive care at home. Still, CMS is looking at additional pay cuts which bring the total payment reduction down 13.72% since 2019. The costs of everything else have increased in that time. According to the U.S. Bureau of Labor and Statistics, the average cost of living has increased 22% since 2019. NAHC President Bill Dombi said, “Where we’re headed in 2024 is that half of all home health agencies will be operating in the red with the cuts facing them in the Medicare program. It’s not a recipe for continued access to care.”

Dombi, along with many others, is predicting that 50 percent of agencies will be operating in the red after the next round of payment reductions and that without a reversal of these pay cuts we could see the end of care at home altogether with a collapse of the home health payment system.

The advocacy event on Capitol Hill helped raise awareness of the plight of care at home among some policymakers, but more help and advocacy is needed. Please, take a few minutes to click the link below and tell your members of Congress to support the Preserving Access to Home Health Act of 2023.

# # #

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.homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com

Please GO HERE to tell your members of Congress to support the Preserving Access to Home Health Act of 2023

Triad of Innovation

Clinical

by Kristin Rowan | Jan 24, 2024 | Clinical, Regulatory, Vendor Watch

by Kristin Rowan, Editor

The Arizona Healthcare Cost Containment System (AHCCCS American Rescue Plan (ARP) Program has awarded a grant to a collaborative group of care providers, solutions providers, and educators. On January 18th, Arizona home care agency Cypress HomeCare Solutions announced they have been selected at the recipient of this program award along with solutions provider PocketRN and educator Nevvon. As a team, they will implement services that improve client and provider experiences while also creating health system savings.

In Her Own Words

Last week, we spoke with PocketRN CEO Jenna Morganstern-Gaines. “Nevvon and PocketRN are working with Cypress to implement [the use of] PocketRN by Cypress’s caregivers to study cost of care, experience for clients, families, and the care team, and outcomes,” explained Morganstern-Gaines. She further explained that part of the requirements of the grant is to issue quarterly reports and a final evaluation of the program after one year. They are currently through the first phase of the study, which was to onboard patients, families, and caregivers.

PocketRN is a telehealth platform that engages in “whole person clinical care.” It is a flexible, virtual nursing and clinical service application that wraps clinical care around non-medical care in the home. The use a proactive approach by assigning a virtual nurse to each patient who continues to check in with the patient and the family to provide coaching and assistance and to help coordinate care.

“There’s a real reason we use the phrase ‘nurse you back to health’ and not ‘doctor you back to health’. The person that will help follow through is the nurse and PocketRN provides you a one-to-one relationship with a nurse that will follow through with all of your care providers to ensure that you are ‘nursed’ back to health.”

Jenna Morganstern-Gaines

CEO, PocketRN

We will be following this ongoing study and providing updates from the reports we receive.

# # #

Kristin Rowan has been working at The Rowan Report since 2008. She is the owner and Editor-in-chief of The Rowan Report, the industry’s most trusted source for care at home news .She also has a master’s degree in business administration and marketing and runs Girard Marketing Group, a multi-faceted boutique marketing firm specializing in content creation, social media management, and event marketing. Connect with Kristin directly kristin@girardmarketinggroup.com or www.girardmarketinggroup.com

©2025 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

Call to Action: Advocacy Is Everyone’s Responsibility

CMS

by Tim Rowan | Jan 24, 2024 | CMS, Regulatory

by Tim Rowan, Editor Emeritus

T

he battle for stable Home Health reimbursement rates continues full speed ahead on Capitol Hill, but the advocacy organizations engaged on the front lines of that battle are losing ground. The Partnership for Quality Home Healthcare and the National Association for Home Care and Hospice have deployed weapons from educating Congressional staffers to suing CMS. Those traditional methods appear to be insufficient, as the specter of draconian rate cuts casts a larger and larger shadow.

Missing from the conflict is the only effective weapon, flooding lawmakers with messages from their constituents.

According to Joanne Cunningham, CEO of the Partnership, the time is now to bring that weapon to the front. She told over 600 attendees at this week’s Home Care 100 event in Scottsdale that she and Bill Dombi have done everything they can up to now, adding that the only way to stop $3.5 to $5 billion in Medicare cuts is for every person of voting age whose livelihood depends on Home Health care to call or write their House Member and Senators.

CMS Payment rate cuts<br />
Joanne Cunningham

STEP ONE: A "Must-Pass" Bill

“Preserving Access to Home Health Act of 2023,” is a pair of bi-partisan bills introduced into the House and Senate in the summer of 2023. (S.2137/H.R. 5159) They would prevent CMS from making new cuts to the PDGM payment system, both now and in the future, by blocking annual “recalculations” that traditionally use flawed formulae.

The bills would require MedPAC to perform more comprehensive calculations before it makes recommendations to Congress. Currently, the Commission only considers revenue and profit margins from traditional Medicare. They determine that Home Health margins are too high without looking at the small-to-negative margins providers accrue from Medicare Advantage, Medicaid, the VA, and private insurance. Medicare profit margins make it possible for HHAs to care for patients with stingier payers. Reducing those margins too far, which MedPAC recommends every year, would remove access to care for millions of beneficiaries.

STEP TWO: Educating Congress

Ms. Cunningham emphasized that elected officials, as well as bureaucrats who write the regulations to implement the “will of Congress,” have yet to understand the impact in-home care has on overall healthcare spending and access to care. “We have to get bureaucrats to look at our data,” she said. “We know we save the trust fund more than we take from it, and we know that we are turning patients away because we cannot pay enough to attract clinicians in sufficient numbers. We have to educate them all.” She offered a few concrete suggestions.

What Works Best

- Data, data, data. The most effective policy argument starts with independent analysis from outside the industry.
- Tell stories. Elected officials and their staffers respond to real-life experiences of people within their districts and states. A group from Inhabit Health, for example, sat Congressional staffers down and told them about individual patients who had been kept out of hospitals and EDs, about great care they had received. They added summaries of their typical patients as well.
- Listen. Staffers will challenge your assertions and ask hard questions. They will help you identify your ‘Achilles Heels.’ See this as helpful preparation for meeting the Member or Senator.
- See them at home. Cunningham underscored the importance of making appointments and meeting with House members and Senators away from DC, for two reasons.
  - “A lot of people approach a Member on the way out of a church they both attend. What they don’t realize is that they are one of ten who will do the same thing between the church door and his car, from ten different industries. You just become ‘part of the clutter’ and are quickly forgotten.”
  - Back home advocacy is the most important thing you can do; it is even better than going to DC. Their main interest is re-election and they respond to messages from constituents. The purpose of advocacy is to cut through the noise. At home, you can say, “Hey, I know you; you’re my neighbor; listen to me!”
- Repetition is key. When you write a letter, it goes on a list. Staffers count up how many constituents have written about each issue. The best strategy is to make them feel pressure from back home. Marshall all the political pressure you can, but fill it with data.

Case in Point

Ms. Cunningham told about leading a group of Home Health providers from Oregon to meet with Senator Ron Wyden in his home office. To make their case for Home Health reimbursement support, they showed him their books, which proved that MedPAC is wrong about Home Health profit margins. They changed his mind. She said that meeting was so powerful and successful, it has become a model for working with other states.

STEP THREE: Expose Medicare Advantage

The Partnership’s goal is to ensure alignment of the MA home health benefit with traditional Medicare – as all Medicare beneficiaries are all entitled to the same home health benefit, regardless of the payor.

“MedPAC met during the first week of January to discuss Medicare Advantage. The meeting, which included a focus on the methodology of payments, was contentious at times.” Cunningham said. “In its January 12 report to Congress, The Medicare Advantage Program: Status Report, MedPAC forecast that CMS will overpay MA plans as much as $88 billion in 2024, based on prior year behavior.”

Higher coding organizations have a competitive advantage because they receive larger payments for enrolling the same beneficiaries as other organizations, and they can offer more extra benefits and attract new enrollees simply because of their coding efforts

Andrew Johnson, PhD

Principal Policy Analyst, MedPAC

MA’s focus on extras such as Silver Sneakers, vision care, and basic dental care, along with low or zero premiums added to the Medicare Part B premium that all beneficiaries pay, are what MA plans emphasize in their annual barrage of TV commercials. Never mentioned on TV or in direct mail brochures are two practices that impact many times more dollars than gym memberships and low premiums. The undeserved $88 billion mentioned in the MedPAC report comes from exaggerating initial assessments of plan enrollees. Payments from Medicare to a plan hinge on patient acuity. When improperly padded, acuity robs the trust fund and pads insurance company profits.

The second downplayed practice is on the care side of the equation. The largest MA plans have often been found to deny procedures that traditional Medicare standards would have covered. When they do pay for care, especially Home Healthcare, they pay rates below traditional Medicare rates, often lower than provider costs. Cunningham concluded her comments with a description of the Partnership’s efforts to bring pressure from MedPAC and the HHS OIG to force MA plans to comply with regulatory requirements. “We are all of one mind regarding MA. I think we are going to see practices change.”

About PQHH

The Partnership for Quality Home Healthcare was established in 2010 to work in partnership with government officials to ensure access to quality home healthcare services for all Americans. Representing community- and hospital-based home healthcare agencies nationwide, the Partnership is dedicated to developing innovative reforms to improve the program integrity, quality, and efficiency of home healthcare for our nation’s seniors.
pqhh.org

# # #

Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

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

MedPAC Report Slammed for Telling Truth About MA Abuses

Regulatory

by Tim Rowan | Jan 24, 2024 | Regulatory

Untitled Document

Analysis by Tim Rowan, Editor Emeritus

P

erennial Home Health enemy MedPAC angered a different group last week by releasing a status report on insurance companies participating in the Medicare Advantage program.¹

The report details the way in which giant, for-profit, health insurance companies improperly increase per-customer payments by upcoding their health assessment at enrollment, and then slash costs by denying coverage for healthcare services that traditional Medicare would have honored. MedPAC was also critical of the practice of requiring prior authorizations, backed up by utilization review algorithms that are supposedly intended to “minimize furnishing unnecessary services” but which effectively increase denials for necessary care.

According to the report, MedPAC expects CMS to pay MA plans $88 billion in 2024.

On January 12, a meeting to discuss the report ended in what one reporter politely described as “a kerfuffle.” Other witnesses to the meeting chose to describe it as a shouting match.

“One member, Brian Miller, MD, MPH, of Johns Hopkins University in Baltimore, accused panel leadership of issuing a negative status report on MA plans’ market dominance, saying it had been ‘hijacked for partisan political aims to justify a rate cut to Medicare Advantage plans.’

“Miller said the analysis … ‘appears to be slanted to arrive at a foregone conclusion in order to set up and provide political cover’ just before the Centers for Medicare & Medicaid Services prepares its annual rate notice for MA plans, expected in coming weeks. ‘The chapter reads like attack journalism as opposed to balanced and thoughtful policy research.'”²

Report authors fired back, citing numerous ways MA plans generate higher revenue, including enrolling people who are relatively healthy, known as favorable selection. They then vigorously scan patients’ medical histories and charts to code for health factors that generate higher per-capita payments, known as coding intensity, often spending less on services. Coding intensity is also the difference between a risk score that a beneficiary would receive in an MA plan versus in fee-for-service. Though MA plans skew toward healthier enrollees, MedPAC found that MA risk scores are about 20.1% higher than scores would be for the same beneficiaries had they enrolled in Fee For Service Medicare.

Namath, Walker, Shatner and Brokers

Criticism of MA plan behavior did not only come from MedPAC commissioners and report authors. For example, Lynn Barr, MPH, founder of Caravan Health, which was acquired by CVS Health through its acquisition of Signify Health, exposed what the annual TV ads do not make clear, that their 800 numbers go to brokers, not to any one plan.

“This is not the big, lovely, glowing success that everybody says it is. And we continue to create policies that drive people into these plans. Medicare allows money paid to MA plans to be used for broker commissions as high as “$600 to recruit them, plus $300 a year every year that they stay in the MA plan.

“We have allowed MA to buy the market, and that is why MA is growing. It’s not because the quality’s so great. People don’t love the prior auth, people are leaving their plans a lot. Aside from Medicaid, Medicare is the least profitable payer for doctors. And at the same time, we give all this money to the plans. It’s unconscionable.”

Adding to the “kerfuffle” with a powerful anecdote, Stacie Dusetzina, PhD, of Vanderbilt University Medical Center in Nashville, Tennessee, noted that even cancer patients often have trouble getting necessary care because of the plans’ limited networks. She referenced a January 7 NPR story³ about an MA enrollee who could not get the cancer care he needed from his MA plan, and could not get out of the plan without facing 20% in expensive copays. In all but four states, supplemental plans that could pick up the difference can reject patients with costly conditions.

“When you are 65 and aging into the program,” Dr. Dusetzina summarized, “you are healthy at that time and may not be thinking about your long-term needs. [If you did], it would push you to think harder about the specialty networks that you may or may not have access to when the MA plan is making your healthcare decisions.”

1 A 30-page slide presentation is available to the public at medpac.gov/wp-content/uploads/2023/10/MedPAC-MA-status-report-Jan-2024.pdf. The complete report is available only to MedPAC commissioners. The charts on slides 26 and 27 show how MA plans learned to pad profits in 2018 and increased the practices exponentially since then.

2 Cheryl Clark, MedPage Today January 16, 2024 medpagetoday.com/special-reports/features/108275

3 npr.org/2024/01/07/1223353604/older-americans-say-they-feel-trapped-in-medicare-advantage-plans

Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. RowanResources.com; Tim@RowanResources.com

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

CMS Proposes Policy Changes to Medicare C & D

CMS

by Rowan Report | Dec 13, 2023 | CMS, Regulatory

From the NAHC Newsroom

Public comments due January 5, 2024

CMS Policy Changes to Medicare C & D. On November 5, 2023, the Centers for Medicare & Medicaid Services (CMS) issued the Contract Year 2025 Policy and Technical Changes to the Medicare Advantage Program, Medicare Prescription Drug Benefit Program, Medicare Cost Plan Program, and Programs of All-Inclusive Care for the Elderly; Health Information Technology Standards and Implementation Specifications.

Key provisions in the CMS policy changes that are of interest to home health and hospice providers are detailed below.

Behavior Health

CMS aims to improve access to behavioral health care by adding certain behavioral health provider specialties to the MA network adequacy standards as a new facility-specialty type. The new facility-specialty type, ‘‘Outpatient Behavioral Health,’’ can include Marriage and Family Therapists (MFTs), Mental Health Counselors (MHCs), Opioid Treatment Program (OTP) providers, Community Mental Health Centers or other behavioral health and addiction medicine specialists and facilities.

Special Supplemental Benefits for the Chronically Ill (SSBCI)

CMS is proposing regulatory changes that would help ensure that SSBCI items and services offered are appropriate and improve or maintain the health or overall function of chronically ill enrollees. The MA organization must be able to demonstrate through relevant acceptable evidence that an item or service offered as SSBCI has a reasonable expectation of improving or to maintain the health or overall function of a chronically ill. The MA plan must follow its written policies based on objective criteria for determining an enrollee’s eligibility for an SSBCI when making such eligibility determinations. CMS is proposing to require that the MA plan document its denials of SSBCI eligibility rather than its approvals.

CMS will also modify and strengthen the current requirements for the SSBCI disclaimer that MA organizations offering SSBCI must use whenever SSBCI are mentioned. Additionally, CMS proposes to require MA plans to notify enrollees mid-year of the unused supplemental benefits available to them. The notice would list any supplemental benefits not utilized by the beneficiary during the first 6 months of the year.

Guardrails for Agent and Broker Compensation

CMS is proposing to generally prohibit contract terms between MA organizations and agents, brokers or other third party marketing organizations (TPMOs) that may interfere with the agent’s or broker’s ability to objectively assess and recommend the plan that best fits a beneficiary’s health care needs, CMS proposes to set a single compensation rate for all plans; revise the scope of items and services included within agent and broker compensation; and eliminate the regulatory framework which currently allows for separate payment to agents and brokers for administrative services. CMS also intends to make similar changes to the Part D agent broker compensation rules.

Health Equity and Utilization Management (UM)

CMS proposes to require that a member of the UM committee have expertise in health equity and that t the UM committee conduct an annual health equity analysis of the use of prior authorization. The analysis would examine the impact of prior authorization on enrollees with one or more of the following social risk factors (SRFs): receipt of the lowincome subsidy or being dually eligible for Medicare and Medicaid (LIS/DE); or having a disability.

Right To Appeal an MA Plan’s Decision To Terminate Coverage for Non-Hospital Provider Services

Beneficiaries enrolled in Traditional Medicare and MA plans have the right to a fast-track appeal by an Independent Review Entity (IRE) when their covered skilled nursing facility (SNF), home health, or comprehensive outpatient rehabilitation facility (CORF) services are being terminated. Currently, Quality Improvement Organizations (QIO) act as the IRE and conduct these reviews. Under current regulations, MA enrollees do not have the same access to QIO review of a fast-track appeal as Traditional Medicare beneficiaries. CMS proposes to (1) require the QIO, instead of the MA plan, to review untimely fast-track appeals of an MA plan’s decision to terminate services in an HHA, CORF, or SNF; and (2) fully eliminate a provision that requires the forfeiture of an enrollee’s right to appeal a termination of services decision when they leave the facility. These proposals would bring MA regulations in line with the parallel reviews available to beneficiaries in Traditional Medicare and expand the rights of MA beneficiaries to access the fast-track appeals process.

Dual eligible Special Needs Plans (D-SNP)
CMS proposes to increase the percentage of dually eligible managed care enrollees who receive Medicare and Medicaid services from the same organization.
CMS is also proposing to limit out-of-network cost sharing for D–SNP preferred provider organizations (PPOs) for specific services.

Further, CMS is proposing to lower the D–SNP look-alike threshold from 80 percent to 70 percent for plan year 2025 and 60 percent for plan year 2026. This proposal would help address the continued proliferation of MA plans that are serving high percentages of dually eligible individuals without meeting the requirements to be a D–SNP.

The National Association for Home Care and Hospice will continue to analyze the proposed rule, but supports CMS’ aim to protect Medicare beneficiaries by modifying policies and procedures that will improve programs under Part C and Part D.

Public comments are due January 5, 2024.

CMS is Already Hurting Home Care and Now MedPAC Wants to Make it Worse

CMS

by Kristin Rowan | Dec 13, 2023 | CMS, Regulatory

by Kristin Rowan, Editor

Last week, MedPAC met for their December meeting to discuss “Assessing payment adequacy and updating payments.” Hospice services and Home health care services were each presented separately to Congress and commissioners are set to review the key indicators and discuss updates to Medicare payment rates for 2024.

The findings presented to Congress gave me whiplash.

Hospice Services

There is ‘mixed evidence’ on whether hospice reduces Medicare expenditures, but is has important benefits for beneficiaries
2021 saw a 6% increase in hospices, mostly in for-profit agencies
Hospice use rates are down overall, but MedPAC blames the effects of the pandemic on death rates and patterns of care
Hospice use continues to shift from SNFs to in-home care
In 2020, 18.6% of hospices exceeded the payment cap
MedPAC recommends the cap be wage adjusted and reduced by 20%

See the full Hospice Services presentation to Congress here.

Opinion

Of the 18.6% of hospices that exceeded the payment cap in 2020, 17.2% of those were also in the highest bracket of hospice providers with stays longer than 180 days. The payment cap is not enough to cover patients who need hospice care for longer time periods, even though the requirement for hospice care is expected death within 6 months. If hospice is intended to care for a patient for 180 days, shouldn’t the payment cap be equal to 180 days of care? If a hospice provider is caring for a patient for longer, shouldn’t they get paid more?

MedPAC is convinced that lowering the cap would only impact those hospice providers who have the longest stays. However, if those hospices can no longer provide care because the payment cap has been reached, it will fall to other providers to continue care, stretching the already overworked hospice nurses even thinner.

Home Health Care Services

The Bipartisan Budget Act (BBA) of 2018 prompted CMS to implement PDGM and required MedPAC to review PDGM in its first year of operation
BBA 2018 changes must be budget neutral
CMS issued a $2 billion one-time reduction for overages and a 3.925 percent permanent reduction
The decline in the number of Home Health Agencies continues
The number of FFS beneficiaries declined, but the per capita use of HHS increased
The median Medicare margin (profit) for efficient providers is 28.4 percent, but only 14% of HHAs met cost and quality criteria
The median Medicare margin indicates Medicare payments are too high

Opinion

This makes about as much sense as the new phenomenon “dog math.” 14% of all Home Health Care agencies are considered efficient. On average, those who are efficient have a 28% Medicare profit margin. Among 133 industries reporting gross profit margins across the U.S., a 28% profit margin puts Home Care Agencies at number 104 out of 133, much lower than the average or median profit margins of every other industry.¹ The all-payer margin is about 12%, making them the second least profitable industry in the U.S., coming in only slightly higher than auto manufacturers. The smallest HHAs have a profit margin just under 6%. MedPAC’s stance seems to be that if an HHA is making enough money to barely survive, they are making too much money.

See the full Home Health Care Agency presentation to Congress here.

©2023 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Home Care Technology: The Rowan Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

Medicare Advantage Dominated November News

CMS

by Tim Rowan | Dec 6, 2023 | CMS, Regulatory

by Tim Rowan, Editor Emeritus

MA Plans Continue to Exaggerate Patient Conditions for Profit

Medicare Advantage for Profit

As we reported in October (More MA Plans Caught Inflating Patient Assessments, 10/11/23), insurance companies operating Medicare Advantage plans routinely pad the patient assessments that set their monthly revenue from the Medicare Trust Fund. Worse, CMS bowed to industry pressure earlier this year and agreed not to extrapolate the amount of the fraudulent payments, as it does with Home Health and Hospice overpayments (Government Lets Health Plans That Ripped Off Medicare Keep the Money, 2/22/23).

Now, we hear that the HHS OIG has totaled its 2023 audits and announced it found over $213 million in padded Medicare Advantage overpayments so far this year. In its latest semiannual report, covering fraudulent patient assessments between April and September, the OIG said it recovered $82.7 million. Total recoveries would have been higher except for that CMS ruling that prevents the agency from extrapolating payments before contract year 2018.

Will SEC Allow Cigna/Humana Marriage?

Early last month, Bloomberg broke the news that Cigna was in talks to sell its Medicare Advantage business to Health Care Service Corporation, the parent company of BCBS in Illinois, Texas, New Mexico, Montana and Oklahoma. Should that sale be approved, it would remove an obstacle to Cigna’s rumored desire to merge with Humana.

Though approval is uncertain — the SEC has squashed more than one similar attempt under both the current and former Presidents — it would create what Axios called “another Titan” that would rival UnitedHealth Group and CVS Health in size. CVS acquired Aetna in 2018. It would also combine two Pharmacy Benefit Managers, giving the new entity control of a third of the market, which would be equal to the market share owned today by CVS.

In 2017, a proposed merger between Cigna and Elevance Health, formerly Anthem, was struck down in court. A proposed merger between Humana and Aetna was also canceled in a federal court the same year. Large, powerful insurers, and the PBMs they own, have come under increased scrutiny from federal regulators.

The Biden administration has already launched a warning shot, indicating it will be scrutinizing private equity acquisitions in health care. In September, the Federal Trade Commission sued private equity firm Welsh, Carson, Anderson & Stowe after it bought up nearly all of the anesthesiology practices in Texas and then, with competition removed, began to jack up prices. FTC chair Lina Khan made it clear the suit was intended to send a message to all consolidation attempts that might harm patients.

United to Change Prior Authorization Policy

According to a November 27 policy update from UnitedHealthcare (UHC), the payer is updating its Home Health prior authorization and concurrent review process for services that are delegated to Home & Community Care, the payer’s home care division.

The updated policy, which are set to take effect January 1, will affect United’s Medicare Advantage and Dual Special Needs plans in 37 states, a UnitedHealthcare news release stated.

In Summary

Start of care visits still do not require prior authorization.
Providers must notify Home & Community Care of the initiation of home care services. UHC encourages providing notice within five days after the start of a care visit to help avoid potential payment delays.
Before the 30th day, providers must request prior authorization for days 30 to 60, by discipline, and provide documentation to Home & Community Care.
For each subsequent 60-day period, providers must request prior authorization, by discipline, and provide documentation to Home & Community Care during the 56- to 60-day recertification window.

UHC says it will respond to questions about the prior authorization approval process at HHinfo@optum.com

In related news, in its annual investor conference call, the company projected “revenues of $400 billion to $403 billion, net earnings of $26.20 to $26.70 per share and adjusted net earnings of $27.50 to $28.00 per share” for 2024. Cash flows from operations are expected to range from $30 billion to $31 billion.

Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com
Tim@RowanResources.com

©2023 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. homecaretechreport.com One copy may be printed for personal use: further reproduction by permission only. editor@homecaretechreport.com