REVISED RULES PROPOSED ON CIVIL MONETARY PENALTIES

https://www.federalregister.gov/articles/2014/05/12/2014-10394/medicare-and-state-health-care-programs-fraud-and-abuse-revisions-to-the-office-of-inspector

REVISED RULES PROPOSED ON CIVIL MONETARY PENALTIES

The Office of the Inspector General (OIG) has published a proposed rule, seeking comments on revisions to the rules associated with Civil Monetary Penalties (CMP) for fraud and abuse. The Affordable Care Act significantly expanded OIG's authority to protect Federal healthcare programs from fraud and abuse. The proposed rule codifies the changes for:

• Failure to grant OIG timely access to records
• Ordering or prescribing while excluded
• Making false statements, omissions, or misrepresentations in an enrollment application
• Failure to report and return an overpayment
• Making or using a false record or statement that is material to a false or fraudulent claim

MDSC:  when you modify an MDS and it lowers the PPS RUG, that is an overpayment that must be returned to the treasury. There is no time limit on returning overpayments.

CMS Fact Sheet: SNF Proposed Rule

Fact sheets: Proposed fiscal year 2015 payment and policy changes for Medicare Skilled Nursing Facilities

Date

2014-05-01

Title

Proposed fiscal year 2015 payment and policy changes for Medicare Skilled Nursing Facilities

For Immediate Release

Thursday, May 1, 2014

Contact

press@cms.hhs.gov

Proposed fiscal year 2015 payment and policy changes for Medicare Skilled Nursing Facilities

Overview
On May 1, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1605-P] outlining proposed Fiscal Year (FY) 2015 Medicare payment rates for skilled nursing facilities (SNFs). The FY 2015 proposals and other issues discussed in the proposed rule are summarized below.

Changes to Payment Rates under the SNF Prospective Payment System (PPS)
Based on proposed changes contained within this rule, CMS projects that aggregate payments to SNFs will increase by $750 million, or 2.0 percent, from payments in FY 2014, which represents a higher update factor than the 1.3 percent update finalized for SNFs last year. This estimated increase is attributable to 2.4 percent market basket increase, reduced by the 0.4 percentage point multifactor productivity adjustment required by law.

Wage Index Update
On February 28, 2013, the Office of Management and Budget (OMB) issued OMB Bulletin No. 13-01, which contained a number of significant changes related to the delineation of Metropolitan Statistical Areas, Micropolitian Statistical Areas, and Combined Statistical Areas, and guidance on uses of the delineation of these areas. To align with these changes, CMS is proposing revisions to the wage index based on the newest OMB delineations for the FY 2015 SNF PPS wage index. CMS is also proposing to use the new OMB delineations to identify a provider’s urban or rural status for the purpose of determining which set of rate tables would apply to the provider. This is consistent with other Medicare payment rules which will also include similar revisions this year as a result of the new OMB delineations.

In an effort to mitigate the potential negative wage index impacts for some providers of this proposed adoption of the revised OMB delineations, CMS is proposing to implement these changes by providing a one-year transition with a blended wage index for all providers. The wage index for each provider would consist of a blend of 50 percent of the FY 2015 wage index using the current OMB delineations and 50 percent of the FY 2015 wage index using the revised OMB delineations. A similar transition wage index was used when CMS adopted the OMB’s Core-Based Statistical Area (CBSA) definitions in FY 2006.

Change of Therapy assessment policy update
The Change of Therapy (COT) Other Medicare Required Assessment (OMRA) is used to classify a resident into a new resource utilization group (RUG) when, based on the therapy services provided during the previous seven days, the resident no longer qualifies for the RUG into which they are currently classified for payment. Recently, some providers have raised concerns regarding a technical aspect of the rules governing when the COT OMRA may be completed, which generally limits the use of the COT OMRA to instances where the resident is already classified into a therapy RUG.

Therefore, CMS is proposing a revision to the current COT OMRA policy to address this concern, which would permit providers to use the COT OMRA to reclassify a resident into a therapy RUG from a non-therapy RUG, but only in certain limited circumstances.

Civil Monetary Penalties
The proposed rule provides clarification of statutory requirements under Section 6111 of the Affordable Care Act regarding the approval and use of Civil Money Penalties (CMPs) imposed by CMS against nursing facilities. We clarify that states may use federal CMP funds only after obtaining prior approval from CMS, and may not use these funds if CMS has disapproved their intended use, or use these funds for purposes other than to support activities that benefit residents as specified in statute. CMS also proposes that States provide more public transparency on the projects that have been funded by CMP funds.

The proposed rule went on display on May 1 at the Federal Register’s Public Inspection Desk and will be available under “Special Filings,” at http://www.federalregister.gov/inspection.aspx.

For further information, see http://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/SNFPPS/index.html. Public comments on the proposal will be accepted until June 30, 2014.

SNF Pepper Reports Now Available On-line

Program for Evaluating Payment Patterns Electronic Report     The Q4FY13 release of your new Skilled Nursing Facility (SNF) Program for Evaluating Payment Patterns Electronic Report (PEPPER), with statistics through September 2013, is now available for download through the Secure PEPPER Access page atPEPPERresources.org. To obtain your SNF's PEPPER, the Chief Executive Officer, President or Administrator of your SNF should:  Review the Secure PEPPER Access Guide. Visit the Secure PEPPER Access page at PEPPERresources.org. Review the instructions and obtain the information required to authenticate access. Click on the button to Access the Secure Portal. Complete all the fields. Download your PEPPER.  The SNF PEPPER will be available to download as a Microsoft Excel file for approximately one year. The previous Q4FY12 SNF PEPPER, originally released in August 2013, will be made available via the Secure PEPPER Portal in the summer of 2014; an email notification will be sent when these PEPPERs are available. New for this release in the SNF PEPPER: The "State" comparison group now includes all SNFs in a state. Previously, the "State" comparison group included all SNFs in a state that were in the same MAC jurisdiction. As a result, state percentiles will be available for most SNFs; state percentiles will differ from the previous PEPPER release.   For more information, visit the SNF Training and Resources section ofPEPPERresources.org. About PEPPER PEPPER is an educational tool that summarizes provider-specific data statistics for Medicare services that may be at risk for improper payments. Providers can use the data to support internal auditing and monitoring activities. Visit PEPPERresources.org to access resources for using PEPPER, including recorded web-based training sessions, a sample SNF PEPPER and the current SNF PEPPER User's Guide, which are available on the SNF "Training and Resources" page. PEPPER is distributed by TMF® Health Quality Institute under contract with the Centers for Medicare & Medicaid Services. Do you have questions or comments about PEPPER or need help obtaining your report? Visit our Help Desk to request assistance with PEPPER. Provide your feedback or suggestions regarding PEPPER through our feedback form.  The PEPPER Team

CMS Announces Two New Focused Surveys

 Memorandum Summary 

Focused Nursing Home Surveys Under Development: The Centers for Medicare & Medicaid Services (CMS) is currently developing two distinct focused survey processes to assess dementia care and Minimum Data Set, Version 3.0 (MDS 3.0) coding practices in nursing homes. CMS is planning to pilot these survey types beginning in 2014. The intent of the dementia care focused survey is to document dementia care practices in nursing homes. The intent of the MDS focused survey is to document MDS 3.0 coding practices and associated care planning in facilities. 

Training: CMS will provide training for those States participating in the focused reviews via webinar. This training will be mandatory for those State Survey Agency (SA) staff conducting reviews as well as one manager or trainer within the SA. 

Enforcement Implications: Deficient practices noted during the survey will result in relevant citations.

The S&C Letter is found here:  http://www.cms.gov/Medicare/Provider-Enrollment-and-Certification/SurveyCertificationGenInfo/Downloads/Survey-and-Cert-Letter-14-22.pdf

SENATE PASSES ICD-10 DELAY BILL: AHIMA Alert

Today, the US Senate voted to approve H.R. 4302, Protecting Access to Medicare Act of 2014, which included language delaying the implementation of ICD-10-CM/PCS by at least one year. The vote was 64 to 35 at 6:59 p.m. ET. The bill now moves to President Obama, who is expected to sign it into law.

The H.R. 4302 bill mainly creates a temporary "fix" to the Medicare sustainable growth rate (SGR). But a seven-line section of the bill states that the Department of Health and Human Services (HHS) cannot adopt the ICD–10 code set as the mandatory standard until at least October 1, 2015—a year after the October 1, 2014 implementation date for which the industry has been preparing.

AHIMA to Seek Immediate Clarification on Technical Issues

Effects of a one year delay include an estimated likely cost of $1 billion to $6.6 billion to the healthcare industry and lost opportunity costs for failing to move to a more effective code set. A cloud will also be cast over the employment prospects of more than 25,000 students who have learned to code exclusively in ICD-10 in HIM associate and baccalaureate educational programs. In a statement on the Senate vote, AHIMA officials said they will work to clarify outstanding questions raised by the delay and continue to work with government officials to implement ICD-10.

"On behalf of our more than 72,000 members who have prepared for ICD-10 in good faith, AHIMA will seek immediate clarification on a number of technical issues such as the exact length of the delay," said AHIMA CEO Lynne Thomas Gordon, MBA, RHIA, CAE, FACHE, FAHIMA. "AHIMA will continue our work with various public sector organizations and agencies such as the Centers for Medicare and Medicaid Services, the Office of the National Coordinator for Health IT, and the National Center for Health Statistics, along with our industry partners such as the ICD-10 Coalition so that ICD-10 will realize its full potential to improve patient care and reduce costs. These are goals that AHIMA and other healthcare stakeholders and our government leaders all share."

AHIMA Thanks Members and ICD-10 Proponents for Remarkable Grassroots Fight

AHIMA thanks its members and other stakeholders for their efforts over the last six days to stop an ICD-10 implementation delay. Proponents of ICD-10 responded to AHIMA's call for a grassroots campaign by making nearly 10,000 phone calls and sending over 1,000 letters to their elected representatives, urging them to vote against an ICD-10 delay and to pass a clean SGR bill. ICD-10 supporters also took to social media, with messages on Twitter containing the hashtag #NoDelay numbering more than 5,000, including several thousand during this morning's hour-long virtual rally. During that hour, a flood of tweets on the topic of ICD-10 catapulted hashtag #ICD10 onto Twitter's "trending topics" list.

While today's vote has delayed ICD-10 implementation, AHIMA will be working to ensure that another delay does not occur legislatively. In the coming weeks, updates will be added to AHIMA's Advocacy Assistant with instructions on how members can continue to advocate for ICD-10.

For more on today's vote and what happens next, visit the Journal of AHIMA website.

From Provider Magazine: CMS extends audit moratorium to MMRs

CMS Extends Audit Moratorium to MMRs

The Obama administration has extended its moratorium on health care audits to include the controversial manual audits, offering another olive branch to long term and post-acute care advocates.

Last week, providers breathed a sigh of relief when the Centers for Medicare & Medicaid Services (CMS) announced that it would “pause” reviews under its Recovery Auditor Contractor program. The reviews were principal culprits behind a monstrous backlog of audit appeals that has swamped the agency.

The CMS pause announcement left open questions about whether the so-called Manual Medical Reviews (MMRs) would continue.

In a clarifying letter to advocates, CMS says that the manual reviews are on hold as well. The suspension is applied retroactively to last week’s recovery audit announcement, CMS says.

Additionally, CMS says that it’s tweaking its audits to address many provider concerns.  Under just-announced or pending rules, auditors now must:

• Wait at least 30 days “to allow for a discussion” if a provider says that he or she will appeal an audit decision.  Previously, auditors had to end talks when notified of an appeal. 
• Wait to be paid any contingency fees until after the second level of administrative appeals has concluded. Previously, auditors were allowed to take the cash even if a case was on appeal; and
• Adjust their document requests to a provider’s denial rates.

Overall, advocates say they’re pleased with CMS’ new posture but still say the central problem isn’t so much the audit process as the audit policy itself. Providers say they have no objection to catching crooks, but the current policy treats everyone as if they were already guilty and ties innocent providers up for weeks, and even months, on endless reviews and paperwork requests—only to be followed by months of appeals.

Bill Myers is Provider’s senior editor. He can be reached at wmyers@providermagazine.com.  Follow him on Twitter, @ProviderMyers.

CMS SUSPENDS RAC OPERATIONS

February 18, 2014 – CMS is in the procurement process for the next round of Recovery Audit Program contracts.  It is important that CMS transition down the current contracts so that the Recovery Auditors can complete all outstanding claim reviews and other processes by the end date of the current contracts.  In addition, a pause in operations will allow CMS to continue to refine and improve the Medicare Recovery Audit Program.   Several years ago, CMS made substantial changes to improve the Medicare Recovery Audit program.  CMS will continue to review and refine the process as necessary. For example, CMS is reviewing the Additional Documentation Request (ADR) limits, timeframes for review and communications between Recovery Auditors and providers.  CMS has proven it is committed to constantly improving the program and listening to feedback from providers and other stakeholders.  Providers should note the important dates below:
• February 21 is the last day a Recovery Auditor may send a postpayment Additional Documentation Request (ADR)
• February 28 is the last day a MAC may send prepayment ADRs for the Recovery Auditor Prepayment Review Demonstration
• June 1 is the last day a Recovery Auditor may send improper payment files to the MACs for adjustment
CMS will continue to update this Website with more information on the procurement and awards as information is available. Providers should contact RAC@cms.hhs.gov for additional questions.