by Elizabeth E. Hogue, Esq. | May 23, 2024 | Clinical, Regulatory
by Elizabeth E. Hogue, Esq.
Preferred Provider Agreements as Referral Source
In a highly competitive marketplace, home care providers of all types, including home health agencies, hospices, private duty/home care companies and home medical equipment (HME) suppliers are looking for a “leg up,” especially for patients with certain types of payors. Providers may be able to cement important referral sources using Preferred Provider Agreements. For example, a provider may wish to approach an assisted living facility (ALF) to see if it is interested in a preferred provider relationship. If so, then management of the ALF may want to sign a Preferred Provider Agreement in order to further a relationship with this provider.
Problems with Preferred Provider Agreements
The anti-kickback statute may apply if providers involved in referral arrangements receive any type of federal or state funds, including, but not limited to, payments for services provided from Medicaid waiver programs, managed Medicaid programs, the Tri-Care Program, the VA, or any other state or federal programs. The anti-kickback statute generally says that anyone who either offers to give or actually gives anyone anything in order to induce referrals has engaged in criminal conduct. There are, however, several exceptions to this statute that may be applicable.
How to Assess Your Preferred Provider Agreements
Providers should ask two crucial questions about the application of the anti-kickback statute to referral arrangements:
- Is there a kickback or rebate?
- If so, is there an exception or “safe harbor” that permits the arrangement even though it would otherwise violate the statute?
kickback or rebate occurs when a provider receives referrals from another provider and something flows back to the referral source from the provider who received referrals. If there is a kickback or rebate, providers must automatically ask the second question listed above. If they fail to utilize applicable exceptions, they may miss out on useful marketing strategies that are likely to result in numerous referrals.
With regard to Preferred Provider Agreements, however, it is important to note that they can be structured so that no money or anything of value changes hands between providers and the other party involved. If so, there is no kickback or rebate.
Patient Choice
The parties to Preferred Provider Agreements must also make certain that they honor patients’ choices of providers. There are a number of sources of patients’ right to freedom of choice of providers applicable to preferred provider arrangements, including:
- Court decisions or the common law says that all patients – regardless of payor source, type of care rendered, or types of providers involved – have the right to control the care they receive and who provides it.
- A federal statute that guarantees all Medicare and Medicaid patients the right to freedom of choice of providers. This statute may be applicable if either party receives reimbursement from the Medicare or Medicaid Programs.
When patients express preferences for certain providers, however, their choices must be honored despite the existence of Preferred Provider Agreements. The agreement of the parties to honor patients’ choices should be included in Preferred Provider Agreements.
Final Thoughts
The market to provide services to patients in their homes is expanding, but the competition for referrals among providers seems to be extremely fierce. Providers are well advised to utilize Preferred Provider Agreements to help them to increase and/or maintain referrals in order to help ensure profitability.
©2024 Elizabeth E. Hogue, Esq. All rights reserved.
No portion of this material may be reproduced in any form without the advance written permission of the author.
by Rowan Report | Apr 26, 2024 | Admin, Clinical, CMS, Regulatory
by Johnathan Eaves, Senior Director of Communications, Axxess
Treating Medicare patients comes with a level of nuance that is important to understand to ensure that organizations remain compliant and patients receive appropriate care. Standards for quality care and payment can sometimes be dictated by Medicare’s payment policies and at other times be decided by the Conditions of Participation. There is an important difference between these two governing principles that providers should understand to ensure compliance.
Care at home industry veteran and Axxess Senior Vice President of Clinical Services Arlene Maxim RN, HCS-C, offered insights into the differences between Medicare’s policy and its Conditions of Participation during a recent webinar.
Explaining the Difference
Maxim pointed out that the differences between policy and the conditional requirements comes down to what can be billed and what are the quality standards for the services provided.
“The Conditions of Participation are dealing primarily with quality, whereas Medicare policy is related to payment,” said Maxim. And while there is a difference, that doesn’t mean both aren’t important and must always be followed.
“If Medicare policies are not followed, you are audited and if you do not have documentation to support those policies, you’re not going to get paid,” said Maxim “Oftentimes, with PDGM, staff members are not getting past that first 30 days. They’re not understanding what they need to do to keep that patient who continues to qualify for services on for longer.”
Maxim says that the problem is often that clinicians do not understand Medicare policy. “Every piece of documentation we submit to the Medicare program for review [needs to be] as pristine as we can possibly get it,” she said.
Assessment and Documentation
Proper assessment and documentation is something Maxim feels is critical in ensuring quality care, meeting Medicare requirements, and receiving payment for services.
“Complete and detailed documentation is going to be the key for agency payment by the Medicare program,” Maxim said.
Maxim pointed out certain services covered under Medicare policy may include observation and assessment, management and evaluation of a care plan, maintenance therapy, teaching and training activities, administration of medications, wound care, ostomy care, rehab nursing, venipuncture, skilled nursing visits, and more.
She also cautioned that agencies need to be prudent with the funds they receive from Medicare, viewing them as a potential “short-term, interest-free loan” until undergoing any audit. Until their documentation is reviewed and approved, there are no guarantees.
“Medicare is an insurance and it’s not free,” said Maxim. “Medicare policy provides us with a list of covered items. If experiencing an audit, and if the documentation is not there to cover the covered service, you’re not in compliance with that Medicare policy and you will not be paid for the services.”
Communicating With Physicians
Maxim further emphasized the importance of frequent contact with physicians, adherence to care plans, and ensuring that care plans are simple with individualized plans and goals that are achievable.
“You want to make sure that you have orders that physicians are actually going to read and to determine that they make sense and they’re going to sign off on them,” said Maxim.
“Keep your plan of care simple.”
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Axxess Home Health, a cloud-based home health software, streamlines operations for every department while improving patient outcomes.
© 2024 Axxess. For reprint permission, please contact The Rowan Report: kristin@therowanreport.com
by Rowan Report | Apr 26, 2024 | CMS, Medicare Advantage, Regulatory
By Beth Noyce, RN, BSJMC, BCHH-C, COQS
CHAP-certified home health & hospice consultant
This is part 3 of the 3 in the series, outlining the discussions and implications in adopting new outcome and process measures for Hospice care. The final segment addresses future process and outcome measures that the board discussed, but did not yet implement. Read Part 1 on Outcome Measures and Part 2 on Process Measures.
The TEP discussed potential future process and outcome measure concepts that Abt Associates presented to the panel as well.
The process measures included:
- Education for Medication Management
- Wound Management Addressed in Plan of Care
- Transfer of Health Information to Subsequent Provider
- Transfer of Health Information to Patient/Family Caregiver
Hope-based outcome measures were:
- Patient Preferences Followed throughout Hospice Stay
- Hospitalization of Persons with Do-Not-Hospitalize Order
Developing education for medication management as a process measure was a popular concept, and the top priority of the recommended measures with the TEP as they “broadly agreed that CMS should develop this measure,” the report says, citing “a significant need for training in medication management for patients and their caregivers.” They recommended that the measure weigh more heavily when care is provided in a home setting than in a facility setting because hospices are unable to control facility training and hiring practices. One panelist commented that including the phrase “during today’s visit” in the measure is important.
Whether CMS should further develop the process measure addressing wound management in the plan of care was less straight-forward, as panelists provided varied feedback. They generally agreed that this measure is important, as having a record of wound management addressed in the plan of care can hold the staff accountable for treating the wounds. But some members recommended measuring wound management with outcome measures rather than process measures. One panelist cited potential problems from patients’ deterioration over time and another noted that the time frame of this measure is important, and encouraged recording the process of getting care in place once a wound is identified. The panel agreed CMS should carefully define the measure’s specifications.
Because standard practice for most agencies is, when a patient is discharged live, to transfer health information to the subsequent provider and to the patient and family or caregiver, TEP members expressed that the two measures were likely to “top out,” meaning they would almost always be marked “Yes,” making them of no value in differentiating between hospice providers. The group generally discouraged developing these process measures.
The group strongly rejected any merit in developing two outcome measures concerning Patient Preferences Followed Throughout Hospice Stay and Hospitalization of Persons with Do-Not-
Hospitalize Order. The report says “Multiple TEP members described situations in which patients who had preferred not to be hospitalized changed their minds when a crisis occurred. Patients’ preferences and unexpected crises are usually out of the hospice’s control. Although it is still important for hospices to ask patients about their preferences as part of patient-centered care, the TEP did not believe these two items would be practical measures of a hospice’s care quality.”
Dr. McNally expects that Abt. Associates will apply the HQEP TEP’s suggestions to the HOPE tool.
“Oh yeah, they did it,” he says. “Abt would come to a specific meeting with information, data, suggestions, and specific information about how these things would be measured. We’d give feedback. Then they’d come back to the next meeting having incorporated our suggestions,” he explains. “All of us felt very much heard and responded to. It didn’t feel in the least bit perfunctory.”
Whatever specific measures are eventually included in the HOPE tool, Lund Person sees value in its implementation. “Hospice providers have had a woeful lack of outcome measures for hospice patients, which has made the evaluation of quality hospice care based only on process measures and the family’s evaluation of hospice care in the CAHPS® Hospice Survey, she explains. “Implementing HOPE will begin to identify outcome measures that can be compared between providers.”
Lund Person warns of potential challenges as well. “The selection of risk adjustment and stratification must be carefully done to minimize bias and maximize effectiveness of measures,” she says. “In addition, hospice providers have been awaiting the release of the HOPE tool with significant anxiety about content and administrative burden.”
Dr. McNally is confident the HOPE tool will be a healthy change for hospices.
“A lot of my role as a medical director and hospice physician is supporting our nurses,” he says. “They do 95% of the work. I really would like to see this not be burdensome for our hospice nurses. I’m looking forward to seeing what the [HOPE tool] beta testing translates to in our own hospice world.” He added “What I would hope to see is that the tool feels user-friendly to the hospice team, the people who have to use it, and that it also provides useful information to patients and families.”
NAHC’s Wehri says that standardizing processes through the HOPE tool is the key foundational element for the hospice industry. “High quality care is driven by reducing variance through standardized processes, Wehri writes. “Also, CMS will have a better idea of how the type of population a hospice serves impacts some of the clinical care.” This small glimpse into hospice variances that CMS does not currently have could be very helpful in future policy and payment decisions, according to Wehri. “What CMS finds in terms of differences between hospices and their care for patients may be a bit of a surprise to CMS,” she says. “I hope they are pleasantly surprised with the overall quality of care that is revealed.”
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Beth Noyce provides education, consulting, mentoring, compliance assessments and auditing services to home health and hospice agencies and their clinicians in several states. She also now provides patient and family guidance concerning hospice and home health services. Beth loves teaching and helping others succeed. She also makes available recordings of much of her education for her clients’ convenience.
©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com
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
