the rowan report Archives - Page 20 of 26

NHPCO and NAHC Announce New Name and Website

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

by Kristin Rowan, Editor

The Alliance

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

Alliance Updates

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

National Association for Care at Home (NACH)

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

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

From The Alliance

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

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

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

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

About Us

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

More to Come

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

# # #

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

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

Meet Dr. Steve Landers, MD

by Rowan Report | Aug 29, 2024 | Admin, Breaking News

Get to know the new NAHC-NHPCO Alliance CEO

Dr. Steve Landers

Dr. Landers named CEO for joint NAHC NHPCO. A recognized leader and innovator in home health, primary care and aging services, Dr. Steven “Steve” Landers brings almost two decades of experience as a physician, executive leader and public health policy advocate to lead The Alliance as its first Chief Executive Officer.

Physician

As a board-certified physician in family medicine, geriatric medicine, and hospice and palliative medicine, Dr. Landers has dedicated his career to seeking home- and community-based solutions for ill and aging Americans. He is a champion of the impactful role home care and hospice play in the health and lives of communities, acknowledging that as an aging nation, providing compassionate, dignified and cost-effective systems of care to patients is critical.

Education

Dr. Landers graduated from Case Western Reserve University School of Medicine, where his training included a family medicine residency at Case Western and a geriatric medicine fellowship at the Cleveland Clinic. He also attended the Johns Hopkins Bloomberg School of Public Health, where he focused on health policy and management. He received a bachelor of arts in political science from Indiana University in Bloomington.

Early Career

Early in his career, Dr. Landers based his clinical practice on providing health care through house calls and has made thousands of home visits, primarily to low-mobility patients. While in this setting, he saw the need to better connect home care and hospice to the broader health care system and medical community. He understood that to improve patient care, he would need to understand and play a leading role at the intersection of clinical work, health policy and systems of care. He pursued a master’s degree in public health, which contributed to his passion for influencing federal and state policy to improve health care delivery to vulnerable patients.

On The Board

Dr. Landers has served on numerous boards and committees in the home-based care policy space, including past appointments to the boards of directors of the National Association for Home Care and Hospice, American Academy of Home Care Medicine, the Partnership for Quality Home Health, and the Alliance for Home Health Quality and Innovation (now Research Institute for Home Care). He has represented these organizations by engaging policymakers, including meeting with members of Congress; providing committee testimonies for Congress and state legislatures; and discussing home care policies and regulations with the U.S. Secretary of Health and Human Services, the administrator of the Centers for Medicare & Medicaid Services, Medicare Payment Advisory Commission officials, and federal agency staff.

Home Care

As a renowned author and thought leader in the care at home sector, his work has been published in the New England Journal of Medicine, the Journal of the American Medical Association and the Huffington Post. The work of Dr. Landers and his team to prioritize at-home vaccines for homebound seniors during the COVID-19 pandemic also has been featured by major news outlets such as ABC’S Good Morning America and CBS Mornings with Gayle King.

Personal Life

Steve lives in Little Silver, New Jersey, with his wife, Allison, and their three sons. His hobbies include golfing, fishing, hiking, traveling, enjoying good food and watching horse racing. When he is not taking part in these activities, you can find him cheering on his sports teams — the Browns, Cavaliers, Guardians and Indiana Hoosiers.

This bio originally appeared on the NAHC-NHPCO Alliance web site. It is reproduced in The Rowan Report by permission. It may be freely reproduced.

It’s Official! NAHC NHPCO Alliance Name New CEO

by Rowan Report | Aug 29, 2024 | Admin, Breaking News

WASHINGTON D.C. Steven Landers, MD, MPH, has been named the inaugural Chief Executive Officer of the newly merged NAHC-NHPCO Alliance (The Alliance). A recognized national leader and innovator in home health, primary care and aging services, Dr. Landers brings almost two decades of experience as a physician, executive leader and health policy advocate to The Alliance, which represents care at home and community providers across the country. (Read more about Dr. Landers at our accompanying article in this week’s issue.)

Dr. Landers has dedicated his career to seeking home- and community-based health care solutions for people of all ages. As a board-certified physician in family medicine, geriatric medicine, and hospice and palliative medicine, he is a champion of the impactful role health care at home plays in the health and wellbeing of communities, acknowledging that as an aging nation, providing compassionate, dignified and cost-effective systems of care to patients is critical.

“The Alliance members provide a wide range of high-quality home- and community-based services that promote comfort, dignity and independence. I’m so proud to become a part of this organization, and am eager to serve,” said Dr. Landers. “I’ve had the opportunity in my career to see the health care industry from many vantage points, and in this new role with The Alliance, I will use all that I have learned to make a difference for our members as we continue to expand to meet the growing public needs for our care.”

Prior to joining The Alliance, Dr. Landers served in several executive leadership roles. He was the director of home care at the Cleveland Clinic, and for more than 11 years was the president and CEO of the Visiting Nurse Association Health Group, Inc. — one of the oldest, largest and highly respected home health, hospice and community health organizations in the country. During his most recent tenure as the president and CEO of Hebrew SeniorLife, he led an organization known for superior senior living, geriatric health care, research and teaching.

Dr. Landers has served on numerous boards and committees in the care at home space and has represented organizations by engaging policymakers, including meeting with members of Congress; providing committee testimonies for Congress and state legislatures; and discussing home care policies and regulations with the U.S. Secretary of Health and Human Services, the administrator of the Centers for Medicare & Medicaid Services, Medicare Payment Advisory Commission officials, and federal agency staff.

“Providing leadership around policy and advocacy efforts is critical to our mission at The Alliance,” said Transition Board Chair Ken Albert. “Throughout his career, Dr. Landers served the field as an effective policy advocate, shaping policy at both the state and federal levels. We are thrilled to welcome him as our inaugural CEO, and I know he will build an extraordinary team to offer value for our members.”

Early in his career, Dr. Landers based his clinical practice on providing health care through house calls and thousands of home visits, primarily to low-mobility patients. While in this setting, he saw the need to connect home care and hospice to the broader health care system and medical community. He understood that to improve patient care, health care providers need to explore and thrive at the intersection of clinical work, health policy and systems of care. He pursued a master’s degree in public health, which contributed to his passion for influencing federal and state legislation to improve health care delivery to home-based patients.

“Dr. Landers’ rich and diversified experience makes him the ideal candidate to lead our membership as our organization evolves,” said Alliance Transition Board Vice Chair Melinda Gruber. “Working alongside community health workers and within our patients’ homes, he understands what we need as frontline caregivers and advocates.”

Dr. Landers is a graduate of Case Western Reserve University School of Medicine, where his training included a family medicine residency at Case Western and a geriatric medicine fellowship at the Cleveland Clinic. He also attended the Johns Hopkins Bloomberg School of Public Health, where he focused on health policy and management. Additionally, he received a bachelor of arts in political science from Indiana University in Bloomington.

# # #

About the NAHC-NHPCO Alliance

The NAHC-NHPCO Alliance brings together the National Association for Home Care & Hospice (NAHC) and the National Hospice and Palliative Care Organization (NHPCO), two organizations with more than 90 years of combined experience serving providers of quality care in the home to form one new association. This historic alliance creates a national organization representing providers of home care, home health, hospice, and palliative care, forming the most powerful voice and resource the care-at-home community has seen. The integration process underway is expected to continue through the beginning of 2025. While leadership explores a permanent name, the new organization is operating under the interim name the NAHC-NHPCO Alliance.

Keep track of updated news on the NAHC and NHPCO websites.

This news release originally appeared in The Rowan Report. by permission of the National Association for Home Health and Hospice. It may be freely reprinted.

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

by Kristin Rowan | Aug 23, 2024 | Regulatory

by Kristin Rowan, Editor

False Claims Act Violations

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

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

Whistleblowers

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

Allegations

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

More Allegations

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

Settlement

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

Repeat Offender

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

2014: a class action suit alleged unpaid wages.

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

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

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

Not Alone

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

Evolution Health LLC

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

Halo Home Healthcare

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

Atlantic Home Health Care

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

Speak Up, Speak Out

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

# # #

More Rural Providers Say ‘No’ to MA

by Tim Rowan | Aug 23, 2024 | Artificial Intelligence, Caring for the Caregiver, Clinical, CMS

by Tim Rowan, Editor Emeritus

ne just does not know whom to believe anymore. This week, we were sent three opinions of the pros and cons of Medicare Advantage programs. One says they reduce costs and improve patient satisfaction for rural residents. Another says rural hospitals are turning away MA customers at a growing rate. The third says MA customers utilize healthcare services at a lower rate than traditional Medicare beneficiaries. Let’s take a look at each opinion.

The Pro

Better Medicare Alliance is a non-profit advocacy group that promotes Medicare Advantage. They describe themselves and the genesis of their recent report this way:

“Better Medicare Alliance engaged ATI Advisory to understand Medicare beneficiaries who live in rural areas and how they are served across Medicare Advantage and Fee-for-Service (FFS) Medicare. Understanding geographic differences in beneficiary experiences is important to both the Medicare Advantage and FFS Medicare program. This research can help policymakers and stakeholders identify opportunities to improve access to and quality of rural health care.”

That sounds good so far. Let’s look at their conclusions.

- 30 percent fewer MA client live in rural areas compared to cities and suburbs
- rural MA enrollees are more likely to be Black or LatinX but health needs are consistent across all rural demographics
- satisfaction is the same between rural MA clients and traditional Medicare beneficiaries, though MA enrollees use preventive services more and outpatient services less
- rural MA enrollees spend less in premiums and out of pocket costs than traditional Medicare beneficiaries

Rural Hospitals Tell a Different Story

Healthcare Uncovered, an online publication with a patient advocacy slant, describes BMA as “an active front group for the health insurance industry and perhaps the country’s greatest champion of Medicare Advantage plans.” and “with a well-stocked, industry-financed war chest to promote insurers’ premier product.”

Writing for Healthcare Uncovered, longtime healthcare journalist Trudy Lieberman added perspective to the BMA-sponsored report:

More places say no to medicare advantage

There was evidence last fall that Medicare Advantage was under attack when several hospitals announced they were reviewing their arrangements with Advantage plan sellers and were not accepting some or all plans. The CEO of the Brookings Hospital system in Brookings, South Dakota, told me, “The difference between original Medicare and Medicare Advantage is vast. Advantage plans pay less, don’t follow medical policy, coverage, billing, and payment rules and procedures, and they are always trying to figure out how to deny payment for services.”

In 2023, Becker’s Hospital Review began reporting on hospitals that were dropping some or all of their contracts with Advantage plans. The August 20, 2024 update indicates 18 more hospitals have or will drop MA plans this year.

Ms. Lieberman went on to report that MA plans frequently limit in-plan physicians. When they eliminate a physician in a rural community, patients often must travel miles to reach an approved doctor.

“Another damning report, this one issued by the Nebraska Rural Health Association, also revealed the pitfalls of joining an Advantage plan. The report warned that Nebraskans with Advantage plans ‘have created such a financial burden for rural residents’ that when they get sick, those with Medicare Advantage coverage ‘represent the largest growing segment of charity care for Nebraska’s rural hospitals.’ I’d bet few if any seniors are told they may end up on charity care if they choose an Advantage plan.”

A hospital in 23,000-resident North Platte, Nebraska has stopped accepting all MA patients. CEO Ivan Mitchell told Ms. Lieberman that transfers to nursing home and Home Health are denied 13 percent of the time. “Hospital stays are 40 percent longer for MA patients. They are stuck in the hospital two or three days waiting for approval to be transferred, and we need those beds for sicker patients.”

Home Health Weighs In

The Research Institute for Home Care awarded a grant to Tami M. Videon, PhD, and Robert J. Rosati, PhD, of the VNA Health Group, the honored Home Health not-for-profit in New Jersey. The researchers divided beneficiaries into three groups: Traditional Medicare, MA with a premium, and MA without a premium. Their findings resonated with the experiences of rural hospitals more than those of the MA advocacy group.

Research Findings

- Traditional Medicare (TM) beneficiaries were more likely to utilize outpatient, inpatient, and home health care services than beneficiaries in Medicare Advantage (MA) plans, regardless of whether the plan had a monthly premium or not.
- Beneficiaries who reported being in zero premium MA plans were substantially less likely to use dental, hearing, and vision services compared to other beneficiaries.
- Rates of utilization of hearing and dental services were relatively similar for beneficiaries reporting they were in MA plans with a premium and those enrolled in TM. Access to vision services was greatest among beneficiaries reporting being in MA plans with a premium.

In their research briefing, the researchers stated:

“Consistent with the literature, this study found beneficiaries enrolled in MA plans had lower utilization for services required to be covered by Medicare (outpatient visits, inpatient admission, and home health care use) than beneficiaries enrolled in TM. The observed lower rate of home health care utilization among MA beneficiaries may result from restrictions in inpatient care. However, prior research indicates when analyses are restricted to similar patient populations (a subset of diagnostic codes), MA beneficiaries are less likely to receive home health care than TM beneficiaries.”

Where Does the Money Go?

We have often reported on the lawsuits that various federal departments have lodged against the largest health insurance companies for their Medicare Advantage practices. With their payments from the Medicare Trust Fund based on patient assessments, they have been caught exaggerating illnesses, adding chronic conditions that do not exist, and conducting periodic home visits to “update” their data on the health condition of their customers. These nurse visits to the home frequently “identify” serious health conditions that the person did not know they had, or in most cases did not have at all.

As a consequence of this practice, coupled with denying care that Traditional Medicare would have covered, the program has been determined by government audits to cost 119 percent of what Traditional Medicare costs.

Final Thoughts

Should Home Health follow the lead of so many rural hospitals and begin to Just Say No? Our guess is that this will be a prominent topic at this October’s NAHC Conference in Tampa.

# # #

Tim Rowan is a 30-year home care technology consultant who co-founded and served as Editor and principal writer of this publication for 25 years. He continues to occasionally contribute news and analysis articles under The Rowan Report’s new ownership. He also continues to work part-time as a Home Care recruiting and retention consultant. More information: RowanResources.com Tim@RowanResources.com ©2024 by The Rowan Report, Peoria, AZ. All rights reserved. This article originally appeared in Healthcare at Home: The Rowan Report. One copy may be printed for personal use: further reproduction by permission only. editor@therowanreport.com

HHVBP Model Payments Begin January 1, 2025

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

by Kristin Rowan, Editor

Background on the HHVBP Model

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

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

HHVBP Model Expansion

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

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

HHVBP Model Performance Year

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

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

Interim Performance Report

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

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

Points System

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

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

Achievement Points

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

Improvement Points

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

Care Points

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

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

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

Public Reporting

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

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

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

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

Next Steps

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

# # #

Medicare Advantage Predatory Marketing

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

by Kristin Rowan, Editor

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

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

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

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

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

PACE Programs

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

Bait and Switch

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

Your content goes here. Edit or remove this text inline or in the module Content settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.

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

Katie Smith Sloan

president and CEO, LeadingAge

Dire Need for Change

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

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

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

Shawn Bloom

president and CEO, National PACE Association

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

Updates will be provided when we have them.

# # #

Sources:

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

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

Product Review: AI Comes to Data Analytics

by Kristin Rowan | Aug 16, 2024 | Product Review

by Kristin Rowan, Editor

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

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

Data Analytics: From What to Why

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

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

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

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

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

Features

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

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

Platform Agnostic

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

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

Future Plans

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

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

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

Overall Impression

A Familiar Problem

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

A Consolidated Solution

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

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

# # #

AlayaCare to Work With Multi-State Provider

by Rowan Report | Aug 16, 2024 | Partner News

FOR IMMEDIATE RELEASE

Contact: Steph Davidson

steph.davidson@alayacare.com

AlayaCare Selected as Agency Management Platform of Record by Premier Home Health Care

NEW YORK, NY – August 14, 2024 – AlayaCare, a global technology platform for home and community-based care, announced today that it has been chosen as the end-to-end Electronic Health Record (EHR) of choice by Premier Home Health Care Services, Inc., a comprehensive Licensed Home Care Services Agency (LHCSA) and home health care provider based in New York and serving clients across multiple states, including New York, New Jersey, Connecticut, Massachusetts, Florida, Illinois, and North Carolina.

Premier, which provides high-quality care to over 15,000 people under service weekly, will be migrating its legacy EHR software to AlayaCare’s modern, cloud-based home care platform. This partnership is founded on AlayaCare’s support for multiple service lines to fuel Premier’s growth across its Medicaid skilled and personal care businesses, with the caregiver experience at the heart of it all.

AlayaCare’s commitment to leveraging data and technology to optimize care delivery for caregivers and clients aligns with Premier’s focus on the employee experience. “Engaging and retaining our workforce is not just about numbers; it’s about nurturing a supportive environment where every caregiver feels valued and empowered,” said Dr. Marshalina Ramos, President and COO at Premier.

With AlayaCare as its EHR partner, Premier will be able to utilize a modern technology stack to handle scale and to drive better care coordination using best practices in Artificial Intelligence (AI), advanced workflow automation capabilities, and an industry-leading open-API architecture to streamline administrative operations. AlayaCare will transform everything from intake and care plans through to compliance, scheduling, and eligibility monitoring, driving growth and improving experiences for both the care team and the client.

“At Premier Home Health Care Services, we are dedicated to continuous innovation in our care delivery,” said Dr. Ramos. “Partnering with AlayaCare represents a significant step forward in our mission to revolutionize home-based care through advanced technology. By leveraging cutting-edge solutions and fostering ease of partnerships, we are poised to disrupt the market and set new standards in the quality and efficiency of care. This collaboration underscores our commitment to enhancing the caregiver experience and ensuring exceptional outcomes for our clients.”

“We are thrilled to partner with Premier Home Health Care Services as their EHR of choice,” said Adrian Schauer, CEO and Founder of AlayaCare. “This collaboration is a testament to our shared vision of harnessing cutting-edge technology to revolutionize home-based care. By digitizing and modernizing care delivery, we ensure that caregivers are equipped with the tools they need to provide exceptional care, and clients receive the highest quality of care in the comfort of their homes. Together, we are not only improving operational efficiency but also transforming the very experience of care for both caregivers and clients.”

# # #

About AlayaCare

AlayaCare is an end-to-end software platform for public, private, non-profit, and community home-based care organizations that manages the entire client lifecycle, including needs assessments, care plans, scheduling, visit and route optimization, and visit verification. Founded in 2014 and now with over 500 employees, AlayaCare combines traditional in-home and virtual care solutions that enable care providers to lower the cost of care and achieve better outcomes for their clients. For more information, visit: AlayaCare.com

About Premier Home Health Care Services, Inc.

Premier Home Health Care Services, Inc. is a clinician-run organization and a leading provider of personalized home health care, dedicated to improving the quality of life for individuals and families across multiple states. With a focus on compassionate care and innovation, Premier delivers tailored health care solutions that enhance patient outcomes in the comfort of their homes.

Our comprehensive care management approach ensures that each client receives coordinated and continuous care, designed to meet their unique needs and support their overall well-being. As an Article 49 Care Management organization, Premier also assists health plans, providers, and individuals in navigating the complexities of the health care system, ensuring seamless access to the necessary services and support.

Operating in New York, New Jersey, Massachusetts, Florida, Illinois, North Carolina, and Connecticut, Premier fosters a family-like environment for both clients and staff, offering union representation in New York to support our team members.

Cat on a Hot Tin…Keyboard?

by Elizabeth E. Hogue, Esq. | Aug 9, 2024 | Admin, Clinical, Regulatory

by Elizabeth E. Hogue, Esq.

HIPAA Violation

HIPAA violation: Trent James Russell was convicted in federal Court on charges of obtaining another person’s health care information in violation of the Health Insurance Portability and Accountability Act (HIPAA). Russell was employed by an organ transplant organization. As a transplant coordinator, he had access to electronic medical records at George Washington University Hospital in Washington, DC.

Justice Ginberg

In January of 2019, Russell accessed the medical records of U.S. Supreme Court Justice Ruth Bader Ginsburg even though Justice Ginsburg had not been referred as a possible organ donor. He took a screenshot of the records and then posted them on a message board called “4chan.” Ginsberg’s records quickly appeared on Twitter and YouTube, including her name and the exact dates and times when she received radiology, oncology, and surgical treatments at the Hospital between 2014 and 2018.

Hospital officials traced the search of Ginsburg’s records to one of Russell’s home computers. As soon as Russell was identified as a suspect, his access was denied by the Hospital. His request to have access restored was also denied.

The Cat Made me Violate HIPAA Laws

Russell initially told federal agents that his “cats had run across his keyboard.” He later characterized this statement as a “nervous joke.” Russell said that he had no idea how his computer searched terms that produced the Justice’s records and that “everyone makes typos.”

Online users who viewed Ginsberg’s records promoted various antisemitic conspiracy theories. One theory was that Ginsburg had died in late 2018 and that democrats were hiding her death in order to deny President Trump an opportunity to appoint her replacement. A search of Russell’s computer also revealed a search for the term “dirty jew.”

An FBI agent said that she found an image on Russell’s hard drive that mimicked a poster for the film “Weekend at Bernie’s.” The caption said “Weekend at Ginsburg’s” and showed leaders of the U.S. House of Representatives propping Ginsburg up from both sides in a morbid play on how the movie characters covered up Bernie’s death so that they could use his beach house.

Ignorance of HIPAA Law is not a Defense

But, he didn’t even have that. The Chief Executive Officer of the transplant organization at the time the access occurred testified that coordinators like Russell had “no business being inside the chart” of patients who had not been referred to the organization. The CEO said that Russell was certainly aware of this prohibition because of numerous agreements he signed with his employer and the extensive training he received.

Lessons Learned

There are several important takeaways from this case. First, it is important to note that Russell had extensive training about the requirements of the HIPAA Privacy Rule. He also agreed to comply with these requirements. The temptation is great, but employees must be reminded not to succumb. In addition, practitioners should take note of the fact that Russell was criminally prosecuted. Since he was convicted, he faces up to twenty-two years in prison and fines in the tens of thousands of dollars. Serious business!

# # #

Elizabeth Hogue is an attorney in private practice with extensive experience in health care. She represents clients across the U.S., including professional associations, managed care providers, hospitals, long-term care facilities, home health agencies, durable medical equipment companies, and hospices.

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

« Older Entries

Next Entries »