(CMS) Proposes to Restrict Diagnoses from Home Visits for Medicare Advantage Risk Adjustment

Centers for Medicare and Medicaid Services 

The Centers for Medicare and Medicaid Services has proposed to limit how Medicare Advantage Organizations can use in-home wellness or risk assessment visits of their enrollees to affect the risk adjusted payments they receive.  The proposal could cause a reduction in the number of such visits and lower overall payments to Medicare Advantage Organizations.
The Centers for Medicare and Medicaid Services (CMS) recently proposed to limit Medicare Advantage Organizations’ (MAOs’) ability to use diagnoses obtained from home risk assessments for Medicare Advantage (MA) risk-adjusted payments.  This is among several significant proposals in the Advance Notice of Methodological Changes for Calendar Year (CY) 2015 for MA Capitation Rates, Part C and Part D Payment Policies and 2015 Call Letter (the Advance Notice), published on February 21.
The Advance Notice includes other significant provisions affecting the MA and Part D programs, including revised MA payment rates and changes to provider network policies.  Comments from MAOs and other interested parties must be submitted by March 7, 2014.  CMS is expected to issue its final notice on April 7, 2014.

The Proposal and Its Background

The proposal would require that diagnoses from a home visit be excluded from risk adjustment, unless a subsequent clinical encounter confirms such diagnoses.  CMS’ proposal would not affect risk assessments conducted outside the home.
Risk adjustment modifies the capitation payments that MAOs receive to reflect the health status of their enrollees, thereby eliminating incentives for MAOs to avoid enrolling less healthy beneficiaries.  CMS’ risk adjustment methodology identifies enrollees’ health status based on diagnoses for those enrollees.
The present proposal follows a similar one in the 2013 Advance Notice, which was not finalized.  In 2013, CMS initially proposed to eliminate diagnoses identified in all risk assessment visits.  However, in its final notice issued in April 2013, CMS did not implement any such requirement and stated it would further study the issue.
CMS subsequently required that, for all 2014 dates of service, MAOs’ risk-adjustment submissions must code whether the visit was in a clinical setting or in the home.  For home visits, MAOs are additionally required to identify whether the visit is an Annual Wellness Visit, as that term is used in traditional Medicare.  The current proposal would apply to diagnoses from visits performed in 2014, which CMS uses for purposes of CY 2015 payments.

CMS’ Reasons for the Proposed Change

CMS’ proposal expresses skepticism about the clinical value of in-home risk assessments.  Indeed, CMS states that “to the extent that commenters believe that home assessments improve care, and are not just efforts to increase the diagnoses collected,” CMS would like to receive specific and measurable ways to identify and use certain home risk assessment diagnoses.
CMS notes that in-home risk assessments “are typically conducted by healthcare professionals who are contracted by the vendor and are not part of the plan’s contracted provider network, i.e., are not the beneficiaries’ primary care providers” and do not include treatment.  CMS also states that there is “little evidence that beneficiaries’ primary care providers actually use the information collected in these assessments or that the care subsequently provided to beneficiaries is substantially changed or improved as a result of the assessments.”
CMS suggests that if in-home risk assessments are, in fact, used to guide treatment, then diagnoses should also be documented in a follow-up visit in a clinical setting.  The Advance Notice suggests that the proposal would ensure that in-home risk assessments “serve as an effective vehicle to improve follow-up care and treatment for beneficiaries.”
CMS also expresses concern that diagnoses from risk assessments performed in the home inflate risk scores, without a corresponding increase in MA plan financial liability, and contribute to differences in coding patterns between MA and Fee For Service Medicare.  Although the Advance Notice expresses skepticism about whether risk assessments have real clinical value, it does not expressly state that CMS believes diagnoses obtained through these visits are inaccurate.

Impact of the Proposal

Home risk assessments have been used in MA to enhance the management and coordination of members’ care and are an additional avenue by which members’ conditions are identified and documented in a medical record.
CMS’ proposal to require a subsequent clinical encounter would limit the value of home risk assessment visits for risk-adjustment purposes, since the risk assessment visit by itself would be insufficient to support a diagnosis.  If there is no subsequent clinical encounter or the provider in the subsequent encounter fails to submit the diagnosis or properly record it in their medical records, the diagnosis and documentation from the home risk assessment visit could, apparently, not be used to establish the member’s condition.  The proposal does not define what qualifies as a “subsequent clinical encounter,” nor does it specify whether the subsequent clinical encounter must occur during the same data-collection period as the risk assessment.
The proposal could potentially increase MAOs’ exposure in Risk Adjustment Data Validation Audits, since documentation from risk assessment visits can presently be used to support diagnoses.  The proposal does not directly address whether medical record documentation from a home risk assessment visit could still be used in a Risk Adjustment Data Validation Audit, if medical record documentation from a subsequent visit in a clinical setting is deemed insufficient.

Timing

After allowing for a brief comment period, CMS will issue its final policy for CY 2015 in April 2014.  However, CY 2015 risk adjustment payments are based on diagnosis data from encounters during 2014, including encounters that occur before the final policy is issued in April.  The current proposal does not specify whether it would apply to data from risk assessment visits that occur before any changed policy is finalized or would be limited to risk assessment visits that occur after that date.

Conclusion

CMS’ proposal may have a significant impact on home risk assessment visits in MA.  MAOs should consider commenting on the proposal.  In addition, MAOs should consider what operational adjustments they may need to make with respect to risk assessments performed in 2014.

http://www.natlawreview.com/article/centers-medicare-and-medicaid-services-cms-proposes-to-restrict-diagnoses-home-visit

Fort Drum Regional Health Planning Organization is looking for it's first Executive Director

A six-hospital effort that has been finding ways to work together to reduce unnecessary, repeat Medicaid readmissions and create efficiencies in health care delivery may have its first executive director by April 1.

Operating in partnership with the Fort Drum Regional Health Planning Organization, the North Country Initiative director will oversee the program’s administration and help develop a management services organization and a clinically integrated network.

“As it moves forward, it’ll need staffing in order to meet goals of the organization,” said Denise K. Young, FDRHPO executive director.

River Hospital, Alexandria Bay; Samaritan Medical Center; Carthage Area Hospital; Lewis County General Hospital, Lowville; Clifton-Fine Hospital, Star Lake, and Claxton-Hepburn Medical Center, Ogdensburg, have worked in collaboration throughout the past two years to initiate a plan that could curb costs and create healthier communities.

Through those efforts, hospital administrators determined a management service organization would provide centralized nonphysician services and functions to all participating hospitals. What may be included could be joint purchasing, reference laboratories and synchronized revenue cycles, such as billing, coding, collection and admissions. A clinically integrated system would involve outcome-based measurements and physicians working collaboratively.

Meanwhile, Mrs. Young said, applications for the North Country Initiative’s top post already have come in.

“I think we have a good pool that we’ll get to begin interviewing next week,” she said.

According to a position description, which was posted on FDRHPO’s Facebook page, the director will be responsible for helping to develop the initiative’s business plan and budget and overseeing daily operations.

Up until this point, River Hospital Chief Executive Officer Ben Moore III has served as the group’s spokesman. The position description states that the initiative director will coordinate development and will be responsible for all communication materials. The director will work closely with hospital administrators, community members, community groups and various health organizations.

Once initial steps are complete, the director also will determine the North Country Initiative’s total staffing requirements.

FDRHPO is looking for someone with a master’s degree in health care administration or a related field, and at least five years’ experience in leading or working with independent employed physicians or other professionals. Resumes are due Saturday. For more information, email Mrs. Young at dyoung@fdrhpo.org.

CMS and OIG announce plan to exclude “recalcitrant providers”

Faegre Baker Daniels

• Thomas W. Beimers
• USA
• January 31 2014
• 

Author page »

In a move that made little immediate splash, but has since received considerable media attention, including a recent article in the New York Times, the Department of Health & Human Services announced that it will take additional steps against “recalcitrant providers,” including exclusion from participation in federal health care programs. CMS issued a notice, on January 15, stating that it intends to refer recalcitrant providers to the Office of the Inspector General, which will review the cases for potential administrative action.

CMS defines a “recalcitrant provider” as one who is “abusing the program and not changing inappropriate behavior even after extensive education to address these behaviors.” The definition refers to existing procedures whereby a program contractor who identifies improper billing may require the offending provider to obtain education. Contractors sometimes place providers on pre-payment review if their billing practices continue to raise red flags. In the program directive, CMS noted that some providers remain on pre-payment review for years. The new program is intended to provide another level of review for providers who are a drain on CMS contractor resources.

Last year, OIG excluded over 3,000 providers from participation in Federal health care programs. Most of these exclusions are mandatory, and typically are triggered by a violation of the law. The exclusions contemplated by the new CMS initiative will be permissive, meaning that OIG will need to make an affirmative case for exclusion, and the department will provide the physician with an opportunity to have the matter adjudicated by an administrative law judge.

The initiative is reflective of the government’s continued focus on fraud, waste, and abuse in federal health care programs, which many sources estimate at over $10 billion per year.

http://www.lexology.com/library/detail.aspx?g=450e5463-1cad-4b11-b4df-7605cc5069d8

Medical Homes and Quality of Care, Costs

(HealthNewsDigest.com) - Chicago - One of the first, largest, and longest-running multipayer trials of patient-centered medical home medical practices in the United States was associated with limited improvements in quality and was not associated with reductions in use of hospital, emergency department, or ambulatory care services or total costs of care over 3 years, according to a study in the February 26 issue of JAMA.

The patient-centered medical home is a team-based model of primary care practice intended to improve the quality, efficiency, and patient experience of care. Professional associations, payers, policy makers, and other stakeholders have advocated for the patient-centered medical home model. In general, medical home initiatives have encouraged primary care practices to invest in patient registries, enhanced access options, and other structural changes that might improve patient care in exchange for enhanced payments, according to background information in the article. Dozens of privately and publicly financed trials of the medical home model are under way. "Interventions to transform primary care practices into medical homes are increasingly common, but their effectiveness in improving quality and containing costs is unclear," the authors write.

Mark W. Friedberg, M.D., M.P.P., of the RAND Corporation, Boston, and colleagues measured associations between participation in the Southeastern Pennsylvania Chronic Care Initiative, a multipayer medical home program, and changes in the quality, utilization, and costs of care. Pilot practices could earn bonus payments for achieving patient-centered medical home recognition by the National Committee for Quality Assurance (NCQA). Thirty-two volunteering primary care practices participated in the pilot (conducted from June 2008 to May 2011). Using claims data from 4 participating health plans, the researchers compared changes in care (in each year, relative to before the intervention) for 64,243 patients who were attributed to pilot practices and 55,959 patients attributed to 29 comparison practices. Measured outcomes included performance on 11 quality measures for diabetes, asthma, and preventive care; utilization of hospital, emergency department, and ambulatory care; standardized costs of care.

Pilot practices successfully achieved NCQA recognition and reported structural transformation on a range of capabilities, such as use of registries to identify patients overdue for chronic disease services (increased from 30 percent to 85 percent of pilot practices) and electronic medication prescribing (increased from 38 percent to 86 percent). Pilot practices accumulated average bonuses of $92,000 per primary care physician during the 3-year intervention.
Of the 11 quality measures evaluated, pilot participation was significantly associated with greater performance improvement, relative to comparison practices, on only l measure: monitoring for kidney disease in diabetes. There were no other statistically significant differences in measures of utilization, costs of care, or rates of multiple same-year hospitalizations or emergency department visits.

The authors conclude that "a multipayer medical home pilot, in which participating practices adopted new structural capabilities and received NCQA certification, was associated with limited improvements in quality and was not associated with reductions in utilization of hospital, emergency department, or ambulatory care services or total costs over 3 years."
"Despite widespread enthusiasm for the medical home concept, few peer-reviewed publications have found that transforming primary care practices into medical homes produces measurable improvements in the quality and efficiency of care."

The authors add that their "findings suggest that medical home interventions may need further refinement."
(doi:10.1001/jama.2014.353)

Editor's Note: This study was sponsored by the Commonwealth Fund and Aetna. Please see the article for additional information, including other authors, author contributions and affiliations, financial disclosures, etc.
Editorial: The Patient-Centered Medical Home - One Size Does Not Fit All

"Before confidently promoting the patient-centered medical home (PCMH) as a core component of health care reform, it is necessary to better understand which features and combination of features of the PCMH are most effective for which populations and in what settings," writes Thomas L. Schwenk, M.D., of the University of Nevada School of Medicine, Reno, in an accompanying editorial.

"The identification of specific PCMH features for various risk strata will likely have significant influence on the work patterns of physicians, who may be responsible for a larger panel of patients than currently but for whom only routine care is needed, often by other members of the health care team. The physician's time and expertise will be best focused on a relatively small number of the most complex and expensive patients."
(doi:10.1001/jama.2014.352)

http://www.healthnewsdigest.com/news/Research_270/Medical-Homes-and-Quality-of-Care-Costs.shtml

Norwalk physical therapist charged on 46 counts of fraud, as well as obstruction of an audit.

Written by Aaron Boyd.

A Norwalk physical therapist was arrested Monday on 46 counts of health care fraud and one count of obstruction of a federal audit.

Danielle Faux, 46, of Weston, owns and manages a physical therapy operation, Danielle Faux PT, LLC, and is also part owner in Achieve Rehab and Fitness gym, both on Lois Street in Norwalk.

According to court documents, Faux would refer clients to Achieve Rehab and Fitness for personal training sessions but bill them through Medicare as physical therapy. 

Documents also allege that Faux fabricated and altered patient records before a Medicare audit in August 2009.

Faux was indicted on Feb. 19 and, if convicted, faces 10 years in prison and fines of up to $250,000 for each count of health care fraud — a total of 460 years and $11.5 million — and 5 years imprisonment and a $250,000 fine for the count of obstruction.

Faux pleaded ‘not guilty’ on all charges Monday and was released on $50,000 bond.

http://greenwich.patch.com/groups/police-and-fire/p/physical-therapist-faces-465-years-12m-fine-for-medicare-fraud_50f896ad

Holder, Sebelius tout billions in healthcare fraud recoveries

The U.S. recovered $4 billion last year through healthcare fraud prevention and enforcement efforts, according to a report released Wednesday by Attorney General Eric Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius.

The report says that the Health Care Fraud and Abuse Control Act (HCFAC) recovered more than $8 for every $1 it spent on healthcare fraud investigations over the last three years, the best ratio in the 17-year history of the program.

“With these extraordinary recoveries, and the record-high rate of return on investment we’ve achieved on our comprehensive health care fraud enforcement efforts, we’re sending a strong message to those who would take advantage of their fellow citizens, target vulnerable populations, and commit fraud on federal health care programs,” Holder said in a statement.

The joint effort between the Department of Justice and HHS has recovered more than $19 billion over the last four years, the agencies said.

In addition, the report said the agency strike forces filed 137 cases, charged 345 individuals, secured 234 guilty please, and won 48 trial convictions. All of these are record highs, according to the DOJ and HHS.

“These impressive recoveries for the American taxpayer are just one aspect of the comprehensive anti-fraud strategy we have implemented since the passage of the Affordable Care Act,” Sebelius said in a statement.

Around the time of the passage of the Affordable Care Act, President Obama launched initiatives aimed at rooting out waste and fraud in Medicare and Medicaid, saying that federal overpayments to doctors and hospitals, and other misallocated funds, should be recovered and redirected to patients.

“We’ve cracked down on tens of thousands health care providers suspected of Medicare fraud,” Sebelius continued. “New enrollment screening techniques are proving effective in preventing high risk providers from getting into the system, and the new computer analytics system that detects and stops fraudulent billing before money ever goes out the door is accomplishing positive results – all of which are adding to savings for the Medicare Trust Fund.”

Still, the FBI says that the U.S. spends at least $80 billion a year in healthcare fraud.

http://thehill.com/blogs/healthwatch/health-reform-implementation/199276-holder-sebelius-tout-billions-in-healthcare