http://www.homehealthnews.org

Aug

New NAHC President Launches Top to Bottom Reorganization

stored in: Tim Rowan's Home Care Technology Report and tagged: Bill Dombi--as newly named President of the National Association of Home Care & Hospice (NAHC)- and plans for reorganization of NAHC (as of Aug. 2017), NAHC 2.0--and description of this effort to improve/modify the NAHC for next generations, National Association of Home Care & Hospice (NAHC)-- and newly named President Bill Dombi, Tom Price (US Secretary of Health and Human Services--and DFombi's views on Price's impact on changes in healthcare at home policies, Val Halamandaris--and expected influence on 2017 NAHC annual meeting

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

The National Association for Home Care and Hospice announced last week that its board of directors has appointed Bill Dombi as Interim President. Immediately curious about how long an “interim” is and what might be in store for the association after the untimely passing of its 35-year and only president, we called Bill and were graciously given some time during what must have been an extremely busy week. [Rowan had initially provided extensive details about Dombi’s role as Interim President of NAHC; however,; within days of this announcement, the board of directors named Dombi NAHC’s new President. This article summarizes Dombi’s views on changes to be expected for the next generation of followers of NAHC and healthcare at home industry players.] (more…)

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Aug

Which EVV Model is Right for Your State?

stored in: Tim Rowan's Home Care Technology Report and tagged: Electronic Visit Verification (EVV) as mandated for service providers to submit--according to the 21st Century CURES Act, Electronic Visit Verification (EVV)--and 4 models from which each state might choose, Underwood Tom -- and details of advantages of 4 electonic visit verification (EVV) model from which each provider entity must choose as mandated by the 21st Century CURES Act

By Tim Rowan, Editor & Publisher

Last week, in the first installment of our series on mandated Electronic Visit Verification, we reported on our conversation with Sandata CEO Tom Underwood about the ways states might choose to comply with the 21st Century CURES Act. (See “Four EVV Models States Might Choose; Three Lead to Disaster” HCTR, August 16) In part two, we reprint, with his permission, charts that detail his recommended strategy for each stakeholder category: providers, states, and MCOs. [Rowan presents 4 decision criteria from which states can choose an EVV model: compliance, cost, business burden, ease of implementation, and outcomes. Three detailed charts are presented indicating expected benefits to accrue to each entity implementing each EVV model. A thorough overview of states’ need to select an EVV model is presented; and an example of the Open Vendor model choice [in, this case, by Florida] is described.]

Decision Criteria for States
Underwood emphasizes that each state must carefully evaluate its unique environment in order to select the EVV model that is right for its program. Factors to consider include concerns impacting fraud, waste and abuse, impacts to the provider network, overall service quality, and how states are using Managed Care companies to deliver services. He explained that his company has summarized each of the models based on how favorable they are to the state using the following measures:

Compliance: Measured in terms of rate of adoption of the mandated EVV technology;
Cost: Cost to the state to implement (assumes enhanced federal match of 90%);
Business Burden: How much time and effort the state must expend to implement and manage the program;
Ease of Implementation: How easy or challenging is the program to implement on a statewide basis;
Outcomes: How much savings will the state expect to recoup based on impacts to fraud, waste and abuse.

Chart #1 shows the Sandata scoring of these measures on a five-point scale for each of the EVV models described in last week’s installment, where one indicates the fewest advantages to the state and five the most:

On all five measures, two of the models offer mixed benefits to states, the Open Vendor model scores a perfect row of fives, and the model that allows MCOs to select the EVV vendor of their choice is disastrous for all.

Decision Criteria for Providers
To the extent that a state’s providers can influence the path their state takes, it is essential that providers and their state association representatives know what direction their advocacy should take. Before lobbying, therefore, each provider must carefully evaluate the available models and know how each will directly impact their business. Underwood reported on a summary Sandata prepared showing how favorable each model is to providers, factoring in the needs of and burdens on providers operating in multiple states, using the following measures:

Compliance: Measured in terms of rate of adoption of the mandated EVV technology;
Cost: Cost to the provider to implement;
Business Burden: How much time and effort the provider must invest to be compliant;
Ease of Implementation: How easy or challenging is the program to implement;
Outcomes: How much savings will the state expect to recoup based on impacts to fraud, waste and abuse.

Chart #2 shows the Sandata scoring of these measures on a five-point scale for each of the EVV models described in last week’s installment, where one indicates the fewest advantages to the state and five the most:

According to these scores, allowing MCOs to select different vendors is as harmful to providers as it was shown to be to states in the previous chart. The preferred model, Open Vendor, is not perfect from the provider’s perspective. This model shares some costs between the state and the provider and it does not score quite as high on the “ease of implementation” scale as the Provider Choice model does. Nevertheless, overall, it is the model that best supports provider compliance and outcomes while imposing the least burden on the provider’s business.

Decision Criteria for MCOs
In his presentations to state association audiences, Underwood includes a message for Managed Care Organizations. “Each MCO must carefully work with the state to support EVV in a managed care model,” he explains. “Factors to consider include concerns impacting fraud, waste and abuse as well as impacts to the provider network.” His summary of each of the models is based on how favorable they are to MCOs, using the following measures:

Compliance: Measured in terms of rate of adoption of the mandated EVV technology;
Cost: Cost to the MCO to implement;
Business Burden: How much time and effort the MCO must expend to implement and manage the program;
Ease of Implementation: How easy or challenging is the program to implement on a statewide basis;
Outcomes: How much savings will the MCO expect to recoup based on impacts to fraud, waste and abuse.

Chart #3 shows the Sandata scoring of these measures on a five-point scale for each of the EVV models described in last week’s installment, where one indicates the fewest advantages to the state and five the most:

This is the only stakeholder group that gains even a minor benefit from the MCO Choice model, though not enough to justify implementing it. Conversely, the State Choice model is stronger than the Open Vendor model with regard to compliance support. Nevertheless, the State Choice model’s extreme business burden and implementation difficulty put it second to the overall preferred model, Open Vendor, provided measures are put in place to bolster compliance in other ways.

Pennsylvania Makes A Move

The Department of Human Services (Department) is soliciting public input on the use of electronic visit verification (EVV) systems for Medicaid-funded personal care and home health care services in Pennsylvania.

EVV will be required for personal care and home health care services provided in more than a dozen state Medical Assistance programs.

Stakeholder Input
The Department is soliciting input from beneficiaries, family caregivers, provider agencies, and individuals who furnish personal care services or home health care services, managed care organizations, and other stakeholders on the current use of EVV in the commonwealth and the impact of EVV implementation. The Department would like feedback on existing best practices; EVV systems currently in use in Pennsylvania; and preference for a state, state-contracted or provider agency-operated EVV system.

The Department intends to implement the EVV requirements so that the system is minimally burdensome and will take into account the input from stakeholders. Input received within 30 days will be reviewed and considered as the Department works to comply with the EVV requirements. Input should be submitted to
RA-PWEVVNotice@pa.gov

Watch Results From First Open Vendor State
To date, Underwood’s declaration that the Open Vendor model will be more successful than the others for all stakeholders is largely based on theoretical analysis, but not for long. Florida’s Agency for Health Care Administration has accepted the challenge to implement this new model after scrapping its failing first attempt, State Choice. Ohio is also preparing a modified version of Open Vendor but is still in the planning stages.

Details: In Florida, the state will bear the costs if providers select a bare bones solution from a state-approved vendor. Providers needing full EVV functionality and efficiency may contract with — and pay for — any vendor of their choosing that meets certain state standards, such as data exchange compatibility with the AHCA system.

Underwood’s recommendations to Florida providers, which will apply to providers in any other state that opts for Open Vendor, are strongly worded. They apply whether a provider has an existing relationship with an EVV vendor or not, or with an EMR vendor that offers its own EVV module.

Proven compliance with AHCA EVV requirements at no additional charge.
Ability to provide data to/from the state system at no additional charge.
Proven ability to work in an Open EVV environment at no additional charge.
Proven ability to support state billing requirements at no additional charge.
Ability to improve your efficiencies to offset EVV costs and willing to guarantee it.

The steps to vet an EVV vendor will be the same in every state:

Obtain integration specifications from the state before contacting vendors.
Make a thorough evaluation of vendor experience.
Make an equally thorough evaluation of vendor qualifications, especially to meet state standards.
If you already have a vendor, go through your state’s standards with them to obtain assurance they are compatible.

Immediate Steps
In states that have yet to decide which model to use, now is the time to educate them. This series of articles has been written to assist HCTR readers to present a logical, researched argument to state Medicaid officials. With the CURES Act deadline a little more than 15 months away for non-medical home care providers, it is likely discussions have already begun (see sidebar).

This series will continue with state-by-state updates, for which we rely heavily on reader input. If you hear of early meetings or developing plans to select an EVV model, please let us know. editor@homecaretechreport.com

©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

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Aug

Closing the Book on Dr. Jacques Roy; Judge Issues “Essentially A Life Sentence”

stored in: Tim Rowan's Home Care Technology Report and tagged: Dr. Jacques Roy--perpetrator of massive healthcare at home fraud scheme--and sentencing of in 2017, Fraud in healthcare at home-- lists of perpetrators in Texas in 2017, Medicare fraud--and perpetration by and sentencing of Dr Jacques Roy in 2017

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

Some simple advice: when you have an idea the FBI might raid your home, do not leave lying around a book titled, “Hide Your A$$ET$ and Disappear — A Step-by-Step Guide to Vanishing Without a Trace.” It might also be a good idea to hide any birth certificates or passports bearing your photo but under a different name.

According to official news releases from the U.S. Attorney’s Office for the Northern District of Texas and court documents, Dr. Jacques Roy, 60, was sentenced this month to 35 years in prison for conducting one of the largest Medicare scams in the history of the program. He was also ordered to pay $268,147,699.15 in restitution, a staggering sum but less than the more than $375 million he was convicted of stealing from the government. At the time of his arrest, Roy was in possession of a Canadian birth certificate, a Canadian passport application under the name Michel Poulin, and the above mentioned instruction book.[Rowan provides extensive details about Roy’s thefts and sentencing, and about Roy’s co-conspirators among healthcare at home providers in this massive Medicare fraud scheme.]

Roy had been held without bail since his February, 2012 arrest because he was regarded a flight risk. He had been awaiting sentencing since a federal jury found him guilty in April 2016 of six counts of healthcare fraud, one count of conspiracy to commit fraud, two counts of making false statements, and one count of obstruction of justice. (See Texas Physician Succumbs to H.E.A.T., Takes Hundreds of Home Care Agencies Down With Him, HCTR, 2/29/12)

Roy’s medical practice, Medistat, fraudulently approved 11,000 Medicare beneficiaries to receive care from roughly 500 home-health agencies before it was raided. The fraud had many elements:

Home-health agencies recruited fake patients — some from a homeless shelter — with groceries, cash, and fast food.
Medicare documents such as home health patient assessments and plans of care forms were “falsified, backdated, and churned,” prosecutors said. An entire “boiler room” of employees worked all day signing Dr Roy’s name on the forms or affixing an electronic one as if he had reviewed the paperwork.
Dr Roy and other clinicians affiliated with Medistat made unnecessary home visits and ordered unneeded services such as skilled nursing on the basis of bogus chart notes.

“The only thing more stunning than Jacques Roy and his co-conspirators’ shameless methods, said U.S. Attorney Parker, is the staggering dollar amounts involved in this fraud scheme. This takes brazen to a whole new level.”

Though U.S. District Judge Sam A. Lindsay described his decision as “effectively a life sentence” for the 60 year-old Quebec native, Assistant U.S. Attorney P.J. Meitl had asked for 105 years, citing evidence of a pattern of intentional malpractice activities over and above the fraud conviction. “We’ve seen the damage he’s done,” Assistant U.S. Attorney P.J. Meitl told the judge in his fraud case. “There was not one redeeming quality about Dr. Roy.” He described Roy as a “devious criminal” without remorse and a “menace” who used his Hippocratic Oath “as a pickup line.”

Home Health Co-Conspirators

The following defendants have also been sentenced for their role in the health care fraud scheme:

Wilbert James Vesey, Jr., 210 months in federal prison and $23 million in restitution
Cyprian Akamnonu, 120 months in federal prison and $25 million in restitution
Patricia Akamnonu, 120 months in federal prison and $25 million in restitution
Charity Eleda, 48 months in federal prison and $397,294.51 in restitution
Teri Sivils, 3 years probation and $885,714.05 in restitution
Cynthia Stiger will be sentenced October 26, 2017.

Trial evidence showed participation in the scheme by Apple of Your Eye Health Care Services, Inc., Ultimate Care Home Health Services and Charry Home Care Services. Stiger, Veasey and Eleda, along with others, paid recruiters $50 per Medicare beneficiary to escort them from a Dallas homeless shelter to a car parked outside the shelter’s gates. There, Eleda and other nurses would create the phony admission documents. Medistat employees in Roy’s boiler room operation would affix his signature, indicating he had seen the “patients.”

Additional evidence showed approximately 500 home health agencies participated in this scheme, using 11,000 Medicare beneficiaries as their avenue to riches. Evidence that led to Roy’s obstruction of justice conviction showed that, after he was suspended from Medicare participation in 2011 for fraud he immediately formed another company and continued operations virtually uninterrupted.

Once an individual was certified for home health care services, Eleda, nurses who worked for Stiger and Veasey, and other nurses falsified visit notes to make it appear as though skilled nursing services were being provided and continued to be necessary. Dr. Roy would also visit the patients, perform unnecessary home visits, and then order unnecessary medical services for the recruited beneficiaries. Then, at Dr. Roy’s instruction, Medistat employees would submit fraudulent claims to Medicare for the certification and re-certification of unnecessary home health care services and other unnecessary medical services.

The case was investigated by the Federal Bureau of Investigation, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG), and the Texas Attorney General’s Medicaid Fraud Control Unit (MFCU) and was brought as part of the Medicare Fraud Strike Force supervised by the Criminal Division Fraud Section and the U.S. Attorney’s Office for the Northern District of Texas.

Assistant U.S. Attorneys P.J. Meitl and Nicole Dana and First Assistant U.S. Attorney Chad Meacham prosecuted the case.

(more…)

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Aug

Feds Make Their Point; Houston HHA Owner Sentenced to 75 Years

stored in: Tim Rowan's Home Care Technology Report and tagged: Fraud in healthcare at home service delivery--persons convicted of defraudind Medicare in 2017, Marie Neba--and extensive fraud she committed in healthcare at home sector and was convicted of in 2017, Medicare Strike Force known as H.E.A.T. (Health Care Fraud Prevention and Enforcement Action Team)--and its success in Texas convicting Marie Nebo perpetrator of extensive healthcare at home fraud

While Dr. Jacques Roy began serving his 35-year sentence for defrauding Medicare of $375 million through his Dallas clinic, the owner and Director of Nursing of a Houston home health agency was being sentenced to 75 years in prison for her role in a measly $13 million Medicare fraud scheme. This according to an announcement by the Houston area Medicare Strike Force known as H.E.A.T. (Health Care Fraud Prevention and Enforcement Action Team)

Marie Neba, 53, of Sugarland, Texas, was sentenced by U.S. District Judge Melinda Harmon of the Southern District of Texas. In November 2016, Neba was convicted after a two-week jury trial of one count of conspiracy to commit health care fraud, three counts of health care fraud, one count of conspiracy to pay and receive health care kickbacks, one count of payment and receipt of health care kickbacks, one count of conspiracy to launder monetary instruments and one count of making health care false statements. [Rowan details other findings of fraudulent activities and monies collected by Neba as well as other healthcare at home providers who conspired with Neba. It’s noted that the case was investigated by the FBI, then taken over by Fraud Section of the Justice Department’s Criminal Division, Details are provided about the Medicare Fraud Strike Force, which is part of a joint initiative between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country. The Medicare Fraud Strike Force operates in nine locations nationwide. Since its inception in March 2007, the Medicare Fraud Strike Force has charged over 3,500 defendants who collectively have falsely billed the Medicare program for over $12.5 billion.]

According to the evidence presented at trial, from February 2006 through June 2015, Neba and others conspired to defraud Medicare by submitting over $10 million in false and fraudulent claims for home health services to Medicare through Fiango Home Healthcare Inc., owned by Neba and her husband, Ebong Tilong, 53, also of Sugarland, Texas.

Trial evidence showed that using the money that Medicare paid for such fraudulent claims, Neba paid illegal kickbacks to patient recruiters for referring Medicare beneficiaries to Fiango for home health services. Neba also paid illegal kickbacks to Medicare beneficiaries for allowing Fiango to bill Medicare using beneficiaries’ Medicare information for home health services that were not medically necessary or not provided, the evidence showed. Neba falsified medical records to make it appear as though the Medicare beneficiaries qualified for and received home health services. Neba also attempted to suborn perjury from a co-defendant in the federal courthouse, the evidence showed.

According to the evidence presented at trial, from February 2006 to June 2015, Neba received more than $13 million from Medicare for home health services that were not medically necessary or not provided to Medicare beneficiaries.

To date, four others have pleaded guilty based on their roles in the fraudulent scheme at Fiango. Nirmal Mazumdar, M.D., the former medical director of Fiango, pleaded guilty to a scheme to commit health care fraud for his role at Fiango. Daisy Carter and Connie Ray Island, two patient recruiters for Fiango, pleaded guilty to conspiracy to commit health care fraud for their roles at Fiango. On August 11, Island was sentenced to 33 months in prison. Mazumdar and Carter are awaiting sentencing. After the first week of trial, Tilong pleaded guilty to one count of conspiracy to commit healthcare fraud, three counts of healthcare fraud, one count of conspiracy to pay and receive healthcare kickbacks, three counts of payment and receipt of healthcare kickbacks, and one count of conspiracy to launder monetary instruments. Tilong is scheduled to be sentenced on October 13.

The case was investigated by the IRS-CI, FBI and HHS-OIG under the supervision of the Fraud Section of the Justice Department’s Criminal Division and the U.S. Attorney’s Office for the Southern District of Texas. The case is being prosecuted by Trial Attorney William S.W. Chang and Senior Trial Attorney Jonathan T. Baum of the Fraud Section.

The Fraud Section leads the Medicare Fraud Strike Force, which is part of a joint initiative between the Department of Justice and HHS to focus their efforts to prevent and deter fraud and enforce current anti-fraud laws around the country. The Medicare Fraud Strike Force operates in nine locations nationwide. Since its inception in March 2007, the Medicare Fraud Strike Force has charged over 3,500 defendants who collectively have falsely billed the Medicare program for over $12.5 billion.

Source: U.S. Attorney for the Southern District of Texas

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Aug

Veteran Sales Consultants Create “Transformational Event”

stored in: Tim Rowan's Home Care Technology Report and tagged: "High Performance Masters Program"--a 3-day immersion educational program offering to home healthcare service providers by HomeCareSales (educational company), Cheryl Peltekis--and role as co-owner of HomeCareSales, HomeCareSales educational and consulting company--and history of work in the home health industry from 2001-2017, HomeCareSales--educational company with goal to improve senior patient care services, Melanie Stover--and role as home healthcare industry consultant at Home Care Sales

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

After years of working with home health agencies one by one to bring professionalism to their sales staffs, Cheryl Peltekis, RN and Melanie Stover, OT, MBA, MS/ISM, decided they could help more agencies by gathering them for an intensive working weekend. The first “High Performance Sales Academy” is set for October 4-6, 2017 in Las Vegas. The co-owners of a company aptly named HomeCareSales also announced that the event, and those to follow in other cities, will be conjoined with an online educational series in what they have dubbed the “High Performance Masters Program.” [Rowan provides detailed explanations of the company’s history and its current goal to move from providing one-on-one consulting with in-home service providers to offering industry-wide, intensive 3-day immersion educational presentations and ongoing education afterwards.]

“This is not another two-day conference with a series of 90-minute presentations,” Ms. Stover told us. “This will be work, and role-play, and intensive immersion into the best practices we have been teaching over the years.”

[Rowan provides detailed explanations of the company’s history and its current goal to move from providing one-on-one consulting with in-home service providers to offering industry-wide, intensive 3-day immersion educational presentations and ongoing education afterwards.] (more…)

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Aug

Vendor Watch: eSolutions Announces Acquisition of RemitDATA; and PreparedHealth, announces multi-year agreement with Encompass

stored in: Tim Rowan's Home Care Technology Report and tagged: eSolutions Inc (Overland Park KS and Plano TX--provider pf healthcare technology and analytics soltions--and acquisition of RemitDATA (developer of comparative healthcare data analytics

Two Vendor News items this week: 1) eSolutions Announces Acquisition of RemitDATA; and 2) PreparedHealth, announces multi-year agreement with Encompass

Overland Park, KS, and Plano, TX, August 11, 2017 – eSolutions, Inc., a provider of healthcare technology and analytics solutions, has acquired RemitDATA Inc., a pioneer in the field of comparative data analytics in the healthcare industry. The acquisition allows eSolutions to further expand its footprint and promises greater diversification within the FQHC, ambulatory, ASC, and hospital-owned physician markets.[In other Vendor News this week, PreparedHealth (Chicago)–developer of enTouch and DINA (transition-to-home communications programs among all patients’ care providers–announced a multi-year agreement with Encompass Home Health and Hospice–which is currently Home Health and Hospice is the 4th largest provider of Medicare-certified skilled home health service. PreparedHealth executives are expecting, through this partnership with Encompass to help deliver more targeted interventions and better care coordination, leading ultimately, to reduced hospitalizations, fewer ER visits, and overall better quality outcomes for patients served by Encompass Home Health and Hospice agencies.]

“RemitDATA’s technology will provide significant upgrades to our customers’ reporting and analytics services,” said Gene Creach, President and CEO of eSolutions. “RemitDATA fits perfectly into our existing customer base, while also providing a featured service for the ASC market.”

“By combining expertise and offerings, we will be able to achieve results far beyond what each could achieve as stand-alone businesses,” said Dave Ellett, CEO of RemitDATA. “The new entity will strengthen our product suite and the ability to cross-sell into our respective customer bases.”

About eSolutions, Inc.
Founded in 1999, eSolutions specializes in helping health care providers improve revenue cycle management practices. Company products deliver workflow automation and data analytics services in a web-based environment. Customers range small, family-owned home health agencies to nationally recognized corporate health systems. Currently, the company processes over 50 million claims a year for nearly 30,000 providers.
www.esolutionsinc.com

About RemitDATA
RemitDATA is a healthcare technology company that delivers a comprehensive comparative data and analytics platform. Founded in 2000, with offices in Memphis, TN, Plano, TX and Lexington, KY, RemitDATA strives to bring collaboration and 360-degree data transparency to all entities within the healthcare industry by delivering a range of system agnostic, comparative analytic solutions. Through the use of Application Programming Interfaces (API), benchmarking and peer comparison tools, payers, providers, billing companies and other healthcare companies will gain actionable insights to better understand their business and improve operations.

PreparedHealth, announces multi-year agreement with Encompass

“We are excited to work with PreparedHealth and bring another unique technology to our clinicians, patients, and families. We continually look for innovative ways to deliver care in the home. We believe DINA and enTouch will help us deliver more targeted interventions and better care coordination. Ultimately, we anticipate the partnership with PreparedHealth will lead to reduced hospitalizations, fewer ER visits, and overall better quality outcomes for our agencies”, said Bud Langham, Chief Clinical Officer at Encompass Home Health.

Encompass Home Health and Hospice is the 4th largest provider of Medicare-certified skilled home health services and operates in 28 states across the United States. As a leader in value-based payment models, they are joining enTouch and activating DINA to facilitate evidence-based care transitions, interventions and coordination that keep patients proactively out of the hospital and deliver a superior customer experience in the home.

“We’re honored to announce our partnership with Encompass as we continue to expand the enTouch™ network. Their leadership team, culture and out-in-front approach with value-based health care is very well aligned with our company mission. Together, we’re transforming how people can get the care they need to stay healthy at home,” said Ashish V. Shah, CEO and Co-Founder of PreparedHealth.

enTouch, PreparedHealth’s innovative social network for health care, connects patients, providers and payers to the best options for care in the home. Using a blend of machine-learning and artificial intelligence technology, DINA acts as a digital nursing assistant to proactively identify needed interventions and close gaps in care. Encompass will focus its initial work with PreparedHealth on ACO partnerships and home health value based purchasing models.

Mr. Langham added, “We think it is critical in the ever changing environment of home-based care to have the best technology partners at the table working with us to solve pressing problems. We are happy to have PreparedHealth join us on the journey to success in the value-based future of healthcare”.

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Aug

Targeted Probe and Educate Medical Review Strategy

stored in: Tim Rowan's Home Care Technology Report and tagged: CMS and Probe and Educate program--a medical review strategy, CMS--and claims review strategies, Medicare Administrative Contractors (MACs)--and tasks to review clinical documentation of claims to prevent inappropriate service payments, Targeted Probe and Educate (TPE) program--a medical claims review program from CMS

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

Targeted Probe and Educate Medical Review Strategy

The Centers for Medicare & Medicaid Services utilizes Medicare Administrative Contractors (MAC) to review clinical documentation in order to prevent improper payments. MACs choose claims for review based on many factors such as the service specific improper payment rate, data analysis and billing patterns of the provider. CMS is cognizant that this type of review can be burdensome to providers and we are always working to improve the process. [In-depth descriptions follow of CMS’s Probe and Educate medical review strategy begun in 2014. The revised version of this strategy, called “Targeted Probe and Educate (TPE)” medical review strategy is then described, with details on the evolving activities of Medicare Administrative Contractors (MACs). Information is provided about how and why MACs select claims for review. More details are also provided about TPE medical reviews, under this article’s Probe Review and Education Process segment.]

In 2014 CMS began a program that combined a review of a sample of claims with education to help reduce errors in the claims submission process. CMS called this medical review strategy, Probe and Educate. CMS believes results of this program have been favorable, based on the decrease in the number of claim errors after providers received education. CMS is now further improving this strategy by moving from a broad Probe and Educate program to a more targeted one. When performing medical review as part of Targeted Probe and Educate (TPE), Medicare Administrative Contractors (MACs) focus on specific providers/suppliers within the service rather than all provider/suppliers billing a particular service. TPE involves the review of 20-40 claims per provider, per item or service, per round, for a total of up to three rounds of review. Each round of 20-40 claim reviews is referred to as a probe. This term is intended to convey that the number of claims reviewed is relatively small in comparison with previous provider-specific review where the number of claims reviewed for an individual provider may have been much larger. After each round, providers are offered individualized education based on the results of their reviews. This program began as a pilot in one MAC jurisdiction in June 2016 and was expanded to three additional MAC jurisdictions in July 2017. As a result of the successes demonstrated during the pilot, including an increase in the acceptance of provider education as well as a decrease in appealed claims decisions, CMS has decided to expand to all MAC jurisdictions later in 2017.

Selection of Claims

The MACs will select claims for items/services that pose the greatest financial risk to the Medicare trust fund and/or those that have a high national error rate. MACs will focus only on providers/suppliers who have the highest claim error rates or billing practices that vary significantly out from items included in the TPE pilot, and future nationwide from programs of their peers. These providers/suppliers and specific items/services are identified by the MAC through data analysis. TPE claim selection is different from that of previous probe and educate programs. Whereas previously the first round of reviews were of all providers for a specific service, the TPE claim selection is provider/supplier specific from the onset. This eliminates burden to providers who, based on data analysis, are already submitting claims that are compliant with Medicare policy.

Probe Review and Education Process

The TPE review and education process includes a review of 20-40 claims followed by one-on-one, provider-specific, education to address any errors within the provider’s reviewed claims. Providers/suppliers with moderate and high error rates in the first round of reviews, will continue on to a second round of 20-40 reviews, followed by additional, provider- specific, one-on-one education. Providers/suppliers with high error rates after round two will continue to a third and final round of probe reviews and education (Please see the TPE Process Flowchart in the downloads section below). In addition to education at the conclusion of each 20-40 claim probe review, MACs also educate providers throughout the probe review process, when easily resolved errors are identified, helping the provider to avoid additional similar errors later in the process.

Providers/suppliers with continued high error rates after three rounds of TPE may be referred to CMS for additional action, which may include 100% pre-pay review, extrapolation, referral to a Recovery Auditor, or other action. Providers/supplier may be removed from the review process after any of the three rounds of probe review, if they demonstrate low error rates or sufficient improvement in error rates, as determined by CMS.

https://www.racmonitor.com/breaking-cms-adopts-national-targeted-probe-and-educate-policy-nationwide

(more…)

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Aug

Four EVV Models States Might Choose; Three Lead to Disaster

stored in: Tim Rowan's Home Care Technology Report and tagged: 21st Century CURES Act--and specifications with which health service providers in each state must comply by choosing and using an Electronic Visit Verification (EVV) model by Jan. 2019, Electronic Visit Verification (EVV)-- as required by CMS of service providers under the 21st Century CURES Act, Electronic Visit Verification (EVV)--and 4 models of EVV from which health service providers can choose to comply with the 21st Century CURES Act

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

According to Sandata CEO Tom Underwood, there are four models that states might use to implement Electronic Visit Verification, which every state must do by January, 2019 to comply with the 21st Century CURES Act [and hence get paid for these health service visits.] Three of these modules lead to failure. We sat down with Underwood after his standing-room-only presentation for the Home Care Association of Florida last month.

The CEO defined EVV as “a modular technology solution that provides transparency into home-based care delivery, supporting provider network optimization while improving the member’s quality of care.” Typical EVV systems include a scheduling module and a visit verification module, usually using a mobile phone or the patient’s phone, though a fixed EVV device is another option. [Rowan provides details about all 4 EVV models (using at least one of which was prescribed by law in Dec. 2016) and indicates states that are currently using each model–and the upsides and downsides of using each one. He concludes this article with advice for service providers to heed Underwood’s reviews of each EVV choice.]

In December 2016, President Obama signed into law a bill mandating EVV implementation in home care but giving each state leeway in how to comply. Underwood identified four models that have emerged so far among the 18 states that mandated EVV before the CURES law required it.

Provider Choice Model: (used by three states) In provider choice, the state does not become involved in each provider’s vendor selection.
MCO Choice Model: (used by three states)In this model, the state allows each Managed Care Organization to decide which vendor it will accept.
State Choice Model: (used by 10 states)The state Medicaid authority selects one or two approved vendors.
Open Vendor Model: (used by one state with another in planning stages)This is a hybrid solution. The state selects a single vendor while allowing providers and MCOs to continue using their existing EVV systems.

Model 1: Provider Choice
In Washington, Missouri and New York, the state requires the provider community to self-fund, select and implement an EVV solution of their choosing, generally by a required deadline. Some states have offered a preferred vendor list from which providers select one, while other states have simply established a minimum set of standards for vendor product features. Along with standards, some states also require a minimum set of reporting on EVV activity.

Upside:

Low cost to the state.
Unless the state decides to measure or monitor the program (e.g. compliance with minimum standards, review of reporting, etc.) there is low overhead cost to manage the program.
No data integration is required.

Downside:

All costs accrue to providers, including those that may not have the technical expertise to successfully select and deploy a solution or financially stable enough to pay for one.
Some providers have demanded additional state funds to help them comply with the mandate.
The state does not have access to visit data to support quality monitoring unless they implement audits and hire staff to spot check providers.
Without monitoring, EVV utilization (compliance) is lower.
With monitoring, varying features and functions across multiple vendors makes assessing care quality difficult for states.
Where enforcement and monitoring are not in place, published studies show neither cost savings nor reduction in fraud, waste and abuse.

Conclusion: Not recommended.

Model 2: MCO Choice
In New Mexico, Iowa and Tennessee, MCOs that manage Medicaid beneficiaries select and implement an EVV solution from the vendor of their choosing. States may set minimum standards for vendor product features and require a minimum set of reporting on EVV activity.

Upside:

Low cost to the state. No expense of RFP processing, vendor evaluation, selection and procurement.
No data integration between state and EVV systems required unless state desires to measure or monitor for compliance.

Downside:

Costs incurred by MCOs will be passed to the state when they demand higher reimbursement rates.
In states where there is more than one MCO, if each MCO selects a different vendor, program complexity may make data and reporting inconsistencies inevitable.
Providers with contracts to multiple MCOs, each with a different EVV vendor, incur significant inefficiencies and cost burdens. May be forced to teach staff to use multiple EVV systems, requiring much more time for training and more time per visit, potentially reducing compliance.
Caregivers must know which MCO each patient uses, and know if and when a patient changes policies.
Back office staff must maintain multiple systems for scheduling, billing and payroll processing.
Providers achieve no efficiency benefits from EVV system compliance.

Conclusion: Not recommended.

Model 3: State Choice
In Alabama, Connecticut, Illinois, Kansas, Mississippi, Oklahoma, Oregon, Rhode Island, Texas and South Carolina, the state Medicaid program contracts with a single — or sometimes two or three — EVV vendors and mandates that all provider agencies must use that vendor’s system.

Upside:

The selected vendor’s solution is implemented at the state level, often in six months or less.
State maintains direct management and oversight over the entire program.
Typically, the state pays 10% of provider implementation costs and matches 90% of services costs, including purchasing and implementation, program management and provider monitoring.
This model qualifies for an enhanced match of 75% for ongoing program operational costs.
Providers given an EVV system at no cost which may enhance back office process efficiencies, eliminate some paper-based processes and support better management of remote workforce.
If the state uses MCOs, the mandated EVV system can be integrated with MCO systems to improve their efficiencies.
MCOs can use the state-mandated system to standardize management of client home care organizations.
EVV compliance may be enhanced. Easy access to quality reports at all levels of the state system as well as data for state auditing and investigations.
When the vendor’s scheduling component is implemented, alerts can be triggered directly to state or MCO care managers, potentially reducing gaps in care and improving care coordination.

Downside:

This model requires the greatest investment of state resources for vendor selection and ongoing vendor management.
Providers that have already standardized their business processes around an EVV system — from their EMR vendor or a 3rd party supplier — must decide whether to attempt to use both (which never works) or to manage, train, and support a new system that is disparate from their core business systems.
State-mandates cover only minimum requirements for visit verification and some reporting. EMR-vendor and 3rd party EVV systems include a menu of more sophisticated features, including task checklists, reporting, scheduling, emergency missed visit coverage, etc. Switching to the state-mandated system necessarily requires abandoning all of those additional features.

Conclusion: Mixed. Least costly for the state and smallest home care providers. Bad news for providers with existing EVV systems in place.

Model 4: Open Vendor Hybrid
In Ohio and Florida, beginning next year and this fall, respectively, a new, hybrid model is being tried. It allows the state to select a vendor to provide EVV solutions while allowing all providers and MCOs that already have a system in place to keep their existing system. Providers without EVV already implemented can select the system that best suits its needs.

In this model, States establish the technology requirements and configuration, rules and policies regarding the program, and purchase an EVV system on behalf of and at no cost to their Providers who do not currently have an EVV system of their own. States that offer this elect to “open the model” to third party EVV systems. In this Open EVV Model, once a visit is completed, a vendor agnostic Aggregator system takes in data from all EVV systems and applies standardized business rules to ensure the visits are properly verified and ultimately paid, generates alerts as needed and provides comprehensive oversight over the entire program – regardless of EVV system used.

Upside:

All EVV systems in use must meet specific minimum technology standards.
Some system costs may be shared with providers and MCOs that maintain their own systems.
Impact to provider and MCO systems is minimal, especially when all MCOs use the state-sponsored system.
State achieves higher level of EVV compliance.
State can measure utilization through policy; can add incentives and/or penalties.
High level of care coordination is achieved through data aggregation, resulting in improved health outcomes for beneficiaries.
Aggregated data allow alerts to be triggered to state or MCO managers for late/missed visits, additional beneficiary needs, etc.
Higher savings and return on investment (expected) as compared to the unfunded mandate.

Downside:

A level of complexity is added when providers and MCOs are permitted to retain their current systems. State must be fully engaged with establishing requirements, procurement, vendor selection and program management.
If not all MCOs in a state select the same vendor, either the state-sponsored vendor, or another, additional burden may be placed on providers.,

Conclusion: Highly recommended, provided measures are put in place to keep all state MCO partners on the same EVV system.

Closing comments
Underwood’s strong feelings about the pitfalls of the first three models should be heeded by state Medicaid officials who are currently researching their options. No EVV CEO has had interaction with as many state Medicaid offices, no EVV vendor has tried as many different models and learned, sometimes the hard way, what works and what does not. He concludes his presentations, and emphasized to us, the same admonition.

“Each state must carefully evaluate its unique environment in order to select the EVV model that is right for its own program while complying with the new mandate. Factors to consider include concerns impacting fraud, waste and abuse, impacts to the provider network, overall service quality, and how states are using Managed Care companies to deliver services.”

Next week, this series continues with part 2 of our interview with Tom Underwood, Sandata’s summary of each models based on how favorable they are to the state using the following measures:

Compliance: Measured in terms of rate of adoption of the mandated EVV technology
Cost: Cost to the state to implement (assumes enhanced federal match of 90%)
Business Burden: How much time and effort the state must expend to implement and manage the program
Ease of Implementation: How easy or challenging is the program to implement on a statewide basis
Outcomes: How much savings will the state expect to recoup based on impacts to fraud, waste and abuse.

Editor’s note: Readers are urged to be our eyes and ears in their own state. When you learn of hearings or decisions made, or just that a state official is leaning in a certain direction, please let us know. editor@homecaretechreport.com

(more…)

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Aug

HEALTHCAREfirst Updates User Interface

stored in: Tim Rowan's Home Care Technology Report and tagged: EHRs for healthcare at home and hospice services provided using HEALTHCAREfirst software --this software has been revamped as of August 2017 as firstHOMECARE and firstHOSPICE, HEALTHCAREfirst (Springfield MO) provider of Web-based healthcare at home and hospice software billing and coding services-- and August 2017 release of revamoed interface for its EHR software systems

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

Springfield, Mo. – August 2, 2017 – HEALTHCAREfirst, a provider of Web-based home health and hospice software, billing and coding services, and advanced analytics, announced this month the release of a revamped user interface for their industry-leading EHR software systems, firstHOMECARE and firstHOSPICE. We took a look at the UI this week and found that the promotional materials might be right. Clinicians should find it easier to navigate and more intuitive to use than the interface it replaces.[Rowan provides extensive details about the updated and easier-to-use systems from HEALTHCAREfirst’s user interface updates. A brief history of HEALTHCAREfirst is included in this article’s last paragraph.]

We saw a color-coded system against a clean, mostly white background. HEALTHCAREfirst’s familiar pink hue draws the eye to action items. Red exclamation points alert users to items needing immediate attention. The welcome screen presents the user’s schedule and a clear list of messages and to-do’s. Either segment can be changed to full screen with one click.

Behind the UI, the EHR supports clinical compliance, helps nurses build care plans from assessments and combines nursing and therapy care plans into one continuous course of treatment. A physician portal allows documents to sent directly to referring physicians who agree to use the portal, or electronically faxed to others.

The new UI offers a fresh new look and feel to enhance the user experience through:

A visually appealing, functional design that provides greater ease of use for all users throughout an agency.
Clearly organized tabs, modern icons, and smart use of color that make navigation and completing tasks easier and more efficient.
User-friendly screens that function across multiple operating systems, including iOS and Android, and across multiple mobile devices, promoting adoption and productivity by allowing users to work according to their preferences.

“One of the things that we hear from home health and hospice agencies is that they are looking for EHR software that is easy to use,” said Steve Sablan, Chief Information Officer for HEALTHCAREfirst. “Our new, updated user interface leverages a clean, modern aesthetic to make it easy to understand and navigate, while still providing the guidance and functionality needed to meet compliance requirements and successfully manage every aspect of operations.”

HEALTHCAREfirst’s news release says its updated user interface represents a steadfast commitment to advancing product effectiveness and to providing engaging, easy to use solutions that further agency success. To view the new user interface in action, visit www.healthcarefirst.com/new-user-interface-video.

About HEALTHCAREfirst
HEALTHCAREfirst provides cloud based technologies and services to improve business and clinical operations for over four thousand home health and hospice providers across the United States. Based in Springfield, Missouri, the company provides agency and clinical management software, outsourced revenue cycle management services (billing, coding and OASIS review), CAHPS surveys, and advanced analytics, in any combination.
www.healthcarefirst.com

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Aug

What Are Physician Signatures Costing You?

stored in: Tim Rowan's Home Care Technology Report and tagged: Key Performance Indicators (KPIs)--and absence of these entities in healthcare at home service billing needs, physician signatures--and necessity for obtaining by healthcare at home agencies to bill for services, St. Vincent Home Health--and means used to obtain needed physician signatures for service billing purposes, SutureSign (electronic signature network)--and use by St. Vincent's Home Health to obtain needed physician electronic signatures for Medicare billing and payments

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

For all of modern time, the home health industry has been completely dependent on physician signatures for payment by Medicare, the largest payer for home health services in the US. Yet despite this process being so fundamental to running their businesses, home health companies seemingly have no idea what they are spending to get orders signed so that they can bill … and consequently get paid. Sophisticated operators surely know the cost of operating other fundamental aspects of the business, yet the “cost per signed order” eludes them as a “whatever it takes” mentality prevails due to a perceived lack of control. Some have attempted to manage the effort by implementing escalation protocols and/or agency-specific physician portals that are extensions of their clinical system – which typically fail – yet the true cost of the process remains a mystery.

Why do no Key Performance Indicators (KPIs) exist for the industry to serve as a benchmark for such a fundamental process? St. Vincent’s Home Health, a subsidiary of Ascension Health at Home, is a sizable home health company with an average daily census of around 1,000 patients. It has always been a well-run agency, even before a partial equity stake was acquired by Ascension Health at Home in 2011. Many in the industry often think that health system-affiliated home health companies are often poorly run or resource-starved, but that is not the case here. [An extended example is provided of St. Vincent’s Home Health’s work in trying to obtain physician signatures and eventually turning to SutureSign, an electronic signature network. As noted. with SutureSign, physicians’ staff can can log in and review the orders, and the doctor can sign the order directly from the staffperson’s screen just like they would do in the paper process. SutureSign also provides the physicians a comprehensive billing report so that they can reliably capture all of their signature-related revenue. Significant cost savings are defined by the end of this article.]

Like every other home health company, St. Vincent’s struggled with getting orders signed. They had tried every escalation protocol and the physician portal attached to their clinical system, but still they could not control their cost to get signatures. The adoption of the physician portal was dismal, despite having preferred relationships with the collaborative of independent physician groups across the health system. Why? Because even though the physicians were affiliated with St. Vincent’s Home Health, they also work with other home health companies, and other post-acute industries such as DME and infusion. Consequently, the physicians rejected the idea of an agency-specific portal.

Turning to Physician Portals For Help
St. Vincent’s turned to SutureSign, an electronic signature network, to help solve this problem. Not only does SutureSign enable physicians to sign documents from all outside providers in one place as a “one-stop-shop,” it is extremely user friendly and utilizes physician support staff in unique ways to reduce the burden on physicians. For example, the physician’s staff can log in and review the orders, and the doctor can sign the order directly from the staffperson’s screen just like they would do in the paper process. SutureSign also provides the physicians a comprehensive billing report so that they can reliably capture all of their signature-related revenue. Perhaps most unique, SutureSign has built in a service component so that SutureSign staff follow up with slow signing physicians.

Kristi Wood, the Director of Order Management, says this “is a game changer. I can see how their follow-ups have directly improved our cash flow and make my job a lot easier. One difficult group dropped from 90+ days to a 2-week turnaround. And many physicians love the billing report. They didn’t even realize how much money they were leaving on the table.”

A Kick in the Gut
Suture Health assisted St. Vincent’s in performing a pre-SutureSign and post-SutureSign cost analysis, and the results were telling. CEO John Lee lamented, “I didn’t know what we were spending, but I knew it was a lot. When we figured it out, it was kick in the gut. And we were doing the same or better with orders than most agencies out there.”

Before SutureSign, St. Vincent’s estimated it was getting 10% of orders on the 1st attempt, 25% on the 2nd attempt, 40% on the 3rd attempt, 20% on the 4th attempt, and 5% required 5 or more attempts. On the first attempt, 15% were sent via electronic fax, 5% via their agency-specific portal, and 80% were hand carried. On subsequent attempts, those from the portal were converted to hand carry so 85% were hand carried. This process was carried out using 6.6 full-time equivalents. This contributed to an average unbilled of $300,000 and the total cost to the company for all orders was $76,762.88/month.

Sound familiar?
Are you ready to learn what that “typical” process was costing them in Birmingham, AL where the cost of living is average? The delivery cost alone was $23.98, and when you add the personnel costs on top of that it comes to a mind-blowing $42.74 … per signed order! In a time where CMS is cutting reimbursements at every turn, this cannot be ignored any longer.

Robust Return-On-Investment
After only 4 months of using SutureSign, even with getting started being slower than normal due to a December start, all signatures were obtained within two attempts with 75% of signatures being received on the 1st attempt and 25% on the 2nd attempt. On the first attempt, 15% were still sent via electronic fax, but 42% were sent via SutureSign, and only 43% were hand carried. On the second attempt, 15% were still sent via electronic fax and 80% were hand carried, and none of these “second attempts” came from those orders that were initially sent via SutureSign.

Because physicians were still being added to SutureSign when the “post” analysis was done, 43% of orders were still hand carried. Despite this, the delivery cost of orders plummeted to $7.05 per signed order, and including the personnel costs to $19.54. Total cost for all orders dropped to $35,094.31/month, giving St. Vincent’s an additional $41,668.57 of working capital each month. Within only 4 months, St. Vincent’s was able to lower their cost of order management by 54% and reduce their full time equivalents to 4.9.

	Delivery Cost/Signed Order	Total Cost/Signed Order	Total Cost/Month	FTE
Pre-SutureSign	$23.98	$42.74	$76,762.88	6.6
Post-SutureSign	$7.05	$19.54	$35,094.31	4.9
Savings	$16.93	$23.20	$41,668.57	1.7
Return on Investment	71%	54%	54%	26%

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Healthcare at Home: The Rowan Report

By Tim Rowan, Editor & Publisher

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