by Beth Noyce, RN, BSJMC, HCS-C, BCHH-C, COQS CHAP-certified home health & hospice consultant
Process Measures
The outcome measures being considered look at effectiveness of hospice clinical efforts to decrease pain and other symptoms. The process measures paired with them focus on the hospice’s follow up with the patient after moderate or severe symptoms are found during assessment.
Exhibit 6 (below) shows the numerator and denominator for these.
TEP members determined that these two process measures have high face validity. This means the measure items clearly state, or “look like” they will measure what CMS intends them to measure. This allows consumers to see what hospices are assessing and treating. It can also help hospices track how well they are reducing or treating patients’ symptoms.
Katie Wehri, Director of Home Health & Hospice Regulatory Affairs for the National Association for Home Care & Hospice says the face validity of process items is the most important information the HQRP TEP provided to CMS. “Having HOPE items and subsequent measures that actually measure what is intended is key to success,” she says.
Exclusions from Process Measures Success
Exclusions from calculating a hospice’s process measures’ success need careful consideration. Here is the list of options of which patients to exclude:
Patient desired tolerance level for symptoms
Patient preferences for symptom management
Neuropathic pain
Actively Dying (death is imminent)
Other conditions
The report says that reassessing a symptom within two days of identifying that symptom as moderate or severe is fundamental. This is true regardless of the beneficiary’s stated tolerance-level for symptoms. It also said that process measure calculations should include patients with no symptom-management preference. Further, exclusion criteria should be the same for pain and non-pain symptoms.
Neuropathic Pain
The TEP’s recommends including neuropathic pain in the HOPE tool’s pain-reassessment process measure. Including rather than excluding patients suffering neuropathic pain prompts nurses to reassess these patients for changes. The report references research that suggests 40% of hospice patients may experience neuropathic pain. Patients who experience neuropathic pain have more severe and more distressing pain symptoms. [Tofthagen, C., Visovsky, C., Dominic, S., & McMillan, S. (2019). Neuropathic symptoms, physical and emotional well-being, and quality of life at the end of life. Supportive Care in Cancer, 27(9), 3357-3364. doi:10.1007/s00520-018-4627-x]
The TEP agrees that patients with neuropathic pain should be part of the process measure. However, they recommend excluding the same patients from the outcome measure addressing the patient’s pain impact. The report cited TEP discussion that such pain is chronic and not likely to be resolved or decreased within two days when the reassessment captures outcome data.
The TEP broadly agreed that a nurse who assesses a patient who is actively dying (life expectancy of 3 days or fewer based on clinicians’ assessment) as suffering moderate or severe pain should attempt to reassess the patient. Such patientsshould not be excluded.
The panelists agreed that process measures should include patients of all ages. Several TEP members noted that all patients experience pain and non-pain symptoms, and therefore the measures should apply to adults and children alike.
Exclusion Due to Inability to Reassess
When a hospice is unable to reassess a patient for a valid reason process measures should exclude those patients.
Identified exclusion reason were:
discharge, alive or dead
visit refusal
inability to access the patient due to an emergency department or hospitalization event
the patient traveling outside of the hospice’s service area
inability of the hospice to contact the patient or caregiver.
However, the report says, “…hospices should be penalized if reassessment is missing or delayed due to hospice staffing or scheduling issues.”
This article is the second in a series about implementation of HOPE. Next week, Beth Noyce shares details from the panel as it discussed potential future process and outcome measure concepts.
A key purpose of the Health Insurance Portability and Accountability Act (HIPAA) is certainly to protect patient information. Another is to help ensure that patients have access to their health information. In fact, the Office of Civil Rights (OCR) of the U.S. Department of Health and Human Services, the primary enforcer of HIPAA, has focused on enforcement actions against providers that do not make information available to patients on a timely basis. OCR launched a right to access enforcement initiative in 2019 that is continuing.
Providers must give medical information to patients and their representatives within thirty days of requests. When they fail to do so, they may be subject to enforcement action by OCR. Following are two examples of recent enforcement actions.
OCR announced on April 1, 2024, that Essex Residential Care in New Jersey will pay a civil money penalty of $100,000 to resolve violation of HIPAA’s right of access standard. This is the 48th settlement reached under the right of access initiative. OCR received a complaint in May of 2020 from the personal representative of the estate of a patient who passed away. Following an investigation by OCR, the personal representative, who was the son of the patient, received the records in November of 2020. The provider did not contest the fine.
In another recent case, the daughter of a patient who passed away was appointed as the personal representative of her mother’s estate. She made multiple requests to Phoenix Healthcare for a copy of her mother’s medical records. She finally received the records one year after her initial request. Phoenix Healthcare initially received a civil money penalty of $250,000 for failure to provide timely access.
The provider appealed. An administrative law judge (ALJ) upheld the violation and ordered Phoenix to pay a civil money penalty of $75,000. The Departmental Appeals Board affirmed the ALJ’s decision. Then Phoenix agreed to settle for $35,000 and waived the right to further appeals. While it may seem in this case that the provider’s appeals significantly lowered its costs, it is important to note that the provider also undoubtedly expended significant resources on two appeals of OCR’s enforcement action.
Providers have placed a great deal of time and effort into the protection of healthcare information in compliance with HIPAA. Rightfully so, but providers seem to have lost sight of the fact that HIPAA is also about ensuring that patients and their representatives have timely access to their records. Now is the time for providers to conduct intensive education of staff members about HIPAA’s requirements regarding access in order to avoid enforcement actions like those described above.
For a few weeks now, we have been covering the Change Healthcare cyberattack by ALPHV/BlackCat and the subsequent updates from CMS. Pharmacy and medical orders have been delayed, providers and patients are suffering, and CMS has issued “guidance” with no real solution. Underground reports indicate that Change Healthcare paid $22 million to BlackCat following the first cyberattack and that BlackCat stole 6TB of data from the system. Change Healthcare has refused to respond to questions about the alleged payment. Three weeks after the attack, Change Healthcare started to come back online, starting with the pharmacy services, which returned on March 7th. Parent company UnitedHealth Group indicated that other services would return in the coming weeks.
Legal Action
More than 87% of physicians are see more than a 20% drop in daily claim submissions. As of April 9th, physicians are still reporting issues with cash flow and anticipate higher than expected losses due to financing and loans that may be needed to cover them as the effects of the attack continue. Rivals of Change Healthcare are reportedly onboarding hundreds of customers who have left the organization. One of these, Availity, has processed more than $5 billion in claims that were left unprocessed by Change Healthcare’s system and has onboarded 300,000 providers with a backlog of more than 50 health systems waiting to start using the platform.
The attack has caused long-term disruptions, delays, cash flow problems, patient care disruptions, prescription delays, and billing issues. Some physician practices have started using personal money to cover payroll and other expenses. The US Department of Health and Human Services (HHS) has launched a formal inquiry into Change Healthcare’s data protection standards. This inquiry follows six class action lawsuits filed against the organizations. Physicians were still reporting significant impacts on their claims.
Adding Insult to Injury
Change Healthcare has barely gotten their systems up and running were still putting out fires when they were hit again. On April 8, RansomHub contacted Change Healthcare and alleged to have 4TB of data stolen from the system and are demanding an extortion payment to keep the data private . RansomHub has threatened to sell the data, which includes US military personnel and patient data, medical records, and financial data, to the highest bidder in 12 days if the ransom isn’t paid.
Among the prevailing theories as to why Change Healthcare has been hit again is that the first ransom was supposed to have been split between ALPHV/BlackCat and an associate known as “notchy”, but ALPHV absconded with the ransom, leaving the other with nothing. Looking for a payout equal to what they lost, notchy partnered with RansomHub to try to recoup their losses. A second theory is that ALPHV and RansomHub are one in the same and that ALPHV went to ground after the ransom payout and have resurfaced as RansomHub. RansomHub, however, claims that after ALPHV went to ground, some of their affiliates joined the RansomHub operation and this is how they came by the data. Either way, it seems that the data stolen in the first attack was not returned after the ransom was paid and Change Healthcare is still susceptible to further extortion. This also means that the Change Healthcare system was not hacked a second time, but rather this is just an extension of the first data breach.
No word yet on whether Change Healthcare and UnitedHealth Group will pay the second ransom demand.
We will continue to follow this story and provide updates as it impacts payment and claims processing.
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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
By Beth Noyce, RN, BSJMC, HCS-C, BCHH-C, COQS Home health & hospice consultant
The Hospice Outcome Patient Evaluation is a step closer to implementation.
After four years of considering options, the Technical Expert Panel (TEP) has finished its work that will inform future Hospice Quality Reporting Program results. The TEP considered quality measures to include in hospice’s future assessment tool and best choices for risk adjustment and exclusion.
The panel convened in 2019 “[we are] committed to improving the quality of care given to hospice patients,” says the 2022-2023 TEP Summary Report: Hospice Quality Reporting Program. The panel aimed to ensure that hospice quality measures are meaningful for hospice beneficiaries, transparent to hospice providers, and useful to consumers. They considered quality measures from both HOPE and claims data.
“From day one it was very clear Medicare wanted to make this a very different experience for hospice teams and make it a more valuable thing for consumers,” says Dr. Jeff McNally, Hospice Medical Director at Utah’s Intermountain Hospice,” describing his participation on the HQRP TEP. “I was actually encouraged and inspired by it,” he says. “It was the first time I had first-hand experience working with any kind of CMS entity.
“The reality is some clinicians in the field and leaders don’t have the best things to say about CMS,” he explains, but “whatever we were considering we always circled back to whether it would be burdensome to the clinical team and would it be valuable to consumers.”
The panel initially planned to meet multiple times in person, with two meetings per year and potential virtual meetings as needed. “Then COVID hit,” Dr. McNally says. “It slowed the process considerably. We never did meet again in person.”
The HQRP TEP met eight times over four years, virtually after the initial meeting. McNally described participants as coming to each meeting prepared with data and proposals for HOPE measures for which they would request input from panelists.”
From TEP recommendations early in their work, Abt Associates developed two outcome measures and two process measures in harmony with hospice’s central tenet to manage symptoms:
Process measures:
Timely Reassessment of Pain Impact
Timely Reassessment of Non-Pain Symptom Impact
Outcome measures:
Timely Reduction of Pain Symptom Impact
Timely Reduction of Non-Pain Symptom Impact
“The most important [recommendations] were some of the outcome measures about symptom management,” McNally explains. “What should we be helping agencies show that they’re doing well? And how do we do that? Deciding which ones, and how many symptom management measures to use and the most valuable way to show it in a fair way.”
During the past two years, TEP members prioritized which of the risk-adjustment factors suggested by Abt. Associates should apply to outcome measures and which exclusions should apply to both outcome and process measures.
The report describes risk adjustment as using statistics to exclude “confounding factors,” or elements that are outside of a hospice’s control, from calculations that could make a hospice’s performance appear either better or worse than it is. In essence, risk adjustment increases the fairness in outcome-measure calculations while exclusions do the same for both outcome and process measures.
For the outcome measures being considered, the report says that the “TEP broadly agreed that risk adjustment is very important because it accounts for external factors outside hospices’ control and more accurately reflects the quality of care provided.”
Judi Lund Person, Principal of LundPerson & Associates, LLC, agrees. “The discussion of risk-adjustment factors is vitally important to the success of upcoming process measure implementation,” says Lund Person.
Determining which risk-adjustment factors to bring to the table was not easy. “There were some nuance things that we hashed out to try and decide how to weigh some factors in risk adjustment” for outcome measures, McNally explains.
Exhibit 5 (below) summarizes the TEP’s rankings of risk adjustors suggested.
While the TEP’s priorities seem clear, the discussion concerning each risk adjustor was more complex. The TEP broadly agreed that the most important risk-adjustment factors are age and diagnosis. Some diseases are more difficult to manage than others, and patient condition tends to decline with age regardless of provider activity. Therefore, the TEP recommended that CMS adjust for these factors to ensure that common external factors do not adversely affect reported hospice care quality.
Here’s part of the nuance – the TEP also raised concerns that how well other patients with certain diseases or of certain age groups are treated might be valuable to some patients and their families seeking care for someone of the same age group or condition. Panelists fretted over possibly obscuring that information for consumers seeking hospice care by adjusting for those risk factors.
Living situation as a risk adjustor ranked as important to TEP members because hospices have no control over what level of assistance is available to patients. Similarly, site of service ranked high as a risk adjustor because, said some panelists, care is delivered very differently across settings, and patients and/or caregivers tend to provide higher hospice satisfaction ratings for hospices in home settings than for those in facilities,” according to the report.
Lund Person, who is also former Vice President of Regulatory and Compliance at the National Hospice and Palliative Care Organization (NHPCO), notes that the TEP recognized living situation and site of service as “important” risk adjustment recommendations.
“Identifying site of service will help to distinguish between care at home and care in a facility,” she says. Also vital, she continues, “is the recommendation from the TEP to consider length-of-stay as a risk-adjustment factor, including the differences between a 4-day length of stay and a 6-month length of stay.”
One TEP member cautioned that using payment sources, IV therapy, and risk of hospitalization as risk adjustors might tempt some hospices to use them to distort a hospices’ apparent care quality.
TEP members did not recommend using as risk adjustors gender, clinical symptoms, functional status and management of care needs. They did not discuss why they rejected gender, but several agreed that using clinical symptoms would not be of value because of their high correlation with diagnoses. Because hospice providers typically see hospice patients decline in ADL and IADL abilities, and hospice goals are focused on comfort rather than functional improvement, functional status was on the TEP’s “Do Not Include” as a risk adjustor list. And finally, one TEP member strongly opposed adjusting for patients’ medication management, supervision or safety assistance needs (management of care needs), explaining that “the public and CMS should hold hospices accountable for planning around oral medication, injectable medication management, and supervision and safety assistance,” the report says.
The TEP did suggest that using some risk adjustment factors as part of the HQRP could assist hospices internally with quality improvement while others would be more valuable to patients and families. For example, Patients and families would benefit from more straightforward risk adjustment that helps them select a hospice,” the report says, “including factors such as diagnosis. For publicly reported data used to select a hospice, the TEP suggested using demographic factors (including age but excluding gender), socioeconomic factors, living situation, and diagnoses.”
Dr. McNally hopes eventually to use HPRP data to promote Intermountain Hospice’s care. Intermountain Hospice is part of Intermountain Health, a health care provider with presence in multiple states. “You can’t take the current metrics to doctors’ offices and families to show anything meaningful,” he says. “It’d be great to have metrics we could take to our neurology docs and other docs,” he says. “I really think we provide better care and more options when patients stay within our system.
This article is the first in a series about implementation of HOPE. Next week, Beth Noyce shares details from the panel as it evaluated process measures.
HealthRev Partners Launches Velocity as a SAAS, Transforming Revenue Cycle Management for the Home Health and Hospice Industry
Meta: Discover how HealthRev Partners’ innovative SAAS solution, Velocity, is transforming revenue cycle management in the healthcare industry. Gain insights into its key advantages, AI capabilities, and data exchange interface engine feature set. Learn how Velocity empowers agencies with transparency, efficiency, scalability, and security to enhance profitability and operational excellence. Contact HealthRev Partners for a demo and revolutionize your revenue cycle management today.
Ozark, MO – April 1st, 2024 – HealthRev Partners, a leading innovator in healthcare technology, has announced the launch of Velocity as a Software as a Service (SAAS), revolutionizing revenue cycle management in the home health, hospice, and palliative care industries. This game-changing solution is designed to transform revenue cycle management (RCM) for multi-site agencies. In an era where the aging population in America increasingly desires to age in place, mergers and acquisitions in the home health space are driving the necessity for centralized data and operational processes. The trend of overseas hiring to reduce costs has created gaps in insights, emphasizing the critical need for real-time data to impact care promptly.
Michael Greenlee, Founder and CEO of HealthRev Partners, expressed his enthusiasm about the launch, stating, “Velocity as a SAAS represents a significant leap forward in revenue cycle management technology. By offering agencies unprecedented insights into their operations and empowering them with tools for optimization and growth, HealthRev Partners is setting a new standard in RCM solutions.”
Empowering Multi-Site Agencies and Enhancing Management Insights
As multi-site agencies navigate the complexities of managing diverse locations and teams, the demand for comprehensive insights and seamless integration becomes critical. HealthRev Partners recognizes this challenge and introduces Velocity as a SAAS to address the evolving needs of growing agencies. With a focus on providing real-time analytics and enhancing operational efficiency, Velocity bridges the gap between disparate locations and centralizes data for streamlined management.
Seamless Integration with Any EHR System
A key component of Velocity is the data exchange interface engine feature set. The ability to connect, integrate, translate, and import financial, claims, coding, clinical, operational, EHR, clearinghouse, and diverse data sets is vital for any organization. Velocity uses its proprietary interface technology engine along with robotic processing technology (RPA) to connect all disparate data sets within Velocity resulting in actionable data at your fingertips.
AI Capabilities to Increase Coding Accuracy
Velocity harnesses AI capabilities to automatically assign charts to coding professionals, enhancing efficiency and accuracy. By leveraging artificial intelligence, it streamlines the ICD-10 coding process and provides intelligent suggestions for selecting codes at the highest level of specificity to maximize reimbursement. Additionally, it utilizes advanced algorithms to analyze data and offer insights into PDGM-approved primary codes and comorbidity adjustment categories. Furthermore, Velocity’s AI-driven system assists in risk and comorbidity adjustments by recommending compatible code combinations and presenting primary and secondary code sets to facilitate precise coding decisions.
Key Advantages of Velocity:
Increased Transparency and Visibility: Real-time insights into all aspects of the revenue cycle across multiple sites. Identify bottlenecks, track productivity, and optimize operations seamlessly.
Enhanced Efficiency and Accuracy: Streamlined processes and standardized procedures that ensure consistency across all locations. Improve accuracy in coding, claim submission, and reimbursement.
Improved Communication and Collaboration: Facilitate real-time data sharing between clinical, financial, and operational teams at different sites. Enhance collaboration and decision-making.
Scalability and Security: Easily scale operations to accommodate growth needs while maintaining top-tier data security standards. Ensure compliance with regulatory requirements across all locations.
Michelle Mullins, MHA, BSN, RN – Partner & Chief Operating Officer of HealthRev Partners, highlighted the transformative impact of Velocity by stating, “Velocity illuminates your RCM’s path to predictable revenue. It empowers agencies with granular insights, customizable control, streamlined operations, and trustworthy security. This tool is not just a solution; it’s a revolution in revenue cycle management.”
The launch of Velocity as a SAAS marks a pivotal moment for agencies seeking to optimize their revenue cycle processes. With its focus on transparency, efficiency, communication, scalability, and security features, Velocity is poised to reshape how agencies manage their RCM operations.
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For more information about Velocity as a SAAS or to schedule a demo, visit HealthRev Partners’ website.https://healthrevpartners.com/
Viventium Releases its 2024 Caregiver Onboarding Experience Report, Demonstrating a Need to Raise the Bar for Onboarding in the Post-Acute Care Industry
BERKELEY HEIGHTS, N.J., April 02, 2024 (GLOBE NEWSWIRE) — Viventium, the leading SaaS-based human capital management platform serving the post-acute care industry, released its 2024 Caregiver Onboarding Experience Report, a comprehensive research study analyzing survey responses from 175 post-acute care administrators and 220 caregivers. The report finds a shockingly low bar for what passes as a “good” onboarding experience in home-based and facility/community-based care, with strong indications that raising that bar could correlate to higher retention rates.
“Staffing shortages and high turnover rates within post-acute care are recurring issues in need of solutions,” said Navin Gupta, Viventium CEO. “Our research illuminates a crucial pathway towards addressing these persistent challenges, and it begins with onboarding.”
Findings point to post-acute care managers and administrators having a major impact on the steps their organization can take to better engage, motivate, and retain its caregiving staff.
“The study significantly advances our knowledge of what it takes to recruit and retain caregivers in today’s highly competitive workforce market. The onboarding process is fully within the control of the employer, and the study shows that doing it right pays dividends. Most notably, many of the elements of successful onboarding are simple improvements in the process that bring a real return on investment. I would encourage all of home care to learn from this study.”
About Viventium
Viventium provides a SaaS-based human capital management solution that is focused on the post-acute care industry. The company’s mission is to enrich the lives of caregivers through technology so they love going to work every day. By providing specialized software and expert guidance, Viventium helps its clients throughout the lifecycle of each caregiver. The company has clients in all 50 states and supports over 420,000 client employees each year.
Neuropathic pain
On April 8, RansomHub contacted Change Healthcare and alleged to have 4TB of data stolen from the system and are demanding an extortion payment to keep the data private . RansomHub has threatened to sell the data, which includes US military personnel and patient data, medical records, and financial data, to the highest bidder in 12 days if the ransom isn’t paid.
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 
