Client Advisory from Mellette PC: CMS’S NEW YEAR BUNDLE OF JOY: COMPREHENSIVE CARE FOR JOINT REPLACEMENT December 30th, 2015

From Judy only:  I have clients in areas where this is ongoing.  The hospitals are sending the folks directly home to follow up with hospital/ortho MD controlled outpatient therapy.  The SNFs in the affected areas are scrambling to prove a stay in the SNF will shorten the episode and improve outcomes.  I believe the "winner" SNFs will be the ones who are now getting out ahead of it,  sitting down with the hospitals and proving quality outcomes.  We can't sit and wait for our phone to ring, hoping a hospital will 'select' us. We can't be afraid of hospital representatives in our PPS Meetings,  dictating what our therapy and nursing departments are to do.   This is the first mandatory bundled payment plan.  It will expand.  There will be others.   

Client Advisory by my business attorney:  Mellette PC in Williamsburg, VA:

On November 16, 2015, the Centers for Medicare and Medicaid Services (CMS) issued the final rule for the Comprehensive Care for Joint Replacement (“CJR”) payment model governing reimbursement of hip and knee replacement surgeries. 791 hospitals in 67 Metropolitan Statistical Areas (MSA) will receive payment for their care and care provided by their post-acute contractors under this scheme starting on April 1, 2016. No Virginia hospitals were included in the initial test group, but Virginia providers should anticipate receiving reimbursement under this and similar bundled payment programs after the first year of implementation.

CJR will provide a retrospective, bundled payment to hospitals for an “Episode” of care, which starts at admission and extends up to 90 days post-surgery, including care from non-hospital providers for rehabilitation. CMS will provide a target price for each Episode of care depending on the hospital’s historical billing. After the first year, as the CJR payment model expands nationally, CMS will determine target amounts based on regional charges instead of by individual hospital charges.

Hospitals and the post-acute hospital providers and suppliers involved in the Episode of care, referred to as “collaborators,” will continue to be paid under the traditional Medicare system for each service provided. At the hospital’s annual review, Medicare will add up all of the services, including Part A and Part B services, related to all Episodes of care for an aggregate amount and then will add up the target prices for each Episode for a comparison aggregate amount. The hospital and its collaborators—including rehabilitation and long-term care hospitals, nursing facilities and home health providers—will also be required to meet quality measures in addition to coming under the target prices. If the aggregate actual cost of all Episodes is below CMS’s aggregate target cost for the hospital, the hospital will be eligible for “gainsharing” payment subject to its also meeting quality measures. However, if the hospital’s total aggregate cost is above the target aggregate cost the hospital will owe CMS an “alignment” payment for the difference.

Because the financial risk lies solely on the hospital performing the surgery, CMS has encouraged participant hospitals to enter into financial agreements with the collaborators involved in an Episode and has provided for fraud and abuse waivers for these arrangements.[1] Financial agreements should incentivize all providers to reduce cost and increase quality because they will allow for sharing incentive payments for meeting a target price and quality measures. On the other hand, hospitals will be able to reduce their financial risk, as alignment costs may be split by agreement between a hospital and its collaborators if requirements are not met. The final rule also permits hospitals to offer inducements to beneficiaries through provision of preventative services and services that advance clinical goals for recovery. Under the rule, inducements must be provided in kind and must only be provided pursuant to the current Episode of care. If considering financial arrangements, providers should review the final rule requirements for these agreements carefully to ensure compliance.

CMS also responded to provider concerns in drafting the final rule. One of the most prevalent concerns among hospitals was the increased cost of a hip replacement when a hip fracture is part of the diagnosis. In response, CMS agreed to increase the target price for these Episodes, taking into account both the complexity of the surgery and recovery and the emergent circumstances in which hip fractures arise. Additionally, CMS had previously waived the 3 day hospital stay requirement for skilled nursing facilities (SNFs) with a history of 3 star or higher ratings on the Quality Rating System when joint replacement patients are placed in SNFs less than 3 days after surgery.

CMS hopes that the new payment system will encourage hospitals to coordinate with other service providers to bring down the cost of hip and knee replacements and to provide higher quality and more comprehensive care to beneficiaries. Hospitals will have to conduct quality checks on collaborators, as inefficiency or high infection rates at these providers could lead to enormous costs for a hospital if the patient requires more recovery time or readmission due to complications. Home Health agencies and SNFs can anticipate more scrutiny by hospitals. Hospitals will also need to encourage their physician providers to consider efficiency and effectiveness of treatment when performing CJR covered surgeries. For the test group of hospitals, CMS will pay CJR incentives immediately for the first year of implementation. CMS will phase in penalty payments will be phased in after the first year of the CJR program to give hospitals and collaborators time to adjust to the new system.

Should you or your organization have any questions regarding the CJR final reimbursement rule and requirements, please contact Peter Mellette (Peter@mellettepc.com), Harrison Gibbs (Harrison@mellettepc.com), Nathan Mortier (Nathan@mellettepc.com), or Nicole Hartz (Nicole@mellettepc.com), or call Mellette PC at (757) 259-9200.

This Client Advisory is for general educational purposes only. It is not intended to provide legal advice specific to any situation you may have. Individuals desiring legal advice should consult legal counsel for up to date and fact specific advice.

________________________________________________________________________________________________

From Texas RAI Manager: Reversal of previous CMS position on "present on admission"

CMS Clarifies Coding “Present on Admission” for Pressure Ulcers in MDS Item M0300

Question:

A resident was admitted with a pressure ulcer that was “present on admission”. The resident both discharged return anticipated to the hospital and then returned to the facility within 30 days with the same pressure ulcer at the same stage. Can the pressure ulcer be coded in item M0300 as present upon admission/entry or reentry?

Clarification:

The MDS 3.0 RAI User's Manual, Chapter 3, page M-7 contains the following instructions for determining if a pressure ulcer was “present on admission”:

“For each pressure ulcer, determine if the pressure ulcer was present at the time of admission/entry or reentry and not acquired while the resident was in the care of the nursing home. Consider current and historical levels of tissue involvement…

Step 4: If a resident who has a pressure ulcer is hospitalized and returns with that pressure ulcer at the same numerical stage, the pressure ulcer should not be coded as "present on admission" because it was present at the facility prior to the hospitalization.”

• If the resident was admitted to the facility with a pressure ulcer, was subsequently transferred to the hospital with the same pressure ulcer at the same stage as it was at the time of admission, and then returned to the facility with that same pressure ulcer at the same stage, it should be coded as “present on admission” in item M0300. It is coded as “present on admission” because it was not acquired while the resident was in the care of nursing home staff.
• If the pressure ulcer was not “present on admission” when it was identified by nursing home staff or if a pressure ulcer that was “present on admission” increased in stage while receiving nursing home care, it would NOT be coded as “present on admission” when the resident returned from the hospital with the ulcer at the same stage as it was when they left. This is because the ulcer was either acquired or worsened to a higher stage while under the care of nursing home staff.

As required on page 5-10 of the MDS 3.0 RAI User's Manual, nursing home staff should correct all MDS that were not appropriately coded in this fiscal year (since 10/1/15) within 14 days of reading this clarification and noting the error. Modifications to correct the errors must be made, even though there will be no impact on the Resource Utilization Group (RUG) used for payment and no impact on nursing home quality measures.

Posted: 12/30/2015

Another Focus Survey Pilot

It appears that we will see a rash of these as they test tools to update the survey process as the new Conditions of Participation make their way into the SOM over the coming years.  Note this one does not involve citations.  It will be surveyors in the building, and they can always call in complaints on any topic.  We must respond in full survey mode.

Infection Control Pilot Project

Memo # 16-05-ALL

Posting Date 2015-12-23

Fiscal Year 2016

Memorandum Summary 

• Project Overview: The Centers for Medicare & Medicaid Services (CMS) has begun a three year pilot project to improve assessment of infection control and prevention regulations in nursing homes, hospitals, and during transitions of care. 

• Survey details: All surveys during the pilot will be educational surveys (no citations will be issued) and will be conducted by a national contractor. New surveyor tools and processes will be developed and tested, focusing on existing regulations as well as recommended practices (such as those for antibiotic stewardship and transitions of care). Ten pilot surveys to be conducted in Fiscal Year (FY) 2016 will occur in nursing homes. Surveys in FY17 and FY18 will be conducted in nursing homes and hospitals. 

• Project Outcomes: New surveyor infection control tools and survey processes that can be used to optimize assessment of new infection control regulations. 

www.cms.gov/Medicare/...

DMAS released draft MLTSS Datebook: Virginia Medicaid Providers - Chance to provide input

Attention MLTSS Interested Stakeholders:

In keeping with our commitment for transparency and garnering on-going stakeholder input, DMAS in collaboration with PricewaterhouseCoopers LLP (PwC), is pleased to provide stakeholders with a draft MLTSS Databook.  The draft Databook provides detailed information about the service utilization for the MLTSS population. DMAS encourages stakeholders including interested health plans to raise questions that can help to improve the understanding and usefulness of the databook.  We expect that some questions may lead to the need for further analysis, or even revisions to the databook, before DMAS releases the RFP.  The draft MLTSS Databook and other background information on MLTSS is available on the DMAS website at:  http://www.dmas.virginia.gov/Content_pgs/mltss-home.aspx.  We ask that you send your questions/ comments related to the Databook by January 31, 2016.  Please direct all questions and comments via email to: VAMLTSS@dmas.virginia.gov.  

Thank you.

Tammy Driscoll

Senior Programs Advisor to the Deputy of Complex Care and Services

Virginia Department of Medical Assistance Services (DMAS)

600 East Broad Street

Richmond, VA 23219

804-225-2552

Tammy.Driscoll@DMAS.Virginia.Gov 

Virginia Survey Stakeholder Meeting (NFAC): Virginia will be doing 6 MDS/Staffing Focused Surveys in Fy2016 and they want to get them done early

Announced in the Nursing Facility Advisory Committee meeting yesterday by Survey Director:
They are going to do 6 (same number as 2015).  They are selected and they want to get them done early.

GAO Report on Nursing Home Quality Published Oct 30, 2016

What GAO Found

In recent years, trends in four key sets of data that give insight into nursing home quality show mixed results, and data issues complicate the ability to assess quality trends. Nationally, one of the four data sets—consumer complaints—suggests that consumers' concerns over quality have increased, while the other three data sets—deficiencies, staffing levels, and clinical quality measures—indicate potential improvement in nursing home quality. For example, the average number of consumer complaints reported per home increased by 21 percent from 2005-2014, indicating a potential decrease in quality. Conversely, the number of serious deficiencies identified per home with an on-site survey, referred to as a standard survey, decreased by 41 percent over the same period, indicating potential improvement. The Centers for Medicare & Medicaid Services' (CMS) ability to use available data to assess nursing home quality is complicated by various issues with these data, which make it difficult to determine whether observed trends reflect actual changes in quality, data issues, or both. For example, clinical quality measures use data that are self-reported by nursing homes, and while CMS has begun auditing the self-reported data, it does not have clear plans to continue. Federal internal control standards require agencies to monitor performance data to assess the quality of performance over time.

In recent years, CMS has made numerous modifications to its nursing home oversight activities, but has not monitored the potential effect of these modifications on nursing home quality oversight. Some of the modifications have expanded or added new oversight activities, while others have reduced existing oversight activities. According to CMS, some of the reductions to oversight activities are in response to an increase in oversight responsibilities and limited number of staff and financial resources. However, CMS has not monitored how the modifications might affect CMS's ability to assess nursing home quality. For example, CMS reduced the number of nursing homes participating in the Special Focus Facility program—which provides additional oversight of homes with a history of poor performance—from 152 in 2013 to 62 in 2014. State survey agency officials who conduct surveys for CMS also made modifications which could have either a positive or negative effect on oversight, but CMS does not have an effective mechanism for monitoring. Federal internal control standards require ongoing monitoring as a part of normal program operations; without this monitoring, CMS cannot ensure that any modifications in oversight do not adversely affect its ability to assess nursing home quality.

www.gao.gov

Highlights - www.gao.gov

Podcast - www.gao.gov

New SNF Booklet Published by CMS September 2015

CMS has published a new SNF booklet here.  Note that it mentions SNF QRP,  because we will  lose 2% of our FY 2018 SNF payment if we do not report at least 80% of the three QMs with 100% of the data fields on the MDS. The collection period for these three QMs to establish penalties for FY18 is Oct, Nov and Dec of 2016.

Comprehensive Care for Joint Replacement (CJR) Model

FACT SHEET 

FOR IMMEDIATE RELEASE

November 16, 2015                                                                                                                          

Contact: CMS Media Relations

(202) 690-6145 | CMS Media Inquiries

Comprehensive Care for Joint Replacement (CJR) Model

Hip and knee replacements are the most common inpatient surgery for Medicare beneficiaries and can require lengthy recovery and rehabilitation periods. In 2014, there were more than 400,000 procedures, costing more than $7 billion for the hospitalizations alone.

Yet, the quality and cost of care for these hip and knee replacement surgeries still varies greatly. For instance, the rate of complications like infections or implant failures after surgery can be more than three times higher for procedures performed at some hospitals than others. And the average total Medicare expenditure for surgery, hospitalization, and recovery ranges from $16,500 to $33,000 across geographic areas.

This variation is due partly to the way Medicare beneficiaries receive care. Incentives to coordinate the whole episode of care – from surgery to recovery – are not strong enough, and a patient’s health may suffer as a result. When approaching care without seeing the big picture, there is a risk of missing crucial information or not coordinating across different care settings. This approach leads to more complications after surgery, higher readmission rates, protracted rehabilitative care, and variable costs. These are not the health outcomes patients want.

The Comprehensive Care for Joint Replacement (CJR) model addresses low quality and high costs that come from fragmentation by promoting coordinated, patient-centered care. This model aims to improve the care experience for the many and growing numbers of Medicare beneficiaries who receive joint replacements, making the patient’s successful surgery and recovery a top priority for the health care system.

How the CJR model helps—and protects—beneficiaries:

• Patients can benefit from their hospitals and other health care providers (e.g., physicians, home health agencies, and nursing facilities) working together more closely to coordinate their care. Coordination of care leads to better outcomes, a better experience, and fewer complications, such as preventable readmissions, infections, or prolonged rehabilitation and recovery.

• Beneficiaries will benefit from protections including: additional monitoring of claims data from participant hospitals to ensure that hospitals continue to provide all necessary services; continued protection of patient data under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and other applicable privacy laws; and patient notification by providers and suppliers. Further, all existing safeguards to protect beneficiaries and patients will remain in place. If a beneficiary believes that his or her care has been adversely affected, he or she can call 1-800-MEDICARE or contact his or her state’s Quality Improvement Organization (QIO) by going to http://www.qioprogram.org/contact-zones. If concerns are identified, CMS will initiate audits and corrective action under existing authority.

• Patients can continue to choose their doctor, hospital, skilled nursing facility, home health agency, and other provider, but now with the CJR model, their providers have incentives to better coordinate their care. From surgery to recovery, patients can receive more comprehensive, coordinated care from their providers focusing on the most appropriate options for their recovery and rehabilitative care.

How the CJR Model works:

• CMS has learned from other models and projects already underway and has incorporated successful design elements from other initiatives into the CJR model design. The CJR model also reflects best practices in the private sector.

• Under this model, the hospital in which the hip or knee replacement and/or other major leg procedure takes place will be accountable for the costs and quality of related care from the time of the surgery through 90 days after hospital discharge—what is called an “episode” of care.

• Depending on the hospital’s quality and cost performance during the episode, the hospital will either earn a financial reward or, beginning with the second performance year, be required to repay Medicare for a portion of the spending above an established target. This payment structure gives hospitals an incentive to work with physicians, home health agencies, skilled nursing facilities, and other providers to make sure beneficiaries receive the coordinated care they need with the goal of reducing avoidable hospitalizations and complications. Hospitals in the model will be provided access to additional tools – such as spending and utilization data and sharing of best practices -- to improve the effectiveness of care coordination.       The model also gives providers additional flexibilities that are not otherwise available under Medicare so they can better manage the care of patients, including patients who are at home.

• By “bundling” payments for an episode of care, hospitals, physicians, and other providers have an incentive to work together to deliver more effective and efficient care.

• This model is being tested in 67 geographic areas throughout the country, and nearly all hospitals in those geographic areas are required to participate.

Reasons for the CJR Model:

• Lower extremity joint replacements are the most commonly performed Medicare inpatient surgery, and utilization is predicted to continue to grow. These surgeries can require long recoveries that may include extensive rehabilitation or other post-acute care, which provides many opportunities to reward providers that improve patient outcomes.

• By including all eligible hospitals in 67 geographic areas across the country, this model drives significant movement towards new payment and care delivery models for an important set of conditions and surgeries for Medicare beneficiaries.

• This model supports HHS efforts to transform the health care system towards one focused on better quality care, smarter spending, and healthier people through care transformation and payment reform.

For more information, visit: https://innovation.cms.gov/initiatives/cjr

###

Get CMS news at cms.gov/newsroom, sign up for CMS news via email and follow CMS on Twitter 

2016 Medicare Parts A & B Premiums and Deductibles Announced

CMS NEWS

FOR IMMEDIATE RELEASE

November 10, 2015

Contact: CMS Media Relations

(202) 690-6145 | CMS Media Inquiries

2016 Medicare Parts A & B Premiums and Deductibles Announced

Today, the Centers for Medicare & Medicaid Services (CMS) announced the 2016 premiums and deductibles for the Medicare inpatient hospital (Part A) and physician and outpatient hospital services (Part B) programs.

Part B Premiums/Deductibles

As the Social Security Administration previously announced, there will no Social Security cost of living increase for 2016. As a result, by law, most people with Medicare Part B will be "held harmless" from any increase in premiums in 2016 and will pay the same monthly premium as last year, which is $104.90.

Beneficiaries not subject to the "hold harmless" provision will pay $121.80, as calculated reflecting the provisions of the Bipartisan Budget Act signed into law by President Obama last week. Medicare Part B beneficiaries not subject to the "hold-harmless" provision are those not collecting Social Security benefits, those who will enroll in Part B for the first time in 2016, dual eligible beneficiaries who have their premiums paid by Medicaid, and beneficiaries who pay an additional income-related premium. These groups account for about 30 percent of the 52 million Americans expected to be enrolled in Medicare Part B in 2016.

"Our goal is to keep Medicare Part B premiums affordable. Thanks to the leadership of Congress and President Obama, the premiums for 52 million Americans enrolled in Medicare Part B will be either flat or substantially less than they otherwise would have been," said CMS Acting Administrator Andy Slavitt. "Affordability for Medicare enrollees is a key goal of our work building a health care system that delivers better care and spends health care dollars more wisely."

Because of slow growth in medical costs and inflation, Medicare Part B premiums were unchanged for the 2013, 2014, and 2015 calendar years. The "hold harmless" provision would have required the approximately 30 percent of beneficiaries not held harmless in 2016 to pay an estimated base monthly Part B premium of $159.30 in part to make up for lost contingency reserves, according to the 2015 Trustees Report. However, the Bipartisan Budget Act of 2015 mitigated the Part B premium increase for these beneficiaries and states, which have programs that pay some or all of the premiums and cost-sharing for certain people who have Medicare and limited incomes. The CMS Office of the Actuary estimates that states will save $1.8 billion as a result of this premium mitigation.

CMS also announced that the annual deductible for all Part B beneficiaries will be $166.00 in 2016. Premiums for Medicare Advantage and Medicare Prescription Drug plans already finalized are unaffected by this announcement.

To get more information about state-by-state savings, visit the CMS website at

https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-11-10.html.  

Since 2007, beneficiaries with higher incomes have paid higher Part B monthly premiums. These income-related monthly adjustment amount (IRMAA) affect fewer than 5 percent of people with Medicare. Under the Part B section of the Bipartisan Budget Act of 2015, high income beneficiaries will pay an additional amount. The IRMAA, additional amounts, and total Part B premiums for high income beneficiaries for 2016 are shown in the following table:

Beneficiaries who file an individual tax return with income:	Beneficiaries who file a joint tax return with income:	Income-related monthly adjustment amount	Total monthly premium amount
Less than or equal to $85,000	Less than or equal to $170,000	$0.00	$121.80
Greater than $85,000 and less than or equal to $107,000	Greater than $170,000 and less than or equal to $214,000	48.70	170.50
Greater than $107,000 and less than or equal to $160,000	Greater than $214,000 and less than or equal to $320,000	121.80	243.60
Greater than $160,000 and less than or equal to $214,000	Greater than $320,000 and less than or equal to $428,000	194.90	316.70
Greater than $214,000	Greater than $428,000	268.00	389.80

Premiums for beneficiaries who are married and lived with their spouse at any time during the taxable year, but file a separate return, are as follows:

Beneficiaries who are married and lived with their spouse at any time during the year, but file a separate tax return from their spouse:	Income-related monthly adjustment amount	Total monthly premium amount
Less than or equal to $85,000	$0.00	$121.80
Greater than $85,000 and less than or equal to $129,000	194.90	316.70
Greater than $129,000	268.00	389.80

Part A Premiums/Deductibles

Medicare Part A covers inpatient hospital, skilled nursing facility, and some home health care services. About 99 percent of Medicare beneficiaries do not pay a Part A premium since they have at least 40 quarters of Medicare-covered employment.

The Medicare Part A annual deductible that beneficiaries pay when admitted to the hospital will be $1,288.00 in 2016, a small increase from $1,260.00 in 2015. The Part A deductible covers beneficiaries' share of costs for the first 60 days of Medicare-covered inpatient hospital care in a benefit period. The daily coinsurance amounts will be $322 for the 61^st through 90^th day of hospitalization in a benefit period and $644 for lifetime reserve days. For beneficiaries in skilled nursing facilities, the daily coinsurance for days 21 through 100 in a benefit period will be $161.00 in 2016 ($157.50 in 2015).  

Enrollees age 65 and over who have fewer than 40 quarters of coverage and certain persons with disabilities pay a monthly premium in order to receive coverage under Part A. Individuals with 30-39 quarters of coverage may buy into Part A at a reduced monthly premium rate, which will be $226.00 in 2016, a $2.00 increase from 2015. Those with less than 30 quarters of coverage pay the full premium, which will be $411.00 a month, a $4.00 increase from 2015.

Deductibles and Coinsurance for 2016

Part A Deductible and Coinsurance Amounts for Calendar Years 2015 and 2016 Type of Cost Sharing
	2015	2016
Inpatient hospital deductible	$1,260	$1,288
Daily coinsurance for 61st-90th Day	315	322
Daily coinsurance for lifetime reserve days	630	644
SNF coinsurance	157.50	161.00

For more information on the 2016 Medicare Parts A and B premiums and deductibles (CMS-8059-N, CMS-8060-N, and CMS-8061-N), visit: https://www.federalregister.gov/public-inspection.  

Helpful Weblinks:

Federal Register Links:

Part A CMS-8059-N (PDF)- https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-29207.pdf and on 11/16/2015 and available online at http://federalregister.gov/a/2015-29207

8060-N PDF- https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-29176.pdf and 11/16/2015 and on available online at http://federalregister.gov/a/2015-29176

Part B CMS-8061-N (PDF) https://s3.amazonaws.com/public-inspection.federalregister.gov/2015-29181.pdf and on 11/16/2015 and available online at http://federalregister.gov/a/2015-29181

SNF Therapy Payment Model expands to consider SNF non-therapy related refinement possibilities

Phase Two

In the second phase of the project, which is now in process, the contractor is using the findings from this Base Year Final Summary Report as a guide to identify potential models suitable for further analysis.  We have considered stakeholder comments and concerns as we continue to investigate alternative therapy payment approaches and plan to solicit additional feedback on this aspect of our SNF payment research.  As noted above, we expanded the scope of this project during this phase to include ideas for revising the overall SNF PPS and plan to include additional and separate opportunities to obtain stakeholder input on non-therapy related refinement possibilities.  

As the contractor began the process of further narrowing the scope of therapy payment models in this second phase of the project, Acumen hosted a Technical Expert Panel in February 2015 to discuss questions and issues related to the therapy payment research. The following report summarizes the discussion and recommendations of the Technical Expert Panel:

Skilled Nursing Facility Therapy Payment Models Technical Expert Panel Summary Draft [PDF, 264KB] 

https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/therapyresearch.html

Analysis of Medicare Part A SNF PPS Payment Model

In an effort to establish a comprehensive approach to Medicare Part A SNF payment reform, we are expanding the scope of the SNF Therapy Payment Research project.  Although we always intended to ensure that any revisions to therapy payment would consider an integrated approach with the remaining payment methodology, we now plan to examine potential improvements and refinements to the overall SNF PPS payment system. This expansion will allow for improving the ability for Medicare to pay adequately and appropriately for all services provided during a Medicare Part A SNF stay.  

Overview

Since 1998, Medicare has paid for services provided by skilled nursing facilities (SNFs) under the Medicare Part A benefit on a per diem basis through the skilled nursing facility prospective payment system (SNF PPS). Currently, therapy payments under the SNF PPS are based primarily on the amount of therapy provided to a patient, regardless of the specific patient characteristics and care needs. CMS has contracted with Acumen, LLC to identify potential alternatives to the existing methodology used to pay for services under the SNF PPS. Below, we will post information about this project as it progresses.
 

Phase One

In the first phase of the project, the contractor reviewed past research studies and policy issues related to SNF PPS therapy payment and options for improving or replacing the current system of paying for SNF therapy services. The following report summarizes the analysis and findings from this first phase of the project:

SNF Therapy Payment Models – Base Year Final Summary Report, April 2014

The contractor is continuing with further refinements of the therapy model development, based on the panel's recommendations, as well as considering potential improvements to the nursing component and overall SNF PPS payment structure, we welcome your comments and feedback. Comments on the SNF PPS payment methodology may be submitted anytime to:

SNFTherapyPayments@cms.hhs.gov

DOJ still aggressively pursuing unnecessary therapy

FOR IMMEDIATE RELEASE

Thursday, October 29, 2015

Government Intervenes in Lawsuits Alleging That Skilled Nursing Chain SavaSeniorCare Provided Medically Unnecessary Therapy

The government has intervened in three False Claims Act lawsuits and filed a consolidated complaint against SavaSeniorCare LLC and related entities (Sava) alleging that Sava knowingly and routinely submitted false claims to Medicare for rehabilitation therapy services that were not medically reasonable and necessary, the Department of Justice announced today.  Sava is one of the nation's largest healthcare providers, operating approximately 200 skilled nursing facilities (SNFs) in 23 states.

"The provision of Medicare benefits must be dictated by patient need, not by Medicare providers' efforts to maximize profits by pressuring their employees to provide medically unnecessary services," said Principal Deputy Assistant Attorney General Benjamin C. Mizer of the Justice Department's Civil Division.  "The Department of Justice will continue to aggressively pursue companies that seek to engage in this kind of fraudulent scheme."

The government's complaint alleges that Sava exerted significant pressure on its SNFs to meet unrealistic financial goals that resulted in the provision of medically unreasonable, unnecessary and unskilled services to Medicare patients.  Sava allegedly set these aggressive, prospective corporate targets for the highest Medicare reimbursement rates to significantly increase Sava's revenues without regard for its patients' actual clinical needs and then pressured its staff to meet those goals.  Sava also allegedly delayed discharging patients from its facilities, even though the patients were medically ready to be discharged, in order to increase its Medicare payments.

"Enforcing the False Claims Act and combating healthcare fraud remains a top priority of the U.S. Attorney's Office," said U.S. Attorney David Rivera of the Middle District of Tennessee.  "When healthcare providers subject patients to unnecessary treatment, we will intervene and hold them accountable."

The three consolidated lawsuits were filed under the qui tam, or whistleblower, provisions of the False Claims Act, which permit private parties to sue on behalf of the government for false claims for government funds and to receive a share of any recovery.  The False Claims Act also permits the government to intervene in such lawsuits, as it has done in these cases.  Under the Act, a defendant that is found liable is subject to damages equal to three times the government's loss plus applicable penalties. 

The government's intervention in these matters illustrates its emphasis on combating health care fraud and marks another achievement for the Health Care Fraud Prevention and Enforcement Action Team (HEAT) initiative, which was announced in May 2009 by the Attorney General and the Secretary of Health and Human Services.  The partnership between the two departments has focused efforts to reduce and prevent Medicare and Medicaid financial fraud through enhanced cooperation.  One of the most powerful tools in this effort is the False Claims Act.  Since January 2009, the Justice Department has recovered a total of more than $26.2 billion through False Claims Act cases, with more than $16.4 billion of that amount recovered in cases involving fraud against federal health care programs.  Tips and complaints from all sources about potential fraud, waste, abuse and mismanagement, including the conduct described in the United States' complaint, can be reported to the Department of Health and Human Services at 800-HHS-TIPS (800-447-8477).

The lawsuits are being handled by the Civil Division's Commercial Litigation Branch and the U.S. Attorney's Office of the Middle District of Tennessee.  Investigative support is being provided by the U.S. Attorneys' Offices of the Southern District of Texas and the Western District of Texas; the Offices of Inspector General for the Department of Health and Human Services and the Office of Personnel Management and the National Association of Medicaid Fraud Control Units.

The cases are captioned United States ex rel. Hayward v. SavaSeniorCare, LLC, et al., No. 3:11-0821 (M.D. Tenn.);United States ex rel. Scott v. SavaSeniorCare Administrative Services, LLC, 3:15-0404 (M.D. Tenn.); and United States ex rel. Kukoyi v. Sava Senior Care, L.L.C., et al., No. 3:15-1102 (M.D. Tenn.).

The claims asserted in the government's complaint against Sava are allegations only and there has been no determination of liability.

From http://www.justice.gov/opa/pr/government-intervenes-lawsuits-alleging-skilled-nursing-chain-savaseniorcare-provided

CMS Extends Deadline to submit ADR packets

SUBJECT: Pub. 100-08 Chapter 3 Updates: Section 3.2.3.2 Timeframes for Submission and Section 3.2.3.8 - No response to Additional Documentation Requests 

SUMMARY OF CHANGES: The purpose of this change request (CR) is to extend the due date for submitted documentation from providers, requested by the Medicare Administrative Contractors (MACs), Comprehensive Error Rate Testing (CERT) and Recovery Auditors in chapter 3 of Pub. 100-08, sections 3.2.3.2-Timeframes for Submission and 3.2.3.8 - No response to Additional Documentation Requests. 

EFFECTIVE DATE: November 17, 2015 *Unless otherwise specified, the effective date is the date of service. IMPLEMENTATION DATE: November 17, 2015

Requirements:

·         When requesting documentation for post payment review, the MAC, CERT and Recovery Auditors shall notify providers that the requested documents are to be submitted within 45 calendar days of the request

·         MACs and CERT, shall grant at least one extension to providers who need more time to comply with the request.

More information:

https://www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R620PI.pdf

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Caring for the Ages Editor-in-Chief Karl Steinberg, MD, CMD, takes great pride in the publication. "There is something for everyone in it. Every month, we make sure it is chock full of practical ideas and information, nuts and bolts of policy issues and regulatory news, research and drug news, and turnkey type tips and protocols that you can take and put in your arsenal of tools," he says.

"We're thrilled to make Caring available online to a broader audience. I encourage all AMDA members to recommend this opportunity to their colleagues, including physicians, administrators, front-line staff, nurses, and others," he says.

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“We’re thrilled to make Caring available online to a broader audience. I encourage all AMDA members to recommend this opportunity to their colleagues, including physicians, administrators, front-line staff, nurses, and others,” he says. “We will not share their email addresses or contact information with anyone—it will be completely private; and they can un-subscribe at any time.”

Dr. Steinberg takes great pride in Caring. “There is something for everyone in it. Every month, we make sure it is chock full of practical ideas and information, nuts and bolts of policy issues and regulatory news, research and drug news, and turnkey type tips and protocols that you can take and put in your arsenal of tools.” The Caring for Consumers column, he further notes, is a great tool to share with family members and residents; and it is the perfect way to start conversations on a wide variety of issues.

For Caring readers and others, Dr. Steinberg is a familiar face and welcome presence. In addition to being an active medical director and attending physician in California and Editor-in-Chief of Caring, Dr. Steinberg is on the AMDA Board of Directors and chairs AMDA's Public Policy Committee, and he chairs the Coalition for Compassionate Care of California. His smiling face—as well as those of his dogs—can be seen in the pages of the annual AMDA Foundation Caring Canines calendar; in fact, in his facilities, his dogs are as well-known as he is (or more so, he says).

Dr. Steinberg isn’t just Editor of Caring. He also is a devoted reader. “I review every article that goes in and some that don’t. I really get a broad overview of what is happening, and I keep a finger on the pulse of new developments, trends, and studies. I also learn about the great things my colleagues are doing across the country.” 

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