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Medical Rehab

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The Centers for Medicare and Medicaid Services (CMS) recently announced that due to system issues, the February submission deadline for the inpatient rehabilitation facility (IRF) quality reporting program (QRP) data submitted via the Centers for Disease Control and Prevention (CDC) National Health and Safety Network (NHSN) has been extended to May 15, 2017.

The deadline has been extended for the following IRF quality reporting programs, measures, and reporting programs:

May 15, 2017 IRF QRP for Quarter 3 2016

  • CDC NHSN Healthcare-Associated Infection (HAI) Measures for quarter 3 2016
    • Catheter-associated Urinary Tract Infection (CAUTI)
    • Methicillin-resistant Staphylococcus aureus (MRSA)
    • Clostridium difficile Infection (CDI)

CMS is granting this extension to provide facilities additional time to submit quality reporting data and run applicable reports to ensure accurate submission. For further assistance regarding the IRF & long-term care hospitals (LTCH) quality reporting programs and policy information, visit the IRF Quality Reporting Data Submission Deadlines web page.

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On February 8, the Department of Human Services (DHS) Secretary Ted Dallas announced the availability of onboarding grant funds to help connect hospitals and ambulatory practices to the Authority’s Pennsylvania Patient & Provider Network, or P3N.

The P3N enables electronic health information exchange (eHIE) across the state through the connection of health care providers to health information organizations (HIO), and the participation of the HIOs in the P3N.

“These grants will assist providers in the efficient delivery of quality services to the individuals we serve across the commonwealth,” said DHS Secretary Ted Dallas. “As more providers participate, individuals will experience better coordination of care and a better quality of health care.”

The grant program, available to Pennsylvania HIOs to enable the connection of inpatient hospital/facilities and outpatient practice or other outpatient provider organizations participating in the Medicaid Electronic Health Records (EHR) Incentive Program, includes:

  • Up to $75,000 to connect each eligible inpatient hospital or other inpatient facility to an HIO;
  • Up to $35,000 to connect each eligible outpatient practice or other outpatient provider organization to an HIO; and
  • Up to $5,000 to enable other eligible providers that do not fit into the two categories above, but want to enable HIE participation and connect to an HIO via a portal.

Each eligible provider will connect via an HIO to the P3N.

Only a single award is permitted to any one hospital/facility or outpatient practice. The anticipated performance period for this grant runs through September 30, 2017.

The grant will:

  • Help providers deliver higher quality and more efficient care, particularly through better care coordination for patients covered by Medicaid;
  • Support provider participation in private-sector HIOs by offsetting connection costs;
  • Incentivize HIOs to join the P3N, a precondition for receiving funding;
  • Support rapid movement toward the participation in eHIE, and support various care reform efforts currently underway across the Commonwealth; and
  • Defray up-front costs for individual providers to join an HIO, thus helping to achieve meaningful use and satisfy obligations under the Medicaid EHR Incentive Program.

This program will be made possible through an $8.125 million grant from the federal Centers of Medicare & Medicaid Services (CMS). Under the terms of the federal grant, CMS will provide 90 percent of the onboarding grant, with the remaining 10 percent funded by the Commonwealth. The grant applications and supporting materials are available online here.

(Information courtesy of DHS)

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The Department of Human Services (DHS) has announced the recent changes to the OBRA Waiver that have been approved by the Centers for Medicare and Medicaid Services (CMS). Some of the waiver amendments include:

  • Adds five new employment-related service definitions that are replacing two existing employment service definitions. Five employment services have been added (benefits counseling, career assessment, employment skills development, job coaching, and job finding) (C-1/C-3).
  • Corrects the regulatory citation for an Outpatient or Community-Based Rehabilitation Agency provider type in the Occupational Therapy (OT), Physical Therapy (PT), Speech and Language Therapy (SLP) service definitions (C-1/C-3).
  • Clarifies that Personal Assistance Services (PAS) are only available to individuals in the waiver 21 years of age and over. All medically necessary Personal Assistance Services for children under age 21 are covered in the state plan pursuant to the Early and Periodic Screening, Diagnostic, and Treatment (EPSDT) benefit (C-1/C-3).

The complete service definitions and requirements are now included in an updated OBRA Waiver document. The effective date of these changes is February 1, 2017.

The OBRA Waiver PROPOSED rates for the new Employment Services have also been released. Questions regarding these rates should be directed to (717) 783-8412.

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On February 23, 2017, from 1:30 pm to 3:00 pm, the Centers for Medicare and Medicaid Services (CMS) will host a call, “Looking Ahead: The IMPACT Act in 2017,” focusing on the Improving Medicare Post-Acute Care Transformation (IMPACT Act) of 2014. The IMPACT Act requires the reporting of standardized patient assessment data by post-acute care (PAC) providers, including inpatient rehabilitation facilities (IRFs), skilled nursing facilities (SNFs), home health agencies (HHAs), and long-term care hospitals (LTCHs). Agenda topics during this call will include the requirements, goals, progress to date, and key milestones for 2017. CMS will also convene a question and answer session following the presentation. To participate in the call, registration is required.

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On January 17, 2017, the Centers for Medicare and Medicaid Services (CMS) published the final rule in the Federal Register that finalizes changes to the Medicare benefit claim appeals processes that were proposed on July 5, 2016. This final rule is part of the Department of Health and Human Services (HHS) approach for addressing the increasing number of appeals and the current backlog of claims waiting to be adjudicated. This final rule includes new and revised rules that expand the pool of available Office of Medicare Hearings and Appeals (OMHA) adjudicators; increase decision-making consistency among the levels of appeal; and improve efficiency by streamlining the appeals process so less time is spent by adjudicators and parties on repetitive issues and procedural matters. These regulations become effective on March 20, 2017.

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The Centers for Medicare and Medicaid Services (CMS) conducted a national provider call on January 12, 2017, that focused on therapy information data collection for the inpatient rehabilitation facility patient assessment instrument (IRF-PAI). The therapy information section on the IRF-PAI was finalized in the fiscal year (FY) 2015 IRF prospective payment system (PPS) final rule. The call included a review of examples of each type of therapy and how to accurately code and complete the therapy information section on the IRF-PAI. To assist with the call, CMS utilized a PowerPoint presentation for providers to refer to. The written transcript and audio recording of the national provider call will be posted in approximately two weeks.

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In recent months, Pennsylvania’s Learning Community has focused on challenges to financing and payment for mental health care in the primary care and collaborative care settings. The SAMHSA-HRSA Center for Integrated Health Solutions (CIHS) has provided the field with an array of information, presentations, and other resources related to the financing of mental health services in primary care and integrated care settings. Below are some of the resources that CIHS has made available to us here in Pennsylvania.

  • The ability to bill for both behavioral health and primary care services on the same day is an essential part of integrating care. The Center for Medicare and Medicaid Services (CMS) created the Billing Properly for Behavioral Health Services booklet to help providers understand the laws and regulations that govern billing for behavioral health services.
  • The resource also includes a checklist to help evaluate your billing procedures and identify potential errors, as well as a resource guide for your billing staff to review current guidelines, billing and coding, covered services, and compliance information.
  • Learn ways you can enhance and streamline your billing process through Improving Your Third-Party Billing System, a self-paced online course from SAMHSA’s BHbusiness initiative.

CIHS continually updates its website to present the best and newest resources and information relevant to integrated primary and behavioral health care.

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From: “HS, Secretary’s Office”
Date: January 5, 2017 at 1:01:56 PM EST
To: “DHS-STAKEHOLDERS@LISTSERV.DPW.STATE.PA.US”
Subject: [DHS-STAKEHOLDERS] DHS Awards Medicaid Agreements

Department of Human Services (DHS) Secretary Ted Dallas announced that DHS has agreed to move forward and negotiate agreements with six managed care organizations (MCOs) to deliver physical health services to Pennsylvanians through HealthChoices, Pennsylvania’s mandatory Medicaid managed care program since 1997.

“These agreements will be the most significant changes to Pennsylvania’s Medicaid program since we moved to managed care two decades ago,” said Dallas. “Over the next three years, MCOs will be investing billions of dollars in innovative approaches that reward high-quality care that improves patient health rather than just providing services for a fee.”

The $12 billion, three-year contracts include a 30 percent target for payments based on value received or outcomes, rather than on the quantity of services provided.

The MCOs were selected based on several criteria, including their current performance, the level of customer service delivered, member satisfaction, and their value-based performance plan. Performance criteria measured, among other things, management of chronic conditions such as high blood pressure, diabetes, and asthma; frequency of prenatal and post-partum care; and access to preventive services.

“The average performance ratings of the selected organizations are consistently higher than the current averages in every region. This transition will result in higher levels of quality care for the 2.2 million Pennsylvanians served by Medicaid,” said Dallas.

To drive Pennsylvania’s Medicaid system towards these better outcomes, the three-year agreements set gradual targets for all MCOs to increase the percentage of value-based or outcome-based provider contracts they have with hospitals, doctors, and other providers to 30 percent of the medical funds they receive from DHS. The result will be that billions in funds that would have otherwise been spent on traditional payment arrangements will instead be invested in outcome or value-based options such as:

  • Accountable care organizations (voluntary networks of hospitals, doctors, and other providers that work together to provide coordinated care to patients);
  • Bundled payments (increases value-based purchasing);
  • Patient-centered medical homes; and
  • Other performance-based payments.

“We’re going to reward folks for providing the right services, not just more services. You get what you pay for so we’re shifting the focus of Pennsylvania’s Medicaid system toward paying providers based on the quality, rather than the quantity of care they give patients,” said Dallas. “In addition, by focusing on improving the health of consumers, we will drive down the cost of care and ultimately save the taxpayer funds we spend on health care in Pennsylvania.”

HealthChoices delivers quality medical care and timely access to all appropriate services to 2.2 million children, individuals with disabilities, pregnant women, and low-income Pennsylvanians.

For more information, visit www.HealthChoicesPA.com or www.dhs.pa.gov.

DHS has selected the following MCOs to proceed with negotiations to deliver services in Pennsylvania beginning in June 2017. The agreements are awarded in five geographic regions:

Southeast Region Gateway Health
Health Partners Plans
PA Health and Wellness
UPMC for You
Vista–Keystone First Health Plan
Southwest Region Gateway Health
PA Health and Wellness
UPMC for You
Vista—AmeriHealth Caritas Health Plan
Lehigh/Capital Region Gateway Health
Geisinger Health Plan
Health Partners Plans
PA Health and Wellness
Northeast Region Gateway Health
Geisinger Health Plan
UPMC for You
Northwest Region Gateway Health
UPMC for You
Vista—AmeriHealth Caritas Health Plan

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On December 20, 2016, the Centers for Medicare and Medicaid Services (CMS) announced the release of a final rule that will implement three new Medicare Parts A and B episode payment models, a Cardiac Rehabilitation Incentive Payment model and modifications to the existing Comprehensive Care for Joint Replacement (CJR) model under Section 1115A of the Social Security Act.

The finalization of these new Innovation Center models will continue the shift of Medicare payments from rewarding quantity to rewarding quality by creating incentives for hospitals to deliver better care to patients at a lower cost. The models will reward hospitals that work together with physicians and other providers to avoid complications, prevent hospital readmissions, and speed recovery.

The announcement finalizes significant new policies that:

  • Improve orthopedic care: One new payment model will support clinicians in providing care to patients who receive surgery after a hip fracture, other than hip replacement. In addition, CMS is finalizing updates to the CJR Model, which began in April 2016.
  • Improve cardiac care: Three new payment models will support clinicians in providing care to patients who receive treatment for heart attacks, heart surgery to bypass blocked coronary arteries, or cardiac rehabilitation following a heart attack or heart surgery.
  • Provides an accountable care organization (ACO) opportunity for small practices: The new Medicare ACO Track 1+ Model will have more limited downside risk than Tracks 2 or 3 of the Medicare Shared Savings Program in order to encourage more practices, especially small practices, to advance to performance-based risk.

The final rule makes several modest adjustments to the CJR Model that are largely conforming changes for consistency with the other episode payment models. These include refinements for use of the skilled nursing facility waiver, exclusion of beneficiaries participating in selected ACOs, and revising target pricing methodology to include reconciliation and repayment amounts for performance years 3, 4, and 5. CMS is finalizing revisions to the quality adjustment to incorporate improvement as well as absolute performance, and also finalized changes to align CJR with the episode payment models around financial arrangements and beneficiary engagement incentives, compliance enforcement, appeals processes, and beneficiary notifications.

The final rule is scheduled to be published in the Federal Register on January 3, 2017, and is effective on February 18, 2017.

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The decision for Pennsylvania to postpone the implementation of Community HealthChoices (CHC) was announced today. This decision was made as a result of the delays associated with the resolution of several bid protests.

Following the announcement of the selection of the managed care organizations (MCOs) that would deliver health care coverage in Community HealthChoices, several protests were filed. As a result, the progress of major components of CHC implementation was delayed, resulting in the Department of Human Services (DHS) feeling uncertain with moving forward with their established start dates. Some of the impacted activities associated with this decision include:

  • Developing an adequate network: DHS has not been able to engage with the selected offerors. The agreement and rate negotiations and finalization typically take six weeks, and the agreements need to be finalized before the MCOs are able to engage in network development activities. The current delays mean the MCOs will not have enough time to meet the network adequacy requirements by July 1, 2017.
  • Completing a readiness review: Readiness review is a requirement for the MCOs before they are certified to be able to go live and provide services. Protests prohibit MCO engagement for readiness review and the window to complete the certification continuously shrinks. New programs require a minimum of six months to complete a readiness review.
  • Communicating: Communication about selected MCOs and their available networks is a critical component to CHC education and outreach. Individuals who will be enrolling in CHC need to have complete information about the MCO provider network in order to be able to make an informed provider choice. That communication will not be able to take place until the agreements are largely finalized and the MCOs are in a position to provide network information.

Important dates to note include:

  • Phase 1 will now begin in January 2018 in the Southwest region of the state.
  • Phase 2 will now begin in July 2018 in the Southeast region of the state.
  • The January 2019 start date for the rest of the state remains unchanged.
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