Healthcare at Home: The Rowan Report

From the Centers for Medicare and Medicaid Services Office of the Actuary
Released February 14, 2018

National health expenditure growth is expected to average 5.5 percent annually over 2017-2026, according to a report published today as an “Ahead Of Print” by Health Affairs and authored by the Office of the Actuary at the Centers for Medicare & Medicaid Services (CMS). (more…)

NEW YORK — January 30, 2018 — CipherHealth announced today that its automated patient engagement platform has received the highest overall score and was recognized as the #1 performer for Patient Outreach in the 2018 Best in KLAS: Software and Services Report.  (more…)

As healthcare systems adjust their strategies under the new administration, a few key trends will absolutely remain. Value-based care, increased patient power and consolidation for improved profits and coordination will continue to influence the decisions of healthcare thought leaders across the country.

marcus evans is very pleased to announce the National Healthcare CXO Summit taking place May 20-22, 2018 at the Omni Orlando Resort Championsgate, Orlando, FL. (more…)

As of January 13, 2018, home health agencies must comply with new Conditions of Participation (CoPs). Now is the time to review interpretive guidelines and to be prepared to demonstrate compliance during surveys.

New Conditions of Participation (CoPs) of the Medicare Program for home health require agencies to have internal policies and procedures governing plans of care. The Centers for Medicare and Medicaid Services (CMS) issued draft Interpretive Guidelines for the new CoPs for home health agencies on October 27, 2017. The draft provides information about what surveyors will be looking for when they survey agencies based on the new CoPs for patients’ rights. [The author provides detailed summaries of CMS’s requirements of healthcare at home agency staffpersons, with a particular focus on staffpersons’ handling of patients’ refusal of services  and careA brief notice is provided of an upcoming webinar from Hogue, on  February 15 at 1:00 – 2:30 EST titled “How to Prevent Marketers from Taking Referral Sources When They Leave: New Developments.“]

Section 484.60(a)(1) Standard: Plan of Care requires agency staff members to take specific action with regard to refusal of services that may impact patients’ clinical well-being and non-compliance as follows:

If the patient or the patient’s representative refuses care (such as dressing changes, essential medication or other services that could impact the patient’s clinical wellbeing) on more than one occasion the HHA attempts to identify the cause of the refusal. If the HHA is unable to identify and address the cause, the HHA must communicate with the patient’s responsible physician to discuss the options.

Providers may be tempted to overlook repeated refusal of important services and non-compliance on the basis that patients need care. It may be especially difficult to act based on refusal or non-compliance by primary caregivers for home health patients. After all, say some practitioners, patients should not be penalized because of the refusal or non-compliance of their caregivers.

Instead, providers should first carefully document instances of repeated refusal of services and non-compliance as follows:

• Staff must document every instance of refusal of services and non-compliance by both patients and/or their primary caregivers, regardless of the risk associated with the refusal or non-compliant behavior. Agencies cannot possibly know whether the refusal and/or non-compliance has occurred more than once, as required by the draft interpretive guidelines, unless they document each instance.

• Documentation must be very specific. It is insufficient to document as follows: “Patient (or primary caregiver) non-compliant or refused services.” Providers may, for example, document the failure to change the diapers of a bed-bound patient who is incontinent of both bowel and bladder as follows: “RN observed patient with urine and feces in diaper. RN removed diaper, cleaned patient and placed clean diaper on patient. RN marked the right tab of the clean diaper with a red X. When the RN visited the following day, the patient was again observed lying in urine and feces. When the RN removed the diaper, she observed a red X on the right tab of the diaper the patient was wearing when she arrived.”

• Staff must then counsel with patients and/or primary caregivers regarding each instance of refusal of services or non-compliance and document that they have done so.

• If staff cannot identify the reason for the refusal or non-compliance, they must contact patients’ physicians, according to the draft interpretive guidelines.

The number of times practitioners are willing to repeat this “protocol” depends on the risk of injury/damage to patients associated with refusal or non-compliance. If patients are likely to be injured or damaged, providers should not tolerate additional instances of refusal of services or non-compliance after taking the above steps.

There is an old legal adage that “every dog is entitled to one bite.” When an instance of refusal of services that may adversely impact patients or non-compliance has been identified, the “dog” has had its bite!

In some instances, refusal of services or non-compliance may be so serious that immediate termination is warranted. When refusal or non-compliance is serious enough to warrant discontinuation of services, providers may wish to take additional action to protect patients, which may include reports to adult and/or child protective services, as indicated in applicable state statutes. On the other hand, chronic refusal or non-compliance may be acceptable, if it involves very little risk, if any, of poor outcomes or injury to patients.

Providers have always practiced good risk management when they address issues of non-compliance or refusal of services. Now the draft interpretive guidelines make it clear that agencies are required to take action in order to comply with Medicare CoPs, too.

Ms. Hogue will be presenting a webinar on February 15 at 1:00 – 2:30 EST titled “How to Prevent Marketers from Taking Referral Sources When They Leave: New Developments.” Registration information

©2018 Elizabeth E. Hogue, Esq.  All rights reserved. No portion of this material may be reproduced in any form without the advance written permission of the author. This article appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com editor@homecaretechreport.com

DATELINE ORLANDO — A welcome new format by Lincoln Healthcare Leadership treated this year’s Homecare 100 participants to a series of expert panels focused on the issues of greatest concern to Healthcare at Home providers and the vendors that service them. In the past, inspirational, day-long experiences led by authors of books about how to be a champion business leader were fun and appreciated but this year’s focus on immediately usable information, coupled with scheduling the event on a non-Superbowl weekend for the first time, fused the meeting with a gravity that matched the national atmosphere in our sector. [Details are provided in this article on the views of  “friendly competitors Bill Dombi of NAHC and Edo Banach of NHPCO took the stage to compare notes on the regulatory environment that will dominate 2018.” Both shared thoughts on special issues of healthcare at home service providers.  Bill Dombi provided his views on  the defeat of HHGM–the 2017 home health payment system); and Banach provided a keen focus on dismantling of healthcare sector siloes.  Dombi  provided extensive views toward MEDPAC recommendations as well as on Value-based Purchasing (VBP) and uses (and new decisionmaking toward it of healthcare at home  and hospice service provider organizations.]

Out of the gate, friendly competitors Bill Dombi of NAHC and Edo Banach of NHPCO took the stage to compare notes on the regulatory environment that will dominate 2018. Moderated by Sheri Dodd of Medtronic Care Management Services, with just enough humor to keep the entire conversation from growing too dark, the association presidents parsed the short- and long-term significance of new home health regulations, Conditions of Participation, relationships with lawmakers, and what hospice can learn from it all about what to expect in coming years.

The most important lesson learned last year, according to NAHC president Dombi, is that the defeat of HHGM — the radically different home health payment system that he has previously described as “worse than IPS” — demonstrates the power we have in DC. “2,500 comments came in to CMS in a matter of hours,” he reported. “We would have liked to have seen ten times that but we realize that previous open comment periods, even concerning major regulatory changes, only saw one-tenth as many.

“We dodged a bullet,” Dombi asserted. “It would have been a 15% rate cut. But we still need to learn from this experience what we need to do to win next time. HHGM was not literally defeated, only delayed. Elimination of therapy as a payment driver is our next hurdle. We can show them it is in their best interest to keep paying for therapy because it has saved Medicare billions of dollars over the years. It takes people who are dependent and makes them independent. Home health therapy costs a fraction of skilled nursing facility therapy.”

One of the red flags to watch for, Dombi added, is that this time CMS did not control the decision about budget neutrality. “The Office of Management and Budget got their hand in the mix. It seems they want to be in more control going forward.”

Dismantling silos
NHPCO president Edo Banach kept coming back to the problem of healthcare sector silos. “Always keep in mind the value of diversification,” he urged the audience of home health and hospice executives. “CMS pushes us into silos but we should be spending our efforts on breaking them down.” As a strategy, he recommended expanding service lines. “If there is a threat to home health this year, there are opportunities in personal care or hospice.”

Critiquing MedPAC
Asked by Ms. Dodd which voices are most and least heard, Dombi jumped in with the most candid comment ever heard from a NAHC president. “MedPAC recommendations are frequently ignored and they publicly wonder why their analyses, calculations and advice to Congress so rarely become law. Well, I tell them, it’s because you don’t do a good job!” NAHC calculations and forecasts, especially about profit margins and beneficiary access to care, are more accurate, he declared. “Beneficiaries are concerned about access to care, not payment rates.”

Banach agreed. “It is important to organize our voices,” he responded, joking about two supposed competitors appearing on the same stage and agreeing on the basics. “Our two communities have differences but are more powerful when we put those voices together. It is the consumer’s voice that is missing. They are dissatisfied with the way things tend to unravel at the end of life and we should be too.”

Critiquing our critics
“There is certainly some small amount of fraud in our sector,” Banach acknowledged. “But there are also a lot of simple math errors, or other honest mistakes, such as a physician neglecting to add “M.D.” to his signature, resulting in a two year-old claim being denied. Providers are running scared because auditors do not care about the difference between honest mistakes and criminal intent. The result is that providers come right up to the legal line. That can reduce access to care, forcing patients go back to the hospital when they should stay at home.”

About those COPs
“Remember that these new conditions were more than 20 years in the making,” Dombi commented. “and we still do not even have the final Interpretive Guidelines.” He contends that several COP provisions will not work and gave one example. “A new requirement is that home health aides must practice on real patients; they cannot use medical dolls or so-called pseudo patients. There could not be a clearer example that CMS does not understand our business. Try to imagine which one of your patients would be happy to volunteer to be practiced on by a student.”

What happened to VBP?
Both association presidents agreed that we need a definition of “value” before we are able to pay for it. “We believe in Value Based Purchasing because we have seen it change your behavior,” Dombi declared. “But we must actively resist the move to base value assessments on spending per beneficiary. It’s not about spending. If they do that, I’m moving to France!” He added that even Medicare Advantage leadership is starting to understand value instead of just unit price. “It’s taken a long time to get there, but it’s starting.”

They also noted that there seems to be a slowdown in implementing Value Based Purchasing. It is likely due to the change in administrations in Washington. The strategy, they say, has to include flooding CMS with the data we have but the the challenge is in getting them to look at it. “Obama was moving full speed ahead with Value Based Care,” Dombi added. “This new administration is more focused on experiments, waiting to see how the demonstrations pan out, saying they do not know yet what direction to go. For example, we demonstrated that savings from VBP in the first nine states, if extrapolated to all states, could save Medicare $4 billion over 10 years. We had no takers, no interest at CMS.”

NHPCO is working with CMS to update their old data to help them make better decisions. “It is incumbent on us to say, ‘That’s a good first step. Now, before we rush to step two, let’s talk about some data.’ Make them look at merely the quality of hospice services when assessing value. Hospice offers grief counseling to family and, after a natural disaster, sometimes to entire communities. There is a lot of value in that that does not appear in patient outcomes.”

He continued, “When the government comes to hospice and says, ‘‘we should get into non-medical services,’ we remind them, ‘that’s hospice; that’s what we’ve been doing for 35 years, what with spiritual counseling, music therapy and the like. First we need to establish the foundation of who we are, what is hospice and what is palliative care, then we must make clear that more folks need person-centered, interdisciplinary care well before the end of life.

What do we do now?
Sheri Dodd asked them for some concrete recommendations. Bill Dombi said providers should be investing half their resources in preparing for the future but reserve the other half to protect themselves today against payment denials and other accusations from MACs, ZPICs, UPICs, RACs and the like.

“Get your story together,” Edo Banach said. “Use data analytics to tell prospective ACO partners and the government who you are and what you are able to accomplish in terms of quality outcomes and cost savings. I know it is hard to do at a time when we are trying to play defense against fraud accusations but data is your strongest tool.”
©2017 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only.editor@homecaretechreport.com

By Tim Rowan, Editor & Publisher of Home Care Technology Report

In order to reduce identity theft, especially against senior citizens, Medicare has finally decided to stop using social security numbers on Medicare ID cards. Pursuant to the Social Security Act, which has always banned the use of social security numbers for identification by any entity other than the Social Security Administration, Medicare will begin this year to convert beneficiary ID numbers to random number and letter combinations.[Additional means that the CMS is undertaking in 2018 to thwart identity thefts are described in this article.]

To further thwart ID thieves, CMS will go so far as to reissue these random card numbers to deceased beneficiaries as well. This practice may impact home health and hospice providers sending claims for both living and recently deceased persons during the transition period. To help providers prepare for the transition to what they will call the “Medicare Beneficiary Identifier” on Medicare cards beginning April 1 of this year, CMS published the following guidance about Remittance Advices.

Beginning in October 2018, through the transition period, when providers submit a claim using a patient’s valid and active Health Insurance Claim Number, CMS will return both the HICN and the MBI on every remittance advice. Here are examples of different remittance advices:

• Medicare Remit Easy Print (Medicare Part B providers and suppliers)
• PC Print for Institutions
• Standard Paper Remits: FISS (Medicare Part A/Institutions), MCS (Medicare Part B/Professionals), VMS (Durable Medicare Equipment)

Find more new information on the New Medicare Card provider webpage.

New Medicare Card: When Will My Medicare Patients Receive Their Cards?
Starting April 2018, CMS will begin mailing new Medicare cards to all people with Medicare on a flow basis, based on geographic location and other factors. Learn more about the Mailing Strategy.  Also starting April 2018, your patients will be able to check the status of card mailings in their area on Medicare.gov.

For More Information:

• Mailing Strategy
• Questions from Patients? Guidelines
• New Medicare Card overview and provider webpages

©2017 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

LENEXA, Kansas—January 25, 2018 — Mediware Information Systems, Inc., a portfolio company of TPG Capital, and the parent company of Kinnser Software, announced this week that it has acquired MEDTranDirect, Inc., a leader in software solutions for healthcare revenue cycle management and an approved network service vendor for Medicare. The company describes the transaction as one that “complements the revenue cycle management and Medicare claims capabilities in Mediware’s leading home care market solution, Kinnser Software®, while simultaneously leveraging Mediware’s heritage of supporting data-driven clinical excellence and improving efficiencies in administrative workflow.”

We will feature an extended interview with Mediware CEO Bill Miller in next week’s issue.

Established in 1986, MEDTranDirect serves several hundred customers, including providers in the home health, hospice, skilled nursing facility, rehabilitation and rural hospital markets. MEDTranDirect streamlines the submission and processing of providers’ claims to Medicare, Medicaid, and commercial payers, and supports eligibility and remittance transactions, thereby accelerating revenue cycles and improving cash flow. In addition, it is approved to use the Medicare Limited Data Set files to develop analytics solutions for the home health and hospice markets.

MEDTranDirect’s capabilities will eventually integrate with other Mediware software products that collectively provide customers with comprehensive software solutions across the entire care continuum – including home health, hospice, rehabilitation, home infusion, medication management, blood management, and more.

About Mediware
Mediware is a leading supplier of software for healthcare and human service providers and payers. Core Mediware solutions include blood management technologies for hospitals and blood centers; cell therapy solutions for cord blood banks, cancer treatment centers, and research facilities; medication management solutions for hospitals, behavioral health facilities, infusion and specialty pharmacy providers; and rehabilitation therapy and respiratory care solutions.
www.mediware.com

About MEDTranDirect
MEDTranDirect provides SaaS technology solutions for processing and managing HIPAA-compliant healthcare transactions such as eligibility, claims and remittances. MedTranDirect was one of the first approved network services vendors (NSVs), allowing direct access to Medicare’s payments systems, and serves clients in the home health, hospice, skilled nursing, rehab and rural hospital markets.
www.medtrandirect.com

About TPG
TPG is a leading global alternative asset firm founded in 1992 with more than $73 billion of assets under management and offices in Austin, Beijing, Boston, Dallas, Fort Worth, Hong Kong, Houston, London, Luxembourg, Melbourne, Moscow, Mumbai, New York, San Francisco, Seoul, and Singapore. TPG’s investment platforms are across a wide range of asset classes, including private equity, growth venture, real estate, credit, and public equity. TPG aims to build dynamic products and options for its investors while also instituting discipline and operational excellence across the investment strategy and performance of its portfolio. www.tpg.com

2) Netsmart Acquires HomeCare Accounting Solutions
Overland Park, Kan., Feb. 1, 2018 – Today, Netsmart announced it has acquired HomeCare Accounting Solutions, a cloud-based software company that automates back-office and clinical field operations of home care agencies such as home health, hospice, palliative care and private duty.

“Post-acute providers have an opportunity to take the lead when it comes to managing a person’s healthcare journey and coordinating the performance of a variety of providers,” said Netsmart CEO Mike Valentine. “In a value-based world, providers who can prove they can coordinate care across multiple venues and manage the complexities and outcomes will be well positioned for success. The ability to have a seamless connection between clinical and financial will only make reporting easier as providers can show cost savings correlated with clinical outcomes.”

Netsmart announced its acquisition of DeVero in July 2017 and has been deploying enhanced solutions to home health and hospice clients over the last six months. A company notice stated that “the addition of HAS to the Netsmart suite of solutions will enable a more integrated workflow for clients who use our DeVero CareRecord.” HAS has been the financial and billing engine behind the DeVero clinical application for several years.

“Clients want a SaaS approach where all of the operations are managed for them so they can concentrate on what they do best: patient care,” said HAS CEO Mike DelCollo. “We are looking forward to the deep integration and streamlined processes Netsmart provides and giving our clients one system with a single, simple workflow.” In an exclusive, pre-release interview, Mike told us he plans to stay around and continue to enhance his product “as long as they will have me.”

As part of this acquisition, Netsmart will further the innovation of the two solutions to create a single unified solution that can grow and adapt as healthcare shifts to different care and payment models. The go-forward platform will maintain focus on the three principles that have made it one of the fastest growing solutions in homecare – simple, scalable and affordable.

“The addition of HAS to our Netsmart family provides our clients who leverage the DeVero CareRecord with a one-stop-shop for clinical and financial solutions,” said Valentine. “We have a long-standing relationship with HAS in serving a shared client base. With this step forward, we will essentially move out of the interface world with HAS and into the integration world. Our mutual clients will benefit greatly by this step.”

About HomeCare Accounting Solutions
HomeCare Accounting Solutions cloud-based software is a powerful and easy-to-use system that increases the efficiency and productivity of home health agencies. Whether an organization is small or large, HomeCare Accounting Solutions provides the means to manage a business. HAS software automates the back-office and clinical field operations of home care agencies of all types, including: Home Health, Hospice, Palliative Care, Private Duty and other related community-based services.

About Netsmart
Netsmart provides electronic health records for care team members in behavioral health, post-acute and social services. Recent acquisitions have added the Allscripts Home Care and Hospice, HealthMEDX, and DeVero software to the company’s suite of behavioral health applications. The company employs more than 1,500 associates who serve over 600,000 users in more than 25,000 organizations across the U.S.

©2017 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com