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Authors Posts by Melissa Dehoff

Melissa Dehoff

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Melissa Dehoff is responsible for all medical rehabilitation and brain injury service issues. Ms. Dehoff attends multiple state-level meetings to advocate on behalf of members on brain injury and rehabilitation issues and is a member of the Department of Health Traumatic Brain Injury Advisory Board.

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In an effort to reduce the large backlog of Medicare coverage and payment appeals, the Centers for Medicare and Medicaid Services (CMS) released a proposed rule that would revise the procedures the Department of Health and Human Services (HHS) would follow at the Administrative Law Judge (ALJ) level for appeals of payment and coverage determinations. This proposed rule covers items and services provided to Medicare beneficiaries, enrollees in Medicare Advantage and other Medicare competitive health plans, and enrollees in Medicare prescription drug plans, as well as appeals of Medicare beneficiary enrollment and entitlement determinations, and certain Medicare premium appeals. In addition, the proposed rule would revise procedures that HHS would follow at CMS and the Medicare Appeals Council levels of appeal for certain matters affecting the ALJ level. As of April 2016, the Office of Medicare Hearings and Appeals (OMHA) had over 750,000 pending appeals, while OMHA’s adjudication capacity was 77,000 appeals per year, with an additional adjudication capacity of 15,000 appeals per year expected by the end of the current fiscal year. The proposed rule includes provisions to expand the pool of available OMHA adjudicators and improve the efficiency of the appeals process by streamlining the processes so less time is spent by adjudicators and parties on repetitive issues and procedural matters. The proposed rule was published in the July 5, 2016 Federal Register. Comments are due by Monday, August 29, 2016.

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The Department of Human Services (DHS) just announced their decision to lengthen the transition time for the start of the Community HealthChoices (CHC) program. The first phase (southwest part of the state) was originally scheduled to be implemented on January 1, 2017. The implementation date of phase one has now been changed to begin July 1, 2017.

The decision to extend the start date allows more time for the 420,000 Pennsylvanians who will ultimately benefit from CHC to understand the program adjustments that will occur, including how access to and receipt of home- and community-based services will be improved.

All other established CHC timeframes will remain the same. The selection of managed care companies, changes in the Commonwealth’s information technology systems, and other changes are still proceeding on the same timeframe. The implementation of phases two and three (the southeast and remainder of the Commonwealth) also remain on the previously announced timelines of 2018 and 2019, respectively.

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The Centers for Medicare and Medicaid Services (CMS) will conduct a call on the key quality measures related to the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 and how they will affect providers. The IMPACT Act requires the reporting of standardized patient assessment data on quality measures, resource use, and other measures by Post-Acute Care (PAC) providers, including inpatient rehabilitation facilities, skilled nursing facilities, home health agencies, and long-term care hospitals. The call is scheduled for Thursday, July 7, 2016 from 1:30 to 3:00 pm ET. Those interested in participating are encouraged to register early as space is limited.

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On May 3, 2016, the Centers for Medicare and Medicaid Services (CMS) issued an update to the additional documentation request (ADR) limits for Medicare institutional providers under the Medicare fee-for-service (FFS) recovery audit program, which will allow recovery audit contractors (RACs) to request more documents from providers who have high claims denial rates.

For example, a provider with a 0 to 3 percent denial rate will receive no additional RAC document requests for three 45-day review cycles, while providers with denial rates between 91 percent and 100 percent could potentially receive RAC document requests of up to 5 percent of their paid claims. A baseline annual ADR limit is established for each provider based on the number of Medicare claims paid in a previous 12-month period. Using the baseline annual ADR limit, which is one-half of one percent (0.5%) of the provider’s total number of paid Medicare claims from a previous 12-month period, an ADR cycle limit is also established. After three 45-day ADR cycles, CMS will calculate (or recalculate) a provider’s denial rate, which will then be used to identify a provider’s corresponding “Adjusted” ADR limit. Recovery auditors may choose to either conduct reviews of a provider based on their adjusted ADR limit (with a shorter look-back period of six months) or their baseline annual ADR limit (with a longer look-back period of three years).

Questions concerning this update can be submitted via email.

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Dear Colleagues:

We are excited to announce that we have received 14 responses to the recent request for proposal (RFP) issued for Community Health Choices (CHC). This vital program will allow the departments of Human Services and Aging to serve more Pennsylvanians in their communities and allow consumers to have an active voice in the services they receive.

Continue

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The Centers for Medicare and Medicaid Services (CMS) released a final rule in the May 4, 2016 Federal Register that updates health care facilities’ fire protection guidelines to improve protections from fire for Medicare beneficiaries in facilities.

The new guidelines apply to hospitals; long-term care (LTC) facilities; critical access hospitals; inpatient hospice facilities; programs for all-inclusive care for the elderly; religious non-medical health care institutions; ambulatory surgical centers (ASCs); and intermediate care facilities for individuals with intellectual disabilities (ICF-IID). This rule adopts updated provisions of the National Fire Protection Association’s (NFPA) 2012 edition of the Life Safety Code, as well as provisions of the NFPA’s 2012 edition of the Health Care Facilities Code.

Some of the main provisions in the final rule include:

  • Health care facilities located in buildings that are taller than 75 feet are required to install automatic sprinkler systems within twelve years after the rule’s effective date;
  • Health care facilities are required to have a fire watch or building evacuation if their sprinkler system is out of service for more than ten hours;
  • The provisions offer LTC facilities greater flexibility in what they can place in corridors;
  • Fireplaces will be permitted in smoke compartments without a one hour fire wall rating;
  • Cooking facilities now may have an opening to the hallway corridor;
  • For ASCs, all doors to hazardous areas must be self-closing or must close automatically; and
  • Expanded sprinkler requirements for ICF-IIDs.

Health care providers affected by this rule must comply with all regulations within 60 days of the May 4, 2016 publication date, unless otherwise specified in the final rule.

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The Department of Human Services (DHS) has made available for public review and comment the proposed Community HealthChoices (CHC) 1915(b) waiver and the proposed CHC 1915(c) waiver amendments, as published in the April 23, 2016 Pennsylvania Bulletin. If approved, the waiver will govern the operation of the CHC program, Pennsylvania’s managed long-term services and supports initiative.

Available for review on the DHS website are the proposed CHC concurrent 1915(b) and (c) waiver application and a detailed summary of all provisions, including a list of long-term services and supports which will be covered under the 1915 (c) waiver, and a summary of the person-centered planning requirements, participant fair hearing rights and grievance and complaint procedures, participant safeguards, quality management processes, payment methodologies, and cost effectiveness demonstration.

The Office of Long-Term Living will offer two CHC Waiver webinars in May for public input and discussion:

The public comment period ends Monday, May 23, 2016. Comments received within the 30-day comment period will be reviewed and considered for revisions to the applications.

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On April 21, 2016, the Centers for Medicare and Medicaid Services (CMS) released the fiscal year (FY) 2017 inpatient rehabilitation facility prospective payment system (IRF PPS) proposed rule. The proposed rule will publish in the April 25 Federal Register. Some of the key provisions proposed include:

Proposed Updates to IRF payment rates:
Updates to the payment rates under the IRF PPS. CMS is proposing to update the IRF PPS payments to reflect an estimated 1.45 percent increase factor (reflecting an IRF-specific market basket estimate of 2.7 percent, reduced by a 0.5 percentage point multi-factor productivity adjustment and a 0.75 percentage point reduction required by law). CMS is proposing that if more recent data becomes available (for example, a more recent estimate of the market basket or multifactor productivity adjustment), it would be used to determine the FY 2017 update in the final rule. An additional 0.2 percent increase to aggregate payments due to updating the outlier threshold results in an overall update of 1.6 percent (or $125 million), relative to payments in FY 2016.

No changes to the facility-level adjustments. For FY 2017, CMS will continue to maintain the facility-level adjustment factors at current levels. CMS will continue to monitor the most current IRF claims data available to assess the effects of the FY 2014 changes.

Proposed Changes to the IRF Quality Reporting Program (QRP):
Beginning in FY 2014, any IRF that does not submit the required data to CMS receives a 2.0 percentage point decrease in its annual increase factor for payments under the IRF PPS. The Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 requires the continued specification of quality measures, as well as resource use and other measures, for the IRF QRP.

In order to satisfy the requirements of the IMPACT Act, CMS is proposing four claims-based measures for inclusion in the IRF QRP for the FY 2020 and FY 2018 payment determination and subsequent years and one new assessment-based quality measure for inclusion in the IRF QRP for FY 2020 and subsequent years, respectively:

  1. Discharge to Community – Post Acute Care (PAC) IRF QRP (claims-based);
  2. Medicare Spending Per Beneficiary (MSPB) – Post-Acute Care (PAC) IRF QRP (claims-based);
  3. Potentially Preventable 30 Day Post-Discharge Readmission Measure for IRFs (claims-based);
  4. Potentially Preventable Within Stay Readmission Measure for IRFs (claims-based); and
  5. Drug Regimen Review Conducted with Follow-up for Identified Issues (assessment-based).

Pending final data analysis, CMS is also proposing to add four new measures to IRF QRP public reporting on a CMS website, such as Hospital Compare, by fall 2017. In addition, CMS is proposing to extend the timeline for submission of exception and extension requests for extraordinary circumstances from 30 days to 90 days from the date of the qualifying event.

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A Question and Response Addendum has been added to the PA e-Marketplace website, for the request for proposals (RFP) for managed care organizations that will be submitting their proposals and responses for the Community HealthChoices program. The addendum is located under “Flyers/Addendums” on the web page. The 81-page addendum includes the RFP section, questions, and answers to each question posed.

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In late February, the Office of Medicare Hearings and Appeals (OMHA) announced an expansion (Phase III) of its Settlement Conference Facilitation pilot to include Medicare Part A claims, which includes claims under dispute from Inpatient Rehabilitation Facilities. This announcement was part of an Appellant Forum hosted by OMHA. The agenda and slide presentation from the forum provide additional information.

OMHA is the entity that is responsible for administering the Administrative Law Judge (ALJ) level of the Medicare appeals process. This expansion, which became effective on February 25, 2016, is an effort to help resolve the extensive backlog of ALJ hearing requests, which is approximately at 240,000 for FY 2015. The previous phases of expansion were limited to Part B claims and have been in effect since June of 2014. To date, only a small amount of claims have been removed from the queue.

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