On March 15th, the Centers for Medicare & Medicaid Services (CMS) issued a Center Informational Bulletin (CIB) that provides guidance and flexibilities to mitigate the impacts on providers resulting from the Change Healthcare Hack. In the guidance, CMS advises state Medicaid agencies that certain requirements will not be enforced, until June 30th, to enable ongoing funds to flow to providers and to prevent disruption of access to Medicaid services, prevent associated negative health outcomes, and avoid solvency issues for providers.
The most important component of the guidance is the ability for states to make interim payments to providers to avoid operational disruptions. Federal law and regulation does not allow for “advance payments” in Medicaid fee-for-service systems, despite their availability in Medicaid managed care environments; however, states can make interim payments to providers subject to reconciliation with actual services delivered.
CMS stresses that such interim payments are not advanced payments or prepayments prior to services furnished by providers, but rather are payments for services furnished that are subject to final reconciliation once the state has access to individual claims data currently inaccessible due to the cybersecurity incident.
The flexibilities CMS discusses in the guidance include:
Modifying required timelines for public notice, public process, and Tribal consultation and to obtain an earlier effective date for certain kinds of SPAs than would otherwise be possible;
Use interim payment methodologies to pay providers without current period claims data, as long they are determined via current approved payment rates, limiting the interim payments to the amount expected for each specific provider based on recent history, and reconciling the interim payments with final payments based on the actual services provided once they can be properly identified. These could be effective retroactively to the date when claims payment processing was disrupted due to the cybersecurity incident and could last until June 30, 2024;
Suspend beneficiary cost sharing requirements described in their state plans when necessary to avoid service disruptions for Medicaid beneficiaries for services affected by the hack;
CMS also includes language urging Medicaid managed care plans to make prospective payments to impacted providers and reiterating that plans do not need prior CMS authority to make prospective payments to providers. CMS also indicates that plans can:
Suspend or modify prior authorization requirements;
Allow early prescription refills and/or extend the length of prescription refills;
Extend existing prior authorizations;
Suspend out-of-network requirements; and
Modify or update cost-sharing requirements to be consistent with any changes that are made in the Medicaid state plan.
This week, we look at the state of the healthcare industry, vis a vis payers that do not pay.
While Home Health and Hospice leaders talk at every gathering about refusing to accept Medicare Advantage clients, some large Integrated Healthcare Systems are actually doing it. Other hospitals are responding to difficult payers by laying off staff, or even closing. The HHS Office of Inspector General repeatedly fines insurance companies for upcoding to gain inflated, unjustified monthly payments. Meanwhile, insurance companies report record profits, with their MA divisions leading the way. The fines go into the “cost of doing business” column.
March, 2024, Becker’s Hospital Review: Bristol (Conn.) Health will eliminate 60 positions, 21 of which are currently occupied and will result in layoffs at Bristol Hospital. The hospital’s CEO, Kurt Barwis, told a local newspaper a lack of reimbursement from insurers left the hospital without a choice but to cut staff.
October, 2023, NPR: Since 2010, 150 rural hospitals have closed. Under CMS’s “Critical Access” designation, Medicare pays extra to those hospitals to compensate for low patient volumes. MA plans do not. Instead, they offer negotiated rates that are lower than what traditional Medicare would pay.
December, 2023, Becker’s Financial Management: 13 additional hospital systems cut ties with Medicare Advantage plans since October.
What is going on?
The Medicare Payment Advisory Commission, MedPAC, believes it has learned the answer. In its March 15, 2024 report to Congress, the Commission called for a “major overhaul” of Medicare Advantage policies. It says it found that the program, designed to lower costs and extend the lifespan of the Medicare trust fund, does not save money but costs the fund more than if all beneficiaries were on traditional Medicare, $83 billion more in 2024.
Calling it, too politely, “coding intensity,” MedPAC concurs with the OIG that MA plans routinely exaggerate patient conditions. The report claims it will amount to MA clients appearing to need 20% more healthcare than fee-for-service beneficiaries, when they do not. Padded coding, MedPAC says, will increase Medicare premiums by $13 billion in 2024.
“A major overhaul of MA policies is urgently needed for several reasons,” the commission wrote in its report. MedPAC cited several problems that need to be addressed, including the disparity in costs between beneficiaries in fee-for-service Medicare and MA, a lack of information on the use and value of supplemental benefits, and challenges setting benchmark payment rates.
A proposal currently making its way through Congress would reduce supplemental payments to insurers, who threaten to raise premiums and cut benefits if their inflated benchmark payments are lowered.
“If payments to MA plans were lowered, plans might reduce the supplemental benefits they offer,” MedPAC wrote in its report. “However, because plans use these benefits to attract enrollees, they might respond instead by modifying other aspects of their bids.” The barrage of TV ads, featuring aging celebrities, have been found to be deceptive and too often backed by shady front companies representing brokers, not insurance companies. The brokerage company behind the Joe Namath ads, for example, has reorganized and changed its name three times.
Pushback from AHIP, the insurance industry lobbying organization, has been as expected. “MedPAC’s estimates are based on ‘speculative assumptions’ and ‘overlook basic facts about who Medicare Advantage serves and the value the program provides.'”
MedPAC asserts that its estimates are based on history, not speculation.
Healthcare Providers Beg to Differ
A lack of payments from Medicare Advantage plans is one reason the Connecticut hospital is laying off staff, the Hartford Courant reported March 14. CEO Kurt Barwis told the newspaper Medicare Advantage plans have been denying claims more frequently while delaying payments for the claims they do approve. “Our primary care is to take care of patients, their single focus is shareholder value and profits,” Mr. Barwis told the Courant. “The Medicare Advantage abuse is outrageous.”
The strategy insurance companies deploy to avoid providing care, Barwis continued, is excessive prior authorizations, coupled with delayed payments. This obstacle to care is directly in opposition to CMS policy. MA divisions of large insurers respond that they are private insurance and allowed to impose their own treatment approval policies. MedPAC says this claim is incorrect.
Richard Kronick, a former federal health policy researcher and a professor at the University of California-San Diego, said his analysis of newly released Medicare Advantage billing data estimates that Medicare overpaid the private health plans by more than $106 billion from 2010 through 2019 because of the way the private plans charge for sicker patients. Kronick added that there is “little evidence” that MA enrollees are sicker than the average senior, though risk scores in 2019 were 19 percent higher in MA plans than in original Medicare. That gap continues to widen.
Where does this excess taxpayer money go?
2023 Medicare Advantage business division profits and 2022 CEO compensation reported by publicly traded companies:
UnitedHealth Group: $22.4 B (Andrew Witty $20,865,106)
Aetna (CVS): $8.3 B (Karen Lynch $21,317,055)
Elevance Health (Anthem): $6 B (Gail Boudreaux $20,931,081)
Cigna: $5.1 B (David Cordani $20,965,504)
Centene: $2.7 B (Sarah London $13,246,447)
Humana: $2.5 B (Bruce Broussard $17,198,844)
We found one curious outlier. Molina Health, with annual revenue 10 percent of UnitedHealth Group’s income and 2.16 percent of the market, paid its CEO $22,131,256 in 2022.
Download the entire MedPAC 2024 report here. Chapter 7 is the Home Health section. A summary of MedPACs recommendations begins the chapter thus, “For calendar year 2025, the Congress should reduce the 2024 Medicare base payment rates for home health agencies by 7 percent.”
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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
The U.S. House Ways and Means Committee held a hearing on March 12, 2024 to address the need for access to care-at-home services in rural and underserved communities. The advisory board heard from several witnesses including two care at home patients, a medical doctor, the founder and CEO of Cadence, and a professor of Health Care Policy and Medicine at Harvard Medical School.
Committee Chairman Jason Smith (MO) said, in his opening statement, “Where someone lives, works or raises a family should not be a barrier to getting top of the line health care. One of our priorities on this Committee is helping every American get health care in their community.”
With the Medicare telehealth and Hospital at Home programs scheduled to expire at the end of this year, Smith is urging the committee to see the profound impact that lack of access to healthcare would have on patients in rural and underserved communities. He want on to say that the “tired approaches…have not made a meaningful impact for enough patients.”
Cutting edge technology and new approaches to make Americans healthier and increase access to care in rural areas are needed. Smith recommends examining provider reimbursement and adding patient and taxpayer protections to “ensure access, demonstrate value, and prevent waste, fraud, and abuse.”
Read Chairman Smith’s opening statement here. Watch the witness statements at the hearing here.
The American Telemedicine Association and ATA Action expressed appreciation to the Committee in a press release issued just after the hearing. “We are grateful to the House Committee on Ways and Means for examining the opportunities in moving care into the home in order to benefit patients, particularly those in rural and underserved communities,” said Kyle Zebley, Senior Vice President, Public Policy, the ATA and Executive Director, ATA Action.
Read the full press release from the American Telemedicine Association and ATA Action here.
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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
On Monday, March 11th, President Biden released a $7.26 trillion proposed budget for fiscal year (FY) 2025, which begins October 1st, 2024. While the White House budget is simply a request and Congress has final say on government spending, it does provide a window into the president’s priorities and where his administration wants to direct its efforts going forward. Lawmakers have not yet finalized spending for the current fiscal year — which runs through Sept. 30 — and will need to begin negotiating funding legislation for FY2025 simultaneously with ongoing debates over current fiscal year appropriations.
The FY2025 budget requests more than $130.7 billion to fund the Department of Health and Human Services (HHS). In addition to this $130.7 billion of requested appropriations, HHS also projects spending over $1.7 trillion on mandatory programs, such as Medicare and Medicaid, that are not subject to the annual appropriations process. Notably, the budget also would extend the Medicare sequester cuts by one year until 2032 (they were previously extended through 2031 by The Infrastructure Investment and Jobs Act of 2021), which would provide savings of around $7.6 billion. The budget also proposes to increase contributions to the Medicare trust fund and extend its projected solvency by increasing taxes on earned and unearned income for those individuals with annual income over $400,000 from 3.8% to 5%.
Over the coming weeks members of the Executive Branch will be testifying before key committees in the House and Senate to provide additional detail around the recommendations put forth in the budget documents. As additional relevant detail is made available, it will be covered in “NAHC Report.”
Provisions of interest in the Budget include:
Medicare
Multiple provider types:
HOME HEALTH
Create a Permanent Medicare Home Health Value-Based Purchasing Program: The Home Health Value-Based Purchasing Model, which the CMS Innovation Center launched in 2016 and expanded nationwide in 2022, successfully improved the quality of home healthcare at lower cost without evidence of adverse risks. This proposal converts the expanded model into a permanent Medicare program, similar to value-based purchasing programs already in place for other Medicare providers. [Budget Neutral]
HOSPICE
The Budget proposes to implement a new “value-based purchasing” (VBP) program for hospices (and many other provider sectors that do not already have a VBP program) starting in CY2027. No further details are provided about this VBP-for-hospice program, or the other sectors’ VBP programs, other than that they would be budget-neutral, and that CMS would consider granting “hardship exemptions” to certain providers. NAHC reminds members that just last week, CMMI decided to terminate the Value-Based Insurance Design (VBID) hospice “carve-in” demonstration at the end of CY2024 (the demo had been set to run through CY2030). Over the years, various policy stakeholders have floated different Medicare hospice benefit (MHB) payment reforms, and 2010’s Affordable Care Act legislation called on CMS to pilot test a VBP program for hospices, which it has not done to-date.
Medicaid
Mirroring previous year proposals, the budget includes $150 billion over 10 years to improve and expand Medicaid home and community-based services (HCBS).
The budget also proposes to require that states report on the national Medicaid Adult and HCBS Quality Reporting measures. Notably, this budget proposal seeks legislative authority to mandate this reporting while CMS included a mandate for states to submit HCBS Quality Reporting in their 2023 proposed Medicaid Access rule.
The Budget proposes to require a Medical Loss Ratio (MLR) for Medicaid and CHIP managed care organizations, with required remittances if plans do not meet the minimum standard. Current law allows, but does not require, states to impose a MLR on their health plans.
Proposes to authorize CMS to negotiate supplemental drug rebates on behalf of interested States in order to leverage savings from pooled purchasing power. (5.18 billion savings) As discussed in the State of the Union address, President Biden’s budget includes a proposal to create a Federal option that provides health care coverage to low-income individuals in States that have not expanded Medicaid. As a corollary to this proposal, the budget includes incentives for states to retain existing Medicaid expansions not default to the Federal Option. The budget contains several proposals to strengthen and streamline services for dual eligible individuals including:
Aligning Medicare Savings Programs and Part D Low income Subsidy Eligibility Methodologies to make it easier for states and individuals to determine eligibility and enroll in both.
Extending the Qualified Medicare Beneficiary (QMB) certification period. Currently states can limit QMB eligibility to periods less than one year, whereas this proposal would establish a 12-month eligibility certification. Provide CMS with the authority to unify appeals processes for Medicare and Medicaid review for individuals enrolled in integrated managed care plans by waiving amount-in-controversy minimums and allowing benefits to continue while an appeal is pending.
Allow retroactive coverage of Medicare Part B premiums for QMB applicants.
A proposal to allow CMS to issue partial deferrals and disallowances that target issues of noncompliance in managed care environments and to provide CMS with additional managed care enforcement options.
DEPARTMENT OF LABOR (DOL)/HEALTH CARE WORKFORCE
The President’s Budget proposes to establish a national, comprehensive paid family and medical leave program administered by the Social Security Administration to ensure all workers can take up to 12 weeks of leave to care for a seriously ill loved one. Further, the President continues to call on Congress to require employers to provide at least seven paid sick days per year to all workers, and to ensure that employers cannot penalize workers for taking time off to address the health needs of a family member.
The Budget expands workforce training along with creating career pathways to in-demand jobs through an $8 billion mandatory Career Training Fund.
Broadens Access to Registered Apprenticeships: The Budget increases support for Registered Apprenticeships, a training tool for future workforces in a number of in-demand industries, including health care.
The proposal seeks to invest $70 million in the Strengthening Community college training program, which builds community colleges’ capacity to design and deliver high-quality, evidence-based training programs.
Invests in Caregivers Support Programs through the VA. Recognizing the critical role family caregivers play in supporting the health and wellness of veterans, the Budget provides critical funding for the Program of General Caregivers Support Services. The Budget also specifically provides $2.9 billion for the Program of Comprehensive Assistance for Family Caregivers, which includes stipend payments and support services to help empower family caregivers of eligible veterans.
Nursing Workforce Development — The FY 2025 budget includes $320 million for Nursing Workforce Programs, an increase of $20 million above FY 2023. The budget includes an additional $10 million to address national nursing needs, train more nurses, and strengthen workforce capacity in education, practice, and retention. HRSA will support an increase in the number of nurses trained to provide prenatal care through investments in perinatal maternal healthcare in rural and underserved community settings to increase access and improve the quality of patient care. The investment also increases the number of nurse faculty and clinical preceptors which are critical to expanding nurse training and producing more new nurses.
The budget also includes an increase of $10 million for Advanced Nursing Education to bolster the maternal and perinatal workforce by supporting maternal health nurses available to provide specialized care. The program will continue to increase the number of qualified nurses in the primary care workforce, including nurse practitioners, clinical nurse specialists, and Sexual Assault Nurse Examiners.
Health Care Workforce Innovation Program — The FY 2025 budget invests $10 million for a new program to jumpstart strategies to grow the healthcare workforce and address healthcare workforce shortages across disciplines such as physicians, nursing, and behavioral health. This new program would invest in innovative approaches to accelerate the transformation of healthcare workforce training to support a modern, robust, and diverse workforce training pipeline.
HRSA supports the health workforce through health professions scholarships and loan repayments in return for service in underserved and rural communities. The FY 2025 budget requests $16.3 billion for HRSA, which is $2.0 billion above FY 2023. This total includes $8.3 billion in discretionary budget authority and $8.0 billion in mandatory funding and other sources.
PROGRAM INTEGRITY AND OVERSIGHT EFFORTS
The Budget includes a proposal to “Increase Private Equity and Real Estate Investment Trust Ownership Transparency in Long-Term Care Facilities.” This proposal continues the Administration’s aggressive oversight of Wall Street activity in health care and would require skilled nursing facilities with either of these ownership types, whether direct or indirect, to provide additional financial disclosures above and beyond other provider types.
The budget also includes a proposal that would modify the requirement that owners with a five percent or greater direct or indirect ownership must be reported on the provider/supplier’s enrollment application, to require owners with any percentage-level of interest be reported.
HHS states that “top priorities that would require additional funding for CMS include:
Increasing Medicare fee-for-service medical review, including the possible adoption of artificial intelligence (AI) and natural language processing technologies;
Addressing vulnerabilities identified by the Vulnerability Collaboration Council, report recommendations from the Government Accountability Office (GAO) and HHS-OIG, and emerging issues;
Increasing nursing home enforcement (e.g., ownership reporting validation, reviewing Part D data of beneficiaries who reside in nursing facilities, and supporting DOJ in cases brought under the False Claims Act related to quality of care) and enforcement of home and community-based services (HCBS); and
Quickly addressing fraud scams, as needed, above current levels.”
HHS states that OIG’s “key focus areas” will include managed care, nursing homes, and home and community-based services.
Health Equity
SURVEYS AND CERTIFICATIONS (MEDICARE & MEDICAID)
Generally and across provider types, CMS indicates in many places in the budget documents that they are struggling with survey backlogs, primarily amongst state survey agencies (SSAs), and mostly as a result of both lingering COVID impacts and multi-year stagnant funding from Congress for Survey & Certification activities. CMS states that “With years of flat funding, the Survey and Certification program can no longer meet statutory frequency requirements or adequately guarantee the safety and quality of care for patients receiving care in CMS certified facilities.”
They also write that “CMS forecasts an increased number of complaint surveys pending and overdue for investigation across all provider types, including some immediate jeopardy complaints. The concern with the backlog is further confounded by the aforementioned increasing number of complaints being reported as well as surveyors finding more serious quality of care issues when conducting onsite surveys. These findings result in longer surveys and possible onsite revisit surveys. They also indicate a general worsening in the quality of services being provided to patients and residents.”
Specifically for the hospice program, CMS states that “CMS did not meet the FY 2020 – FY 2022 target of 98% [of hospices surveyed within the last 36-months, as required by law] due to the COVID-19 Public Health Emergency (PHE) and reprioritization of survey activities based on guidance published throughout the PHE.”
“While Accrediting Organizations have eliminated backlogs resultant from the PHE, SAs still face challenges. As SAs reduce the backlog, we anticipate meeting the target goal of hospice facilities surveyed within the required 36 months in the upcoming years.” CMS indicates that for FY2022, the most recent year with complete data, 87.1 percent of hospices were surveyed in the last 36 months.
NAHC POSITION: “This is important data for NAHC’s advocacy around CMS’ flawed Special Focus Program (SFP) design and the CMS’ plan to launch the program at the end of 2024. Given that hospice surveys are such a critical component of the SFP algorithm, it is important that CMS use accurate and up-to-date survey data; however, the budget language here seems to indicate that CMS is not caught up on the hospice survey backlog and may not be able to ensure that all hospices have indeed been surveyed in the last 36 months for at the near future.”
The budget requests $492 million for Survey and Certification, an increase of $85 million or 21 percent above FY 2023, to fund Medicare and Medicaid provider survey and certification activities. If funded at this level, CMS claims it would have sufficient resources to ensure states:
Complete approximately 85% of the recertification surveys for statutory facilities (up from the current 65% via FY2024 levels), survey projected complaints in all facility types at an Actual Harm, Immediate Jeopardy (IJ), and Non-IJ High levels, address a portion of the current complaint backlog, and a proportional recertification survey frequency rate for non-statutory facilities with a focus on those facility types with higher beneficiary risks.
CMS also states that at this level, Hospice and ESRD facilities will have funding to perform initial surveys on new providers wanting to enter the program to gain Medicare and/or Medicaid certification
Additionally, the budget proposes, effective in FY 2026, to shift the funding mechanism for nursing home surveys from discretionary to mandatory appropriation and to increase the amounts to a level necessary to achieve a 100 percent nursing home survey frequency, adjusted annually for inflation.
ADMINISTRATION FOR COMMUNITY LIVING (FUNDING FOR AGING AND DISABILITY COMMUNITY-BASED ORGANIZATIONS)
The proposal includes $2.7 billion for ACL, which is an increase of $70 million on paper above FY 2023 amounts, but it effectively represents an approximately $112 million increase due to eliminating $42 million of earmarks in the accounting tables.
ACL requests an additional $10 million to expand their Direct Care Workforce Strategies Center and fund capacity-building grants to states to support building partnerships among state Medicaid, aging, disability, and workforce agencies; coordinating and leveraging programs and funding streams; and developing and testing strategies to attract, train and retain direct care professionals.
ACL also requests $1.1 billion for nutrition services, which is the largest part of the Older Americans Act and would be an increase of $83 million above FY 2023.
HEALTH RESOURCES AND SERVICES ADMINISTRATION
HRSA — $320M line item for Nursing Workforce Development (pg. 25):
Nursing Workforce Development &mndash; The FY 2025 budget includes $320 million for Nursing Workforce Programs, an increase of $20 million above FY 2023. The budget includes an additional $10 million to address national nursing needs, train more nurses, and strengthen workforce capacity in education, practice, and retention. HRSA will support an increase in the number of nurses trained to provide prenatal care through investments in perinatal maternal healthcare in rural and underserved community settings to increase access and improve the quality of patient care. The investment also increases the number of nurse faculty and clinical preceptors which are critical to expanding nurse training and producing more new nurses.
The budget also includes an increase of $10 million for Advanced Nursing Education to bolster the maternal and perinatal workforce by supporting maternal health nurses available to provide specialized care. The program will continue to increase the number of qualified nurses in the primary care workforce, including nurse practitioners, clinical nurse specialists, and Sexual Assault Nurse Examiners. (pg. 30)
HRSA — $10m line item for a Health Care Workforce Innovation Program (pg. 25)
Health Care Workforce Innovation Program – The FY 2025 budget invests $10 million for a new program to jumpstart strategies to grow the healthcare workforce and address healthcare workforce shortages across disciplines such as physicians, nursing, and behavioral health. This new program would invest in innovative approaches to accelerate the transformation of healthcare workforce training to support a modern, robust, and diverse workforce training pipeline.(pg. 30)
HRSA — $51m line item for Medical Student Education (pg. 25)
HRSA — “HRSA supports the health workforce through health professions scholarships and loan repayments in return for service in underserved and rural communities. The FY 2025 budget requests $16.3 billion for HRSA, which is $2.0 billion above FY 2023. This total includes $8.3 billion in discretionary budget authority and $8.0 billion in mandatory funding and other sources. (pg. 27)
DOJ Says “Knock on Our Door Before We Knock on Yours”
On March 7, 2024, the U.S. Department of Justice (DOJ) announced a new pilot program that includes financial incentives for whistleblowers to report violations. The new pilot program will be launched later this year following a process to develop and implement the pilot, which is expected to take ninety days.
The DOJ likens this new program to “the days of ‘Wanted’ posters across the Old West” in the sense that law enforcement has historically benefited by offering rewards for tips and information. When whistleblowers help the DOJ discover significant misconduct, they may benefit financially from monies recovered.
The goals of the pilot program are to:
Produce more evidence for successful white-collar criminal prosecutions
Impose more significant penalties on wrongdoers
Aid in prosecution of large-scale misconduct
Here are some details:
The core principle is that when individuals help DOJ identify significant misconduct that is otherwise unknown to DOJ, they may qualify to receive a portion of any resulting recoupments.
Payments to whistleblowers will be available only when:
All victims are properly compensated before whistleblowers
Whistleblowers provide truthful information
Information provided by whistleblowers is not already known to the DOJ
Whistleblowers are not involved in criminal activity
No other relevant financial disclosure incentive exists
The DOJ says that it expects the pilot program to increase the likelihood that employees will decide to report misconduct to the DOJ without first notifying companies that employ them. This result will significantly decrease benefits to companies that decide to self-report because the benefits of self-reporting are available only when the government does not already know about the misconduct. This incentive may produce a race to the DOJ by employers and their employees reminiscent of races to the courthouse.
These incentives also underscore the importance of making it clear in Compliance Programs that employees and contractors are required to report alleged misconduct to their employers/partners first before they tell outside third-parties. Certain woe will come to companies that ignore these allegations or, God forbid, retaliate against potential whistleblowers!
The DOJ and other fraud enforcers are generally enamored with whistleblowers and the information they provide. They are perhaps even more enamored with encouraging companies to self-report.
March 12, 2024, the National Association for Home Care and Hospice (NAHC), Leading Age, the National Hospice and Palliative Care Organization (NHPCO), and the National Partnership for Healthcare and Hospice Innovation (NPHI), published their findings from a 2023 survey on regulation. These findings were presented to Congress and CMS earlier this year. The organizations surveyed 133 respondents, who noted regulatory issues as the top concern for providers. Of particular concern was the audits that have been increasing steadily for years.
More than half of respondents said they have undergone simultaneous audits, usually the TPE and SMRC audits. 52.9% of respondents said they had multiple audits within six months of each other, conducted by different contractors, and more than half of those said they had to submit the same charts for each audit.
Hospice Auditor Issues
The findings indicate some issues with the training, knowledge, and integrity of auditors. Many respondents indicated having received denials of physician visits, documented separately from face-to-face visits, simply because they occurred on the same day. Some reported denials due to the absence of an IDG meeting even when no IDG meeting was required. Multiple respondents said the denial reasoning was copied and pasted from past denials and/or that the auditor did not seem to have read the documentation that was sent.
Auditing Inconsistencies
The report findings indicate that there are often delays in receiving audit results, sometimes up to 18 months. Some RAC audits had listed available dates for findings, but the findings were not actually available for several months after the listed date. Respondents also indicated that instructions from the auditors were presented using terminology that was not consistent with standard operating procedures in a hospice environment (read: auditors are using hospital lingo and expecting hospices to understand it).
Technical billing issues, when payments are denied not due ineligibility, but because of missing or incorrect information, can be corrected and then processed and paid. However, several respondents indicated that different MACs give different information on how process corrections for election statements and election addendums.
Gross Miscalculations
This was reported in the survey only once, but, as with any survey, extrapolating the data to the whole population, one must assume it has happened more than once: A hospice provider had a claim denied while under a CERT audit. The denial was due to the auditor decided that the patient was not terminally ill, even though the patient expired during the audit.
Recommendations for CMS
The organizations have some recommendations for changes:
CMS should re-focus its audit contractors on patterns and practices characteristic of providers that aim to minimize or avoid therapeutic care and supportive services that are required under the hospice benefit and fully reimbursed through the per diem payment.
CMS should require substantive education and training for all auditors that is consistent with the education given to providers to minimize inconsistencies.
CMS should increase transparency of audit contractor activity, including the number and types of audits being conducted, audit recovery amounts, results of audits by specific audit contractors, including reversal rates, top denial reasons and compliance with required timeframes for notification and review.
CMS should implement an informal mechanism to enable MACs and hospice providers to resolve technical claims denials prior to engaging in the formal appeal process.
CMS should require audit contractor medical reviewers to have an equivalent level of expertise and training in hospice care as the hospice medical director who certified a patient’s terminal illness.
According to a statement from NAHC, in 2023, the organizations have submitted 34 recommendations to CMS. To date, half of them have been implemented. They will continue to work with CMS toward enhanced transparency, equitable auditing, and targeting genuine fraud, waste, and abuse.
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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
Last week, I had the honor of speaking with three of the dynamic leaders of the International Home Care Nurses Organization (IHCNO). Between them, they have more than 150 years of nursing and administrative experience. Beyond that, they are some of the most engaging and amazing women I’ve had the pleasure of interviewing.
Meet the Team
Barbara Piskor is the outgoing President of IHCNO. She started working as a nurse in 1964 and has held positions in home health nursing, clinical nursing, administration, national surveying with the Joint Commission, and consulting.
Marilyn Harris is the IHCNO Treasurer. She became a visiting nurse in 1960, was an administrator for the VNA, and spent 20 years as a hospital-based agency administrator.
Susan Hinck is the incoming President of IHCNO. She become a home health nurse in the 1980s and has been a clinician, educator, administrator, and advance practice nurse.
History of IHCNO
IHCNO started as a grassroots organization to serve the care needs of nurses. Between 2009 and 20012, there were concerns about teaching and practice. The industry was expanding and was in need of consistency. This launched the development of a communication network of home care nurses. Their mission is “To communicate, connect, and collaborate with home care nurses around the globe.”
The first members of IHCNO identified then-current home care nurse issues and developed action plans, a committee, and the first international conference event, which was attended by nurses from thirteen countries its inaugural year. They have since added webinars, outreach, and organizational development and are working on developing international guidelines and standards.
The Conversation
Rowan Report: “Barbara, as the outgoing President, what do you hope for the future of IHCNO?”
Barbara Piskor: “For IHCNO to be effective in helping to develop the area of global excellence in home-based nursing. To be recognized as the “go-to” organization for what’s happening in home-0based care related to nursing, from prenatal through to aging in place. To give the message that real health care is in the home; it’s a privilege to be a guest in the home, delivering care. It’s how you get to know the person, their family, and their home situation.
RR: “Susan, as the incoming President, what are your plans and goals for IHCNO for 2024 and beyond?”
Susan Hinck: “IHCNO has always been a volunteer organization, which comes with some challenges. We are contracting with a management company to provide stability and continuity for the organization. The same committed group of people working full0time to grow the organization will benefit from having a management company overseeing logistics so we can focus on additional projects and work more with home care nurses in different countries. There are some countries and continents where home care is not as well developed. For example, South America and Africa have well developed programs for maternity and pediatric home care, but not for older adults.”
RR: “Marilyn, the IHCNO has offers research grants in your name. Tell me about the IHCNO research.”
Marilyn Harris: “The Marilyn D. Harris research grant offers financial support for nurse researchers around the world. After the submission period, applications go through an international review board and one research topic is chosen. In the past, we have funded research on topics like the use of simulation tools in home care and the transition from home care to hospice. This year we will award our sixth research grant.
“We also have a very active internal research department. We are currently studying the scope and standards of home-based nursing around the world. All countries have scope and standards of practice for nursing, but they are not specific to nurses in home-based care. There are a lot of differences in practice across countries.”
RR: “You also have an award program, right?”
Harris: “Yes, that’s right. The Daisy Foundation was established by Bonnie and Mark Barnes to honor their sone. The Daisy award is given to home nurses for extraordinary compassion and care. It’s a worldwide initiative awarded through nomination and blind review. You can find the criteria and nomination forms on our website: https://www.ihcno.org/.”
RR: “Barbara, besides the research, are there other initiatives IHCNO is working on?”
Piskor: “A lot of our focus has been on short-term post-acute care for recovery and rehabilitation. But, custodial care, long-term skilled care, especially for younger adults who need long-term help is one of the fastest growing segments in the home care industry, but it is hampered by reimbursement. Intermittent visit programs are partially covered by Medicare and some Medicaid reimbursement, but isn’t covered by private insurance unless the patient is placed in a nursing home.”
Hinck: “The U.S. can learn a lot from other countries. We spend twice as much on healthcare but are in worse health and have higher mortality rates.”
Piskor: “That’s so true. Another initiative we have is working with provider, practice-based, and educational entities to let people know that home care is a thing. Clinical rotations in home care are necessary in nursing programs. More people need home-based care than ever before and there aren’t enough nursing students aware that home care is an option for them.”
RR: “Susan, IHCNO recently became a membership organization. Can you tell our readers about the member benefits you offer?”
Hinck: “That’s correct. As of January, 2024, IHCNO is a member organization. The biggest benefit of being a member is having a community of nurses to talk to who know what it’s like to be a home care nurse. You can check in and let people know how things are going in your part of the world. We are fostering communication and collaboration among home care nurses around the globe.
“Membership also gets you discounts for IHCNO hosted conferences and webinars and a discount for our multidisciplinary journal Home Health CareNow. We also have individual and corporate-level memberships available.”
RR: “Thank you all for taking the time to share your story with us.”
We will continue to bring you research and news from IHCNO, starting with some of the published works that have come from the past research grant winners. If you have any questions about membership, the grants, the Daisy award nominations, or any of the resources and support available through IHCNO, please reach out to them through their website: https://www.ihcno.org/
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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
Late on Monday, March 4, the Center for Medicare and Medicaid Innovation (CMMI) announced it plans to formally end the Value-Based Insurance Design (VBID) Medicare Advantage hospice “carve-in” demonstration on December 31, 2024, and that it will not accept applications to the previously released CY 2025 Request for Applications (RFA) for the hospice component of the Model. In its announcement, CMMI stated that it made the decision to terminate the demo “after carefully considering recent feedback about the increasing operational challenges of the Hospice Benefit Component and limited and decreasing participation among MAOs that may impact a thorough evaluation”. CMMI recently solicited input on the carve-in via a public request for information (RFI).
NAHC was pleased to be able to provide detailed comments to the RFI highlighting our members’ ongoing concerns and frustrations with the demonstration and registering our deep skepticism that the model was necessary or appropriate for hospice patients and families. We are pleased to see CMMI has decided to end this particular demo, and we look forward to continuing to work with them to advance innovation in care delivery and payment models for people with serious illness.
Since the carve-in was first announced, NAHC has maintained our strong opposition to the premise that incorporating hospice into the Medicare Advantage was necessary or would lead to positive outcomes. In 2019, NAHC emphasized our “unqualified opposition” to the program when it was first unveiled, and after more details were released in the model’s first request for applications (RFA); We have continued to stress our concerns since model implementation began, working with our hospice members to solicit feedback and translate those experiences into direct advocacy with CMS, CMMI, and members of Congress. As early evaluation data and inputs highlight, the model has been extremely burdensome for both hospices and participating plans, and has had no measurable positive impact on beneficiary or family outcomes, care experiences, or Medicare spending.
In the announcement about the model’s termination at the end of 2024, CMMI stated that the decision is not a result of the demo “not meeting its goals”, and that the agency will continue its evaluations of the hospice component to assess its overall impact. Over the course of the three years of the model, it was clear to NAHC that the demo was not meeting CMMI’s stated goals to drive greater care continuity and higher quality hospice care for beneficiaries and families. We also questioned the premise that a carve-in would save the Medicare program money in the long run. Contrary to what the VBID evaluators found, the seminal 2023 NORC research demonstrated that hospice utilization in the traditional Medicare program saves billions of dollars a year while delivering high-quality care.
CMS also indicated in their notification that later this year, they will issue additional guidance to ensure that “all obligations of any impacted organization may be met in a timely and reasonable manner so that hospice beneficiaries in the Hospice Benefit Component maintain a coordinated, seamless care experience.” NAHC will be following up directly with CMMI to better understand what may be included in this guidance and when it may be released.
Increasing access to hospice care remains NAHC’s primary policy goal. We are committed to working to improve more timely connection to hospice, reducing the percentage of very short stays that make it difficult to benefit fully from the hospice model, and ensuring every provider is capable of delivering high-quality, person-and-family-centered services. We appreciate our engagement with CMMI on the carve-in over the years, and we welcome the opportunity to collaborate with them on new ways to support seriously and terminally-ill people and their families.
CMS recently issued guidance about how to build and maintain worker registries, i.e., management platforms, that make qualified health workers easy to find so that more individuals who receive Medicaid-covered home and community-based services (HCBS) can receive care in settings of their choice. Worker registries are designed to answer these questions: Who is qualified to provide HCBS in each state and how can Medicaid recipients find them?
On February 27, 2024, CMS announced several new initiatives and Resources from the Administration for Community Living’s (ACL) Direct Care Workforce (DCW) Strategies Center to address the shortage of workers who provide direct care to elderly and disabled clients. New initiatives include several types of assistance that are intended to help states strengthen their systems for recruiting, retaining, and developing direct care workers; and a national hub to connect states, stakeholders, and communities to best practices and other resources related to the direct care workforce.
Specifically, DCW Intensive Technical Assistance will facilitate collaboration among state agencies and with stakeholders to improve recruitment, retention, training, and professional development of direct care workers. The DCW Strategies Center will provide up to two hundred fifty hours of individualized technical assistance on a variety of issues for up to six teams involving multi-agency state teams.
A coach will be assigned to each team and have access to subject matter experts to support them in addressing states’ unique needs. Support provided through this initiative will be coordinated by a consortium led by ADvancing States in partnership with the National Association of State Directors of Developmental Disability Services and the National Association of State Medicaid Directors.
The DCW Peer-Learning Collaborative will bring representatives of four to six states into working groups focused on a particular topic. The DCW Strategies Center will host monthly virtual meetings focused on group learning to facilitate information sharing on best practices, innovative strategies, and demonstrated models for growing the direct care workforce. In addition, each participating state will receive up to seventy hours of individual technical assistance on a topic or issue important to each state. Each participating state is expected to accomplish at least one policy or program-related milestone as a result of participation in this initiative.
CMS also announced the official launch of the DCW Strategies Center website at https://acl.gov/dcwcenter. This website is intended to serve as the national hub for resources about best practices, promising strategies, upcoming events, webinars, and technical assistance opportunities to strengthen and expand local direct care workforces.
CMS acknowledges in the announcement that low wages, lack of benefits, limited opportunities for career growth, and other factors have resulted in a continuing shortage of critical workers. The shortage reached crisis levels, says CMS, during the COVID-19 pandemic and currently continues, with more than three-fourths of service providers that decline new clients and more than half of providers cutting services.
According to CMS, the problem described above must be addressed in order to help ensure that people who need assistance have options other than moving to a nursing home or other institutional setting.
Now is the time for providers of private duty or home care services and the associations that represent them to work intensively with state programs, especially Medicaid Programs, to maximize available assistance as described above.
**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
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: 
