What LHC, Almost Family Merger Means for the Home Health Industry

A $2.4 billion merger between two powerhouses in the home health field is expected to create a new industry giant and set in motion significant long-term consequences for the home health field, according to Home Health Solutions Owner and President J’non Griffin.

In a deal set to close in 2018, Kentucky-based Almost Family, Inc., and Louisiana-based LHC Group, Inc, have announced their plans for an all-stock merger of equals, creating a company with a starting roster of more than 30,000 employees nationwide.

“This merger is a huge development, with the potential to shore up confidence in the future of home health, impact stocks and rejuvenate an industry feeling the weight of an increasing regulatory burden,” J’non said.

But she warns that the move could have some negative consequences – especially for smaller agencies.

“The new company created by this merger will be poised to set the professional tone and standards in the entire industry regarding delivery of well-coordinated, patient-centered care,” J’non said.

“Smaller agencies struggling to meet quality expectations may find it increasingly hard to compete in the evolving marketplace. Coupled with increasing regulations, the evolution of a faster-paced, coordination-intensive market with much bigger players could squeeze some smaller, struggling agencies into selling or going out of business,“ she added.

Expect more buyouts and partnerships

The merger between LHC and Almost Family reflects a dramatically shifting turf in the industry, as agencies increasingly look at strategic partnerships, joint ventures and other consolidation efforts to buffer the challenges presented by mounting regulatory burdens.

“Buyouts and partnerships are a growing trend,” J’non said. “We can expect to see increasing numbers as agencies work out innovative answers to the demands for quality outcomes, expedited turnarounds, increasing care coordination, and value-based reimbursement.”

So far this year, LHC Group had acquired more than 35 home health, hospice or community-based locations, as well as six long-term acute care hospital operations, before it announced plans for the merger with Almost Family.

2018: A ‘transformative’ year ahead

Next year is shaping up to be a transformative year in many ways for the home health field, according to J’non. In January, agencies will implement new Conditions of Participation set by the Centers for Medicare and Medicaid Services (CMS), requiring extensive operational, administrative and clinical changes.

“Meeting the demands of the new CoPs is expected to be a watershed moment for some agencies which have been struggling to stay afloat under the compliance burden, and simply may not be able to adapt quickly enough to the new round of regulations,” she said.

Does your agency
need CoPs training?
Click here to read about
J’non’s Dec. 16 seminar
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In addition to new CoPs requirements, agencies throughout the country are expected to be required to transition soon to the value-based reimbursement model already under demonstration in nine states.

Coming soon: Value-based purchasing

Officials at Almost Family and LHC have made no bones about positioning the giant company created by the merger to become the industry leader in value-based reimbursement.

Although a value-based purchasing model is only active in nine states right now, many home health experts believe CMS may have recently signaled its readiness to soon expand VBP to all other states.

“CMS did not really make many adjustments to the value-based purchasing in the 2018 Payment Rule, and the changes that were made were not really significant changes,” J’non said. “That may well indicate that CMS believes the model is ready for a full-scale release.”

The VBP model has largely been considered a success because the nine states participating in the demonstration have seen improvements in outcomes at a faster rate than states which were not included in the program, J’non said.

How to conduct a Hazards and Vulnerabilities Risk Assessment

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THURSDAY, Oct. 19 Giveaway

One of the key components of new Emergency Preparedness Programs which CMS is requiring home health agencies to have in place by the November deadline is an All Hazards Risk Vulnerabilities Assessment.

If you’re still wondering exactly this is and where your agency can download its risk assessment form, we have some disappointing news. There is no standard risk vulnerabilities assessment form agencies can download and fill out to comply. CMS leaves the actual format of the risk assessment – whether it will be a form or even a full, written report with a chapter-by-chapter analysis — to the discretion of the home health agency.

You will see many different versions and samples of suggested risk assessments all over the internet, ranging from basic to complex.

(Because we like things made easy, and because we believe Surveyors appreciate being able to quickly find information, Home Health Solutions suggests using an easy-to-read form for the risk assessment. We provide a fairly simple form in an easy-to-follow 12-step Emergency Preparedness Plan Assembly Kit we sell in the HHS online store.)

Whichever format your risk assessment takes, bear in mind that the easier it is to read, with information presented clearly and concisely, the more likely Surveyors are to look at it favorably. Surveyors are human, too – and no one likes wading through a disorganized mess or too much information.

CMS does provide some guidance about the risk assessment. Your agency will need to determine your vulnerability (based in large measure on your geographic location and the history there of previous events) to all natural or man-made disasters, including weather-related catastrophes such as winter storms, tornadoes, hurricanes, flooding, wildfires, etc. You’ll also need to evaluate your vulnerability to non-weather emergencies, such as nuclear power plant explosions or acts of terrorism.

Each agency’s risk assessment will be based on your particular location and the likelihood of hazardous conditions for you. An agency in North Dakota, for example, will probably devote a great deal of space on its risk assessment to the likelihood of winter storms, so that it can undertake detailed planning for continuity of patient care during ice or blizzards. But an agency in Florida will almost certainly devote most of its space to tropical storms or hurricanes with the potential for high winds and flooding – and may even devote space to the potential for sinkholes.

Your agency’s risk assessment shouldn’t necessarily look just like assessments for other agencies in your state. Is your agency located within a few blocks of a major metropolitan airport? You may want to include the possibility of a major plane crash impacting the building in which your agency is housed. Does the river in your small town flood in years with heavy spring rains, closing roadways? Your risk assessment should highlight that risk. Do frequent rock slides impact roadways in the mountainous areas where you serve clients? That is a risk specific to your area, and should be addressed in your risk assessment.

Remember that CMS loves data, so build your risk assessment to the extent possible around local data showing previous incidences of ice storms, tornadoes, forest fires, etc. which have occurred in your area. Your local Emergency Management Agency should be able to help provide data, or direct you to state web sites where it can be found.

Bear in mind, however, that your risk assessment does not need to be a lengthy and detailed incident report of every power outage or tornado watch experienced in your area over the last few decades. You will only need to provide a comprehensive overview of risks specific to your area.

Think of the risk assessment as your agency’s clear, concise and carefully constructed answer to these two questions:

1. What could possibly go wrong?

2. How will we respond if it does?

The goal is to demonstrate that you have thoughtfully and carefully evaluated many different situations likely to make it difficult for you to care for your patients, seeking input from qualified emergency management officials who are trained in dealing with crisis situations, and that you have set in place mechanisms to maintain continuity of care even under the most challenging circumstances.

CMS specifically uses the term “all hazards” in defining the risk assessment, so be sure to weigh all potential hazards, including those which are not weather related. Your assessment should reflect your agency’s vulnerability to cyber attacks, workplace shootings, hostage situations, acts of terror and other man-made crises which could negatively impact your ability to care for your patients.

On its web site, CMS says the risk assessment should include (but is not limited to):

  • Hazards likely in geographic area
  • Care-related emergencies
  • Equipment and power failures
  • Interruption in communications, including cyber attacks
  • Loss of all/portion of facility
  • Loss of all/portion of supplies

The CMS list above provides the framework for your risk assessment. Flesh it out and make it specific to your agency, and you will have this important element of your Emergency Preparedness Program in place.

The clock is ticking. Check out all the helpful CoPs products HHS offers in our online store, The Solutions Shop: www.homehealthsolutionsllc.com/the-solutions-shop

CMS requires two exercises before November deadline

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WEDNESDAY Oct. 18 Giveaway

Are you still working hard to get your home health agency’s new Emergency Preparedness Program in place by November so that you can meet the CMS deadline and begin all the detailed planning for those two exercises you’re required to stage — the full-scale community disaster drill and a second, smaller-scale  table-top exercise?

We sure hope not.

For compliance, your agency will need to have already staged both these required exercises by November. The Emergency Preparedness Requirements Final Rule was posted to the Federal Register more than a year ago, on Sept. 8, 2016, and the regulation went into effect just two months later, on Nov. 16, 2016. Medicare and Medicaid Participating Providers and Suppliers were given one year from the effective date to comply and implement all regulations. When that year is up – in just one more month – home health agencies will be subject to citations for non-compliance if they have not yet staged both exercises this past year.

The Emergency Preparedness Requirement was confusing to many home health agencies. We talk to agencies every day who are so busy caring for patients and taking care of agency business that they have trouble juggling regulatory deadlines – especially this year, when the start date for new Conditions of Participation was originally set for a July implementation, and then delayed until January.

Isn’t the Emergency Preparedness requirement part of the new CoPs, agencies ask us. Don’t we have until January now? Not for your Emergency Preparedness Programs, we explain.

While the Emergency Preparedness requirement is included as part of the new CoPs, and while  the start date for CoPs was pushed back six months, a delay was never granted for the original Emergency Preparedness Requirements Final Rule which posted to the Federal Register back in 2016.

The clock began ticking then.

Time is up.

Some agencies which experienced actual emergencies this year may be exempt from the community-wide disaster drill (please see Tuesday’s Tip #2).

But agencies which did not activate emergency plans this year and conduct an evaluation afterward are expected to comply with the full-scale community-wide drill prior to next month’s deadline.

In either case, agencies also will be expected to have staged tabletop exercises, in which mock disasters are conducted via paper.

If you’re feeling panicked by the approaching deadline, please visit our online store today and check out our 12-step Emergency Preparedness Plan Assembly Kit. We’re not going to mislead you; it’s getting late in the game to comply, and it will be very difficult now to meet the deadline if you have not yet begun. But don’t wait another day. Our Kit will make it faster and easier.

Click here to visit The Solutions Shop, our online store. 


Tip: CMS offers exemptions to the Community-Wide Disaster Drill

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Tip #2: Full-scale exercise exemption
TUESDAY OCT. 17 GIVEAWAY: Our helpful EP Guide to Survey Readiness

Of all the new Emergency Preparedness requirements expects home health agencies to meet by November, the community-wide disaster drill (full-scale exercise) is the most intimidating and labor-intensive for many agencies.

The community-wide drill is one of two exercises CMS expects home health agencies to stage each year. The second exercise may be a tabletop version, in which the emergency situation is plotted out via paper-only, with participants seated around a discussion table and “talking out” the procedures.

But the community-wide drill is a full-scale exercise requiring agencies to work with other agencies in their communities such as first responders, emergency management officials, hospitals, clinics, assisted living facilities and others to stage a mock crisis, and conduct a detailed evaluation afterward of how well things went, identifying areas for improvement.

The drill is a major undertaking, requiring much planning and coordination.
Did you know, however, that your agency may be exempt from the community-wide drill until next year if you experienced a crisis which required activation of your Emergency Plan? Many agencies in Florida, Texas, Louisiana, South Carolina and Georgia as well as agencies in the Virgin Islands and Puerto Rico were required to activate emergency procedures during this fall’s spate of damaging hurricanes.
Wildfires in California are currently threatening areas served by home health agencies.

If your agency is located in one of these affected areas – or if you are located in a different area of the country where you experienced a crisis such as tornadic activity, flooding, a blizzard or any other emergency which required your agency to activate emergency procedures – you appear to be exempt from staging a community-wide disaster drill before Nov. 16.

Documentation of the activation of your emergency procedures will be required, as well as a thorough evaluation afterward.

Note that you will still need to have conducted a tabletop exercise by the deadline in order to be compliant.

Here is what CMS says on its web site about this exemption:

NOTICE ON TRAINING & EXERCISES: If a facility activates their emergency plan due to a disaster, the facility is exempt from one full-scale/individual based exercise for that year. However, the secondary requirement for a table-top exercise or exercise of choice still applies. Facilities must demonstrate completion of two exercises per annual year.

You can read for yourself what CMS says about the full-scale exercise at:

HHS Countdown to Emergency Preparedness offers tips and giveaways

Look for this picture on the Home Health Solutions Facebook Page every day during our 10-Day Countdown to Emergency Preparedness and comment to win helpful EP products! 

Tip #1:  Are your patients prepared?
MONDAY OCT. 16 GIVEAWAY: Our helpful EP Guide to Survey Readiness

CMS wants to make certain home health agencies have adequately prepared patients and their caregivers for the possibility of evacuation or other possible changes in the delivery of care during or immediately after an emergency situation.

One of the ways agencies should do this is by providing patients two lists: a Medication List and a Special Equipment List. These lists are to be kept in the home and constantly updated so that each list is always current. This means it will be necessary to review and update the Medication List at each visit – a big change for most agencies.

Make certain patients and caregivers understand that these lists are to go with them to a shelter if an evacuation is needed.

The Medication List should include the medication, dose, frequency, route, time of day, and any special considerations for administration. The Special Equipment List will identify the equipment needs of the patient.

Note that lists should include the name and phone number of the patient’s physician and pharmacy, and the address of the pharmacy should also be included.

It is also important to include allergies and adverse events as well the name and contact information for the home health agency on these lists.

During the confusion of an emergency situation, this information could be vital to maintain continuity of care for the patient.  HHS recommends that your agency create a form to be used to collect all the necessary information, so that nothing will be inadvertently omitted.

Be sure to document your discussions with patient and caregivers about the importance of these lists, with reminders that the lists should always travel with the patient if there is an evacuation.

Preparing homebound patients for the possibility of an emergency situation is an important step in your agency’s overall Emergency Preparedness Program. 

Read more tips and enter to win daily giveaways on the Home Health Solutions Facebook Page during our “10-Day Countdown to Emergency Preparedness,” as we help home health agencies meet the CMS deadline to have Emergency Preparedness Programs in place. 

Will HHGM be delayed?

House bill would delay new payment model until 2020,
but agencies still have work to do. Here are 3 priorities.

It’s been a year of remarkable regulatory suspensions and delays for the home health industry – sometimes at the last minute  – and home health agencies are wondering whether another regulatory reprieve could be in the works.

A bill introduced late last week in the U.S. House of Representatives would postpone the costly and controversial overhaul of the Medicare payment system known as the Home Health Groupings Model (HHGM) which CMS proposes to implement in 2019.

Agencies would not see implementation of the proposed HHGM until 2020 under HR 3992, the bill introduced last Friday by Rep. Kristi Noem (R) of South Dakota.

“But it is important to note that the bill in its current form will not address expected losses of as much as $950 million in the first year of implementation due to reduced payments to home health agencies,” said J’non Griffin, owner and president of Home Health Solutions.

HR 3993, or the Rural Home Health Extension and Regulatory Relief Act, does not affect the proposed new 30-day payment episode in the HHGM or the shift away from a therapy-driven payment model to a new system which relies on clinical groupings, J’non said.

“Whether it is implemented in 2019 or a year later, under this proposed bill, the new payment system will still be a coding and OASIS driven payment model,” J’non said. “With that in mind, agencies can begin some important preparations.” She recommends that agencies take the following 3 steps to prepare:

  1. Focus on improved coding accuracy. 

The new HHGM relies heavily on primary diagnoses codes to classify each 30-day episode into one of six clinical groupings. Comorbidities, early or late timing of the episode, admission source and the patient’s cognitive and functional status are also integral to the new classification.

Under the new model, episodes which could not be grouped by primary diagnoses due to coding issues would be considered “questionable encounters” and returned to the provided for more accurate or definitive coding.

Whether agencies rely on in-house coders or outsource coding services, the quality of an agency’s coding will determine its viability under the HHGM, J’non said.

“Some agencies which may have been reluctant to outsource coding services are going to have to make that move, under the new HHGM, to ensure the level of accuracy needed for success, “she said. “And that decision is going to open up new areas of compliance risk, requiring agencies to look beyond cost to determine the credentials of the coders and quality of the services provided. It’s definitely a case of buyer beware in the coding world. If the price seems to be an exceptional bargain, smart agencies should wonder how and ask why.”

2. Provide thorough OASIS C-2 training to all team members.

As part of the HHGM case-mix adjustment, CMS proposes to assign points for each of the responses to certain OASIS functional items. The sum of those points would create a functional score for the period of care. Items to be scored are:

● M1800: Grooming.

● M1810: Current Ability to Dress Upper Body.

● M1820: Current Ability to Dress Lower Body.

● M1830: Bathing.

● M1840: Toilet Transferring.

● M1850: Transferring.

● M1860: Ambulation/Locomotion.

● M1032 (M1033 in OASIS-C1): Risk of Hospitalization.

“OASIS mistakes will be costly under the new HHGM,” J’non warns. “Agencies which may have been reluctant to invest in OASIS training in the past need to make that commitment now. It’s important to note, too, that just because clinicians have had training in the past doesn’t necessarily mean they’re up to speed. Guidance changes frequently in this field – and complete reversals are not unusual. Accuracy requires ongoing training.  Training does pay for itself, directly impacting an agency’s bottom line.”

3. Estimate the HHGM impact on your agency by using a CMS tool.

Determining how the HHGM will impact your agency is a crucial first step in developing plans to stabilize your bottom line. CMS has put together a grouping tool to help agencies understand how the proposed payment grouping parameters would impact payments.

To use it, your agency will need to input several months of data from patients under the current system and see how much of a difference the new payment model would make on payments received.

Click here to access the Excel file available on the CMS web site at http://go.cms.gov/2f12QpC.

Here’s what you need to know about our helpful EP Assembly Kit

THREE MONTHS FROM TODAY.  When surveyors show up at your home health agency in just three months from today, they’ll expect to review your Emergency Preparedness program.

Yes, the start date for new CoPs has been delayed until January 2018 — but don’t get confused. Your agency is still required to have its Emergency Preparedness Plan in place by this November.

Home Health Solutions Owner and President J’non Griffin has been traveling across the country to present workshops to help agencies meet the new Emergency Preparedness requirements in time for November surveys.

Her expertise is also condensed into an easy-to-follow 12-Step EP Assembly Kit available for order now in the Home Health Solutions online store.  The Kit takes the cumbersome process of developing Emergency Preparedness policies and procedures and staging a community-wide disaster drill, and makes it simple to execute.

Wondering how the kit works? Check out these EP Assembly Kit FAQs:


1. What format is the Kit presented in?
The Kit comes to you in DIGITAL format so it is available immediately. You can get started on your Plan instantly!

2. What exactly comes in the Kit?

A VIDEO in which Home Health Solutions Owner J’non Griffin explains the Emergency Preparedness Program which new Conditions of Participation will require agencies to have in place by November of 2017.

A 12-STEP GUIDE which breaks down the cumbersome process of developing your agency’s program into 12 easy-to-follow steps. We explain each step and provide the materials you will need to implement it. One of the steps, for example, explains how to set up a community meeting with Coalition Members to plan your community drill. We include a copy of the invitation letter for you to send, a list of other facilities and/or community groups to send it to, and an agenda to follow at the meeting.

A SAMPLE PLAN to show you what your completed Plan should look like.

— A section we call THE TOOL PACKET.  It is filled with all the forms you’ll need to capture the information to fulfill the requirements of the CoPs for creating an Emergency Plan. There’s a sample Phone Tree and Crisis Communications Form for creating your agency’s Disaster Communications Plan, a sample Hazardous Risk Vulnerabilities Assessment, etc. This section includes more than 30 forms and tools.

An EP Survey Readiness Guide. We’ve used Interpretive Guidelines to create an at-a-glance look at exactly what Surveyors will be looking for when reviewing new agency Emergency Preparedness Plans.

3. Does the Kit explain how to stage a community-wide disaster drill? Yes. Our 12-Step Guide explains exactly how to go about planning this event, from who to invite to participate with you to a sample letter to send out to invite participants to a planning meeting. We include an agenda for that meeting and samples of items you will need to discuss and lists you will need to compile at the meeting. We can’t have the meeting or stage the actual drill for you, but we make it as easy as possible!

4. What about the Training and Testing portion of the Emergency Plan requirements? Our Tool Kit includes training materials on various natural or man-made disasters which you will be able to copy and provide to your patients and staff to fulfill CoPs disaster training requirements. Just be sure to document that you have provided these materials and when the training occurred.
We also include some sample evaluation forms to use to review the communitywide drill afterward to help  in conducting an annual evaluation of your Emergency Plan.

5. What is the “All Hazards” Risks and Vulnerabilities Assessment our agency is required to have, and is it included in the Kit? Our kit explains what this assessment is, and we provide a sample for you to follow. We also explain how to create your own Risk Assessment specific to your agency and community.

6. How long is the 12-Step Guide? How much reading will be required? We know you are busy so we have kept the entire Guide – all 12 steps and all the forms and tools included – right at 100 pages. The EP Survey Readiness Guide is a separate document, provided in spreadsheet format.

7. Our agency will need to have a written Policy outlining our Emergency Plan. Does the Kit address this need? Yes. A sample written Policy is included in the Kit. We recommend that you use it as the basis for your agency’s policy. It will meet federal requirements in its current form, and you can easily add any state-specific requirements to it. Some states, including Florida, will have a few extra Emergency Preparedness requirements that CMS does not require. Our 12-Step Guide directs you to work with your local Emergency Management Agency on the development of your plan, and your local office will be able to provide any local and/or state requirements which must be met in addition to what CMS requires.

8. How long will it take to get together our agency’s Emergency Program using this Kit? That depends on how many components of the program your agency already has in place and how quickly you are able to set up a meeting with your Coalition Partners and stage a community-wide disaster drill. In most cases, this project will take weeks of planning and collecting information, so we recommend that you get in started well in advance of the November deadline.

9. Our agency already has an Emergency Operations Plan in place, so we do not want to order the Kit. But we would like to know whether our existing plan meets new CoPs. We have the solution: the piece of our kit known as the EP Survey Readiness Guide may be purchased separately. Based on Interpretive Guidelines, this helpful guide is available in an easy-to-read, spreadsheet format and will review all aspects of the Emergency Program requirement along with bulleted points showing exactly what Surveyors will be looking for. Check our online store to order the Survey Readiness Guide.

Remember, Home Health Solutions also provides customized education and training to home health agencies. Owner and President J’non Griffin will work with your agency to make certain you comply with the new Emergency Preparedness and Infection Control program requirements as well as any other aspects of the new CoPs.

How the new HHGM would affect home health agencies

This article first appeared in The Monday Fix, our free weekly e-newsletter. To subscribe, click here

proposed rule updating the home health prospective payment system would lower payment rates to home health agencies next year and completely overhaul the way Medicare pays home health agencies the following year.

CMS estimates that the cost to agencies for implementing the rule published to the Federal Registry on Aug. 4 would be about $80 million in 2018. 

But the rule has garnered more attention for the changes it would bring about in payment structure for episodes of care provided by home health agencies, shortening the national standardized 60-day episode payment to just 30 days beginning Jan. 1, 2019, and replacing the current therapy-driven payment system with a model largely based on six clinical groupings. 

CMS calls the revised payment model a “more clinically intuitive system” and said it will align with the way clinicians already categorize their patients to deliver care. 

The new model is predicated on the use of principal diagnoses as the core of the system to more clearly identify the types of patients treated in home health, and the focus of their care,” said J’non Griffin, owner and president of Home Health Solutions LLC.

   Each 30-day payment period would be assigned to a clinical group according to the primary reason the patient was receiving home health. CMS would use the principal diagnosis code reported on the home health claims to assign the grouping to one of these 6 classifications:

  • Musculoskeletal rehabilitation
  • Neurological or stroke rehabilitation
  • Wound care
  • Medication Management Teaching and Assessment
  • Behavioral health care (including psychiatric and substance abuse conditions)
  • Complex nursing care (IV therapy, ventilator, ostomies, parenteral or enteral nutrition, etc.)

Questionable encounters
Under the new payment model, 30-day payment episodes which could not be grouped by primary diagnoses due to coding issues would be considered “questionable encounters” and returned to the provider for more accurate or definitive coding. 

CMS has announced that it will post on its web site a list of codes which would be considered “a questionable encounter.”

“We believe this will help to minimize any returned claims for more definitive coding,” CMS states in its proposal. “Each code should be reported to the level of certainty and specificity known for the home health admission. Under our proposal, secondary diagnosis codes would not be used to assign the clinical group, as the intent of the HHGM is to increase clarity by classifying the 30-day period based on the primary reason for home health services.”
Other factors will be considered 
Although the principal diagnosis code would be the basis for the home health episode, secondary diagnosis codes would be used to case-mix adjust the period further through additional elements of the model, such as co-morbidity adjustment.
“The relationship between function and cognitive status and episode cost will also take on increased significance under the new model,” J’non said. “Each of the primary diagnosis groupings will be ranked either high or low in terms of functional/cognitive level. Four of the 6 clinical groupings will have an additional medium category.”

In all, the new 30-day home health category will be classified according to:
– TIMING — Early or late episode
– REFERRAL SOURCE – Community or institutional
– CLINICAL GROUP – One of the 6 primary diagnosis-based groupings listed above
– COMORBIDITY ADJUSTMENT – Determined by secondary diagnoses  

Under the new model, diagnosis codes would support medical necessity for services furnished, and provide information for establishing the home health Plan of Care, according to CMS.


“Ultimately, developing clinically similar groups based on the reported principal diagnosis as part of the larger structure of the model would allow for more meaningful analysis of home health resource use, ensure that patients are receiving care commiserate with their level of need, and more accurately align payment with cost,” CMS said.


Hospice rule approves 1% payment increase for 2018

As home health news spotlights a proposal by the Centers for Medicare and Medicaid Services to overhaul the Medicare payment system beginning in 2019, hospice agencies have been quietly evaluating some changes CMS has in store for them in the next fiscal year.

CMS has authorized a 1 percent increase for hospice payments beginning Oct. 1, 2017, in a Final Rule for FY 2018 which also updates the hospice wage index and places a cap amount for the fiscal year.

Other noteworthy content in the Final Rule is a decision not to make a previously-discussed regulatory change regarding requirements for clinical information to certify life expectancy, and updated information about a comprehensive new patient assessment tool which is now under development. The tool will eventually be used to replace the existing Hospice Item Set known as HIS.

CMS initiated a 60-day comment period last May on the measures addressed in its FY 2018 Final Rule, and both the comments received and its responses appear in the Final Rule published to the Federal Registry Aug. 4.  The Final Rule may be viewed by clicking here.

“Many of the commenters expressed concerns that the 1 percent increase was not substantial enough, but CMS explained that the 1 percent payment update for FY 2018 is mandated by section 411(d) of MACRA, the Medicare Access and CHIP Reauthorization Act of 2015, ” said J’non Griffin, President and Owner of Home Health Solutions LLC.

“In addition, CMS clarified some aspects of the clinical information now required for certification of life expectancy and decided against making any change at this time in regulations regarding accurate sources of the required information, ” J’non said.

She offered a few other highlights from the Final Rule:

Wage Index Update and Payment Rate
In addition to approving a market basket percentage increase of 1 percent for hospice payments in FY 2018, the Final Rule updates the hospice wage index, which is used to adjust payment rates under the Medicare program to reflect local differences in area wage levels, based on the location where services are furnished. The wage index applicable for FY 2018 is available on the CMS website at:

Cap amount established
The hospice cap amount for the 2018 cap year will be $28,689.04, which is equal to the 2017 cap amount ($28,404.99) updated by the FY 2018 hospice payment update percentage of 1 percent.

Certification of life expectancy
CMS decided not to make a change at this time in the regulations at §418.25, clarifying that the documentation used the initial certification of a medical prognosis of a life expectancy of 6 months or less must come from medical records provided by the referring physician or acute/post-acute care facility.

CMS also confirmed that “…this clinical information can be obtained orally from the referring entity and documented in the patient’s chart within the 2 day time-frame needed for certification” and clarified that the hospice medical director or physician designee would not be required to perform a face-to-face visit before the third benefit period recertification, as currently required by the regulations at §418.22(a)(4).

“In announcing the decision not to make the regulatory change at this time, CMS stated that it plans to work with Medicare Administrative Contractors (MACs) to confirm whether specific information about appropriate sources for required clinical information should be included in additional documentation requests,” J’non said.

HQRP updates
 Quality Reporting updates in the FY 2018 Final Rule include some changes in compliance criteria.

Hospices will be allowed 60 extra days to request an exemption or an extension when submitting quality data for HQRP.  Currently, hospices have 30 days in which to submit requests for extensions or exemptions. Under the change, a hospice which suffered damage due to a hurricane on Jan. 1, for example, would have until March 31 to submit a request form to CMS.

The 90-day period would apply to requests for exemption or extensions in submitting multiple types of data, including HIS data and the requirement to collect Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Hospice Survey data on a monthly basis.

CMS also proposed a scoring change for CAHPS® Hospice Survey measures and proposed some new measures. Details on the specifications of these measures, including details regarding the proposed scoring methodology and mode and case-mix adjustment, may be viewed on the CAHPS® Hospice Survey webpage at http://www.hospicecahpssurvey.org/

Hospice Item Set updates
Although it did not implement a new patient assessment tool in the FY 2018 Final Rule, CMS said it wants to bring the current Hospice Item Set (HIS) data collection instrument in line with other post-acute care settings, and is working with a contractor to develop a comprehensive patient assessment instrument which would replace the current HIS.

The new data collection tool is preliminarily called the Hospice Evaluation & Assessment Reporting Tool, or HEART.

“Basically, the new tool would function as an expanded HIS, with additional clinical items that could also be used for payment refinement purposes or to develop new quality measures,” J’non said.

“HEART would not replace any of the existing requirements set forth in the Medicare Hospice CoPs (such as the initial and comprehensive assessment), the CAHPS® Hospice Survey or the regular submission of claims data, but would instead be designed to complement data collected as part of high-quality clinical care,” J’non said.

Patient assessment data would be collected upon a patient’s admission to and discharge from any Medicare-certified hospice provider, she added.

As OIG looks at improper payments, agencies should look at coders

Here’s why  it’s important to know who is REALLY handling your coding and billing

It may be time to take a harder look at your agency’s coding and billing practices to determine whether you’re at unnecessary risk of being charged with fraud  — particularly in light of this summer’s announcement that the U.S. Health and Human Services Office of Inspector General (OIG) will launch a new probe to identify improper payment patterns.

The OIG will use data from the Centers for Medicare and Medicaid Services CERT Program (Comprehensive Error Rate Testing) to look for agencies with improper payments, honing in on any identifiable patterns to compile a list of common characteristics among agencies CMS believes were improperly paid.

Last year, CERT identified some $7 billion in improper payments among home health claims.

“This new initiative by the OIG sends a strong message to the home health industry,” said J’non Griffin, owner and president of Home Health Solutions LLC. “The period of hesitancy during the administration changeover earlier this year is ending, and we’re getting back to business as usual, with continuing scrutiny on home health for evidence of fraud or wrongdoing.”

How can agencies mitigate their risks for fraud or non-compliance?

Outsourcing services to a competent and professional firm is one of the best ways in which an agency can continue to focus on delivering quality health care instead of struggling to meet the compliance burden – but J’non cautions that outsourcing may have its own risks.

Agencies which rely on outsourcing for coding and billing should protect themselves by being especially  diligent not just in vetting the reputation and credentials of the firms contracted to provide services, but in ascertaining the credentials of the employees who actually perform the outsourced work for the company, J’non said.

Questions which agencies should be asking as they seek reputable outsourcing firms include:

How many of the reviewers are clinicians?

Are employees experienced in the home health and hospice fields? How many years of experience do they have?

Are they credentialed in home health and hospice specific coding?

Are the reviewers located in this country or abroad?

Are they HIPAA trained?

Are they familiar with the U.S. Health and Human Services Office of Inspector General focus on suspected fraud? Do they understand the importance of compliance to your agency’s success?

Are they knowledgeable about CMS requirements and otherwise well prepared to protect your agency?

“These are important questions for agencies to ask – more important in the long run than pricing,” J’non said. “Agencies can’t afford the cost of shoddy work quality in such heavily scrutinized circumstances.”

The HHS Who’s Coding You Challenge

Home Health Solutions LLC has announced an industry-wide “Who’s Coding You?” challenge in an effort to take the anonymity out of the outsourcing business and reassure home health agencies about the credentials and knowledgeability of our staff.

Over the next few months, we’ll be spotlighting the names, faces and credentials of all our team members to introduce to the world the people who make up our company.

“We’re proud of the HHS team and confident in the commitment to quality our team members show every day,” J’non said. “Instead of hiding our best and important assets behind the company name, we want to show them off, creating the opportunity for agencies to get to know each one of them, and learn firsthand how committed they are to doing the right thing for the agencies we serve.”

Other OIG concerns

Other areas of concern for agencies included on  the July work plan posted by the OIG include plans to evaluate Medicare Part A payments to home health agencies to determine whether claims billed to Medicare Part B for services and items were permissible and in accord with federal regulations. Certain supplies, items and services provided to inpatients are covered under Part A and should not be separately billable to Part B.

According to Section 1842 (b)(6)(F) of the Social Security Act, consolidated billing for all home health services is required while the beneficiary is under a home health plan of care authorized by a physician. The Act established a Medicare prospective payment system that pays home health agencies (HHA) for home services and covers all of their costs for furnishing services to Medicare beneficiaries. Pursuant to the home health consolidated billing requirements, the HHA that establishes a beneficiary’s home health plan of care has Medicare billing responsibility for services furnished to the beneficiary. Payment is made to the HHA whether or not the item or service was furnished by the HHA or by others by arrangement.

The OIG will review Medicare Part A payments to HHAs to determine whether claims billed to Medicare Part B for items and services were allowable and in accord with Federal regulations.

The OIG work plan also announced that it will review Medicare claims paid for telehealth services provided at distant sites that do not have corresponding claims from originating sites to determine whether those services met Medicare requirements.

Here is a link to review the OIG work plan.

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