Wednesday, November 26, 2014

AHCA Submits Comments Regarding Hip and Knee Replacement Payment Measure that may Impact SNFs

Dan Ciolek

On November 21, AHCA submitted comments to the Centers for Medicare and Medicaid Services (CMS) regarding a hospital payment outcomes measure being developed for elective total hip and total knee replacements. The proposed hospital measure includes post-acute services furnished within a 90-day window (including skilled nursing facility (SNF) and outpatient therapy services) so there is relevance to SNF providers, and therefore a need for comments on what AHCA perceives as concerns. The CMS documents that AHCA responded to can be found here. A copy of the AHCA comments can be found here.

At the end of the public comment period, all public comments will be posted on the CMS Web site - here.


The Centers for Medicare & Medicaid Services (CMS) contracted with Yale New Haven Health Systems Corporation/Center for Outcomes Research and Evaluation (CORE) to develop a hospital-level measure of risk-standardized, 90-day episode-of-care payments for elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA). The contract name is Development, Reevaluation, and Implementation of Hospital Outcome/Efficiency Measures. As part of its measure development process, CMS requested interested parties to submit comments on the candidate or concept measures that may be suitable for this project.

The purpose of the project is to develop an outcome measure that can be used to support quality improvement. The public comment period provided an opportunity for the widest array of interested parties to provide input on the measure under development. Comments from the public can offer critical suggestions in additions to those identified by the measure contractors and their technical expert panel (TEP).

Project Objectives:

· To develop a hospital-level measure of risk-standardized, 90-day episode-of-care payments for elective primary THA/TKA.

Specific Project Objectives:

The goal of this project is to develop an administrative claims-based, hospital-level, risk-standardized measure for payment associated with a 90-day episode-of-care following an elective primary total hip arthroplasty (THA) and/or total knee arthroplasty (TKA).

The development process includes:

· Identifying importance of outcome

· Conducting a literature review and environmental scan

· Defining and developing specifications for the measure

· Obtaining evaluation of proposed measure by technical expert panel

· Posting measure for public comment

· Testing measure for reliability, validity, and feasibility

· Refining measure, as needed

Details about the measure development process can be found in the Measures Management System Blueprint at

Tuesday, November 25, 2014

CMS Updates the Part B Therapy Code List for 2015

Dan Ciolek

The Centers for Medicare and Medicaid Services (CMS) recently posted a MLN Matters article MM8985 – 2015 Annual Update to the Therapy Code List that updates the therapy code list for Calendar Year (CY) 2015 by adding two "Sometimes Therapy" codes, and deleting two current codes.

The update to the therapy code list reflects those made in the CY 2015 Healthcare Common Procedure Coding System and Current Procedural Terminology, Fourth Edition (HCPCS/CPT-4). Make sure your billing staff are aware of these changes.

Specifically, CR 8985 updates the code list by adding HCPCS Codes 97607 (Neg press wnd tx) and 97608 (Neg press wound tx >50 cm) to the "sometimes therapy" codes and deleting HCPCS Codes G0456 and G0457 from the 2015 therapy code list. Code 97608 replaces current code G0457 effective January 1, 2015 and 97607 replaces current code G0456 effective January 1, 2015. Per CMS policy, therapy codes must always be assigned a discipline-specific modifier (GP = physical therapy, GO = occupational therapy, and GN = speech-language pathology (SLP) services).

For questions please contact Dan Ciolek at


CMS Provides Part B Therapy Cap Updates for 2015

Dan Ciolek
The Centers for Medicare and Medicaid Services (CMS) recently posted a MLN Matters article MM8970 – Therapy Cap Values for Calendar Year (CY) 2015 that indicates that the cap threshold will increase $20 in 2015 to $1,940 per year for physical therapy (PT) and speech-language pathology (SLP) services combined, and $1940 per year for occupational therapy (OT) services.

An exceptions process to the therapy caps for reasonable and medically necessary services was required by section 5107 of the Deficit Reduction Act of 2005. The exceptions process for the therapy caps has been continuously extended several times through subsequent legislation. Most recently, section 103 of the Protecting Access to Medicare Act of 2014 extended the therapy caps exceptions process through March 31, 2015. For questions please contact Dan Ciolek at

Study Shows iPods Are Important for Elders Too!

Katherine Merullo

This fall, Dan Cohen presented "Alive Inside", the remarkable documentary on the impacts of music and memory in dementia patients.  This documentary highlights how residents are happier and more social and have deepened relationships among staff, residents and family after listening to personalized music lists on iPods.
 Music &  Memory is an organization that trains elder care professionals how to set up personalized music playlists, delivered on iPods and other digital devices, for those in long term care. These musical favorites tap deep memories not lost to dementia and can bring residents and clients back to life, enabling them to feel like themselves again, to converse, socialize and stay present. Music & Memory’s work is rooted in extensive neuroscience research.

We are witnessing that a personalized music program gives professionals one more tool in their effort to reduce reliance on anti-psychotic medications. Staff can regain valuable time previously lost to behavior management issues.

The perceived value of music in the long term care setting may be changing some minds considering research by outside groups.   A recent study conducted by Software Advice discovered the appeal of digital music integration in long-term care settings.
 Key Findings Include:
  • Most respondents (83 percent) would favor a nursing home that offered residents iPods with individualized playlists versus a similar nursing home that did not. 
  • Half of respondents would consider moving outside their city to find a nursing home that offered residents iPods, with 8 percent willing to move out of state.
  • More than half of respondents would spend more money on a nursing home that offered residents personalized iPods.  
Research Commentary
  “This is an example of how a small piece of technology can make a big impact,” says Software Advice researcher Gaby Loria. “Our research shows iPod-integrated care has the power to make long-term care facilities more popular and profitable by drawing potential residents who are willing to pay extra and travel farther for it.”
 As for the appeal of digital music integration programs in long-term care settings, Loria says, “We found the overwhelming majority of nursing home seekers think fostering mental agility is just as important as maintaining bodily health.” Research is still underway to define the mental and physical benefits of listening to one’s favorite songs in old age, but respondents who favor the technology already see its value. For all the anecdotal evidence that dementia therapy using music helps people who suffer from Alzheimer's and dementia maintain quality of life, and despite the medical community's general regard of music as a good thing, music therapy still lacks the statistical evidence that shows it works for everyone.
To find the data in this report, Software Advice conducted a three-day online survey and gathered 1,557 responses from people within the United States who were trying to choose or identified as someday needing a nursing home for self or loved one. For more information, visit

Monday, November 24, 2014

National Influenza Vaccination Week December 7-13, 2014
Katherine Merullo

A flu vaccine could help you stay healthy this holiday season.  People at high risk for serious flu complications include: pregnant women; people with underlying chronic medical conditions (such as asthma, cancer, diabetes or hearth disease); adults older than 65 years of age; and children younger than 5 years old. 

The Centers for Disease Control and Prevention (CDC) says the single best way to protect against the flu is to get vaccinated each year.  Learn more about your options available at and ask your health care provider which is right for you.

The CDC recommends an annual flu vaccine as the first and best way to protect against the flu. There are two important reasons to get a flu vaccine every year:

a) The first reason is that because flu viruses are constantly changing, flu vaccines may be updated from one season to the next to protect against the viruses that research indicates will be most common during the upcoming flu season.

b) The second reason that annual vaccination is recommended is that a person’s immune protection from the vaccine declines over time. Annual vaccination is needed for best protection.

According to the CDC, flu vaccination prevented an estimated 13.6 million flu cases, 5.8 million medical visits and nearly 113,000 flu-related hospitalizations in the United States.

For more information check out:
Or contact AHCA/NCAL staff Holly Harmon with any questions you may have.

Modifier 59 Use – Outpatient Therapy Services

Dan Ciolek

Recently there has been some confusion among providers of Part B therapy services regarding how to properly comply with the National Correct Coding Initiative (NCCI) edits. On August 15, CMS released Change Request 8863 and the related MLN Matters article MM8863 – Specific Modifiers for Distinct Procedural Services. These documents discuss changes to HCPCS modifier -59, which become effective January 1, 2015. Modifier -59 is used to define a “Distinct Procedural Service” and indicates that a code represents a service that is separate and distinct from another service with which it would usually be considered to be bundled. CR8863 provides that CMS is establishing the following four new HCPCS modifiers (referred to collectively as -X{EPSU} modifiers) to define specific subsets of the -59 modifier:
· XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter,

· XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure,

· XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner, and

· XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service.

In response to provider questions regarding whether these new modifier codes should be used for outpatient therapy services, CMS provided the following guidance to AHCA and other organizations to share with providers: 

Re: CR 8863 & MM 8863 – Specific Modifiers for Distinct Procedural Services

 · CMS is establishing four new HCPCS modifiers to define subsets of the 59 modifier, a modifier used to define “Distinct Procedural Services”

· The four new modifiers:

o XE Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter

o XS Separate Structure, A Service That Is Distinct Because It Was Performed On A Separate Organ/Structure

o XP Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner

o XU Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service 

At this time, the below statements represent CMS policy about the use of the new X{EPSU} modifiers for therapy services; and, is being sent in response to inquiries about their use on claims for therapy services.  

The following information regards the new X{EPSU} modifiers and their use with therapy procedures and the National Correct Coding Initiative (NCCI) edits: 

· You can keep using the 59 modifier until CMS issues specific instructions about the use of the new X{EPSU} modifiers.  

· Because the X{EPSU} modifiers were developed to be used in the place of the 59 modifier, the XP modifier (used to indicate a different “practitioner”) is not appropriate to use [at this time] to distinguish between therapy disciplines as CMS uses the therapy modifiers — GN, GO, or GP — to track and differentiate between the 3 therapy disciplines.  

· For purposes of applying the NCCI edits for outpatient therapy services, you can continue to use the 59 modifier, rather than the X{EPSU} modifiers, to denote distinct therapy procedures until such time CMS issues future clarifying instructions.  

If you have questions please contact Dan Ciolek at  

Wednesday, November 19, 2014

NCAL's Art for the Ages Submissions- Deadline Fast Approaching

Rachel Reeves

Help us celebrate the many talented artist-residents in assisted living communities by participating in NCAL’s Art for the Ages! Submissions of residents’ artwork is being accepted through November 30.

How to Submit:
Take a digital photograph of your residents’ best artwork. This can be any artwork completed at any time throughout this past year. Images from smart phones and other portable devices will still be accepted, but high quality images are appreciated.

Get your residents’ approval. Each artwork must have a corresponding resident signed authorization form. Please have your resident sign the form, scan it and email it to NCAL along with your photos.
Send your submission to NCAL. Email photo(s) of residents’ artwork and signed authorization forms to NCAL’s Director of Communications, Rachel Reeves: Please include a sentence or two describing your photo (the resident who created the piece, the activity you were holding at the community, etc.) 

Learn more at and check out previous years’ submissions on AHCA/NCAL’s Pinterest boards.

Submit today! This is a great opportunity to showcase amazing residents, as well as the fantastic activities assisted living communities offer.


Secretary Burwell announces Region IX Director of HHS

Dana Halvorson

On November 19, 2014, U.S. Health and Human Services (HHS) Secretary Sylvia Burwell announced the appointment of Melissa Stafford Jones as the Region IX Regional Director. According to the press release on the announcement, as a Regional Director, Stafford Jones will serve as a key representative of the Department of HHS in working with federal, state, territorial, local, and tribal officials on health and social service issues, including implementation of the Affordable Care Act. The Region IX office is based in San Francisco, and works with officials in Arizona, California, Hawaii, Nevada, Guam, American Samoa, Commonwealth of the Northern Mariana Islands, Federated States of Micronesia, Republic of Marshall Islands and the Republic of Palau.

House Elects Leadership and Committee Heads

Drew Thies

The House voted this week to elect its parties’ leadership and committee heads this week, with every member running for reelection winning their race.

The top two members of each party—reps. John Boehner (R-OH) and Kevin McCarthy (R-CA) for the Republicans and reps. Nancy Pelosi (D-CA) and Steny Hoyer (D-MD) for the Democrats—will remain the same in the 114th Congress. Boehner, however, still faces a vote for Speaker of the House upcoming in January when the new session begins.

The retirements of Reps. Dave Camp (R-MI) and Henry Waxman (D-CA) opens up top spots on Ways and Means and Energy and Commerce, respectively. 

The race for the top Democratic seat on the Energy and Commerce committee was tightly contested, where Rep. Frank Pallone (D-NJ) ran against Rep. Anna Eshoo (D-CA). Pallone is more senior on the committee but Eshoo was backed vocally by Leader Pelosi. In party elections today, Pallone edged out Eshoo by a vote of 100-90 among chamber Democrats.

Republicans elected Rep. Paul Ryan (R-WI) to take the gavel at the head of the Ways and Means committee, a move many expected would happen.

Returning chairs and ranking members kept their spot on the two committees. Rep. Frank Upton (R-MI) remains the Chair of the Energy and Commerce Committee and Rep. Sander Leven (D-MI) will continue his tenure as the Ranking Member on Ways and Means.

Free Clinical Practice Webinar Series from AHCA/NCAL

Holly Harmon

Throughout 2014, the Clinical Practice Committee designed a series of free webinars focused on various areas of clinical practice that support the AHCA/NCAL Quality Initiative goals to safely reduce hospital readmissions and the off-label use of antipsychotic medications. These webinars are available on demand so they can be viewed at all hours. The Clinical Practice Series offers webinars useful to all members in the interdisciplinary team including three part reducing rehospitalizations, eight part falls management & prevention, two part antipsychotic medication management & reduction, and considerations for end of life care.

Click here to view all the webinars that have been recorded as a part of the series.

Make the AHCA/NCAL Quality Symposium Your First Conference of the New Year

Jon-Patrick Ewing

With the holidays coming, vacations starting and year-end responsibilities adding up, don't wait any longer, register now for the AHCA/NCAL 7th Annual Quality Symposium: It's Time to Roar! This year’s symposium is schedule for February 23-25, in Austin, Texas.

Registration Deadline: Friday, January 23, 2015

Commit now, and start the new year off with an ongoing, renewed or even a new dedication to performance excellence for yourself, your center and your residents! The symposium provides tools and information at all levels and is an unique and highly-engaging, peer-to-peer learning experience.

What’s in store for this year’s attendees?

· 20 concurrent sessions over three days

· Potential to earn up to 15.5 CEUs

· Hear from inspiring Opening General Session Keynote, Terry Barber

· NEW! LED Talks. These are similar to the popular TED Talks but our version stands for, LEAD, ENGAGE and DISCOVER. Ten topics and ideas that are provocative, inspirational, and sometimes disruptive – all covered in 18 minute individual sessions! Curated by Provider magazine.

· NEW! Sponsor Supported Education Sessions: Join our sponsor partners at Sponsor Supported Education Sessions. These three sessions will feature information about how products/services have contributed to successful quality improvement efforts within their customer community. 

· Registration includes choice of one Intensive Session (four available)

· Quality Initiative Recognition Program Ceremony: Celebrate the incredible success of our state affiliate innovation award recipient and the over 7,000 nursing center or assisted living communities that have met one or more of the AHCA and NCAL Quality Initiative goals.

Reimbursement Resources Available to AHCA/NCAL Members

Abigail Horn

The American Health Care Association and National Center for Assisted Living (AHCA/NCAL) provides many resources for members to help navigate a variety of Medicare and Medicaid issues. Visit the AHCA/NCAL website to check out these available toolkits:

· Medicaid Long Term Services and Supports (MLTSS) Toolkit – This toolkit is based on guiding principles that AHCA believes must be part of any Medicaid MLTSS program. It includes suggestions for statutory, regulatory or contractual agreement language, as well as a checklist of points to review in MLTSS plan contracts.

 · Medicare Advantage Toolkit – This toolkit consists of three modules designed to guide providers through the basics of the Medicare Advantage program and strategies for contracting between providers and plans. The first module provides an overview of the MA program, while the second module does a deep-dive in how plans are reimbursed by the government and how they, in turn, reimburse providers. The final module is a model contract with a discussion of necessary provisions you should be aware of before entering negotiations.

 · Accountable Care Organization Toolkit – This toolkit was developed for providers who are considering entering into contractual relationships with one or more of Medicare’s Accountable Care Organizations (ACOs). The guide is divided into three parts: a primer on the ACO program, a robust discussion to help providers prepare for and negotiate with ACOs and a model contract with discussion around discrete provisions providers should consider when negotiating with ACOs.

· State of the States Clearinghouse – This toolkit provides members with access to key Medicaid and Medicare information. The Clearinghouse is a one stop shop for valuable state-specific data impacting the long term care profession. View this short webinar to learn more about this tool.

AHCA/NCAL will continue to provide new resources in 2015 focused on the issues that matter to our members, such as Fraud and Abuse, MLTSS Contracting and more. Look for more updates to come in the New Year!

Monday, November 17, 2014

2015 AHCA/NCAL Convention Call for Presentations

Teresa Eyet

Don’t miss your chance to submit a proposal idea during the 2015 call for presentations period. Proposals will be accepted through November 30, 2015. Submission information and guidelines as well as the link to the submission database can be found at and click on 2015 Call for Presentations.

ICD-10 Updates

 Dianne De La Mare

As reported previously, the US Department of Health and Human Services (HHS) has released a final rule setting Oct. 1, 2015, as the new compliance date for health care eproviders, health plans and health care clearinghouses to transition to ICD-10. During the upcoming MLN Connects National Provider call on Nov. 5, 2014, CMS subject matter experts discussed ICD-10 implementation issues, opportunities for testing and federal government developed resources. To see schedule for additional calls go to

Further, the Centers for Medicare & Medicaid Services (CMS) has updated five ICD-10 previously released learning tools including: 1) ICD-10-CM/PCS Billing and Payment Frequently Asked Questions at;
2) ICD-10-CM/PCS The Next Generation of Coding at;
3) ICD-10-CM/PCS Myths and Facts at; 4) ICD-10-CM Classificaiton Enhancements at and
4) General Equivalence Mappings Frequently Asked Questions at; and
5)General Equivalence Mappings Frequently Asked Questions at

Lastly, to help providers prepare for the transition to ICD-10, CMS offers acknowledgement testing for current direct submitters (e.g., providers and clearinghouses) to test with their Medicare Administrative Contractors (MACs) and Common Electronic Data Interchange (CEDI) anytime up to the Oct. 1, 2015, implementation date. To participate in testing, go to your MAC website or through your clearinghouse. Any provider who submits claims electronically can participate in acknowledgement testing.

During the testing process, expect to: 1) test claims with ICD-10 codes and within the current dates of service; 2) test claims will receive the 277CA or 999 acknowledgement as appropriate, to confirm that the claim was accepted or rejected in the system; 3) Testing will not confirm claim payment or produce a remittance advice; and 4) MACs and CEDI will be staffed to handle increased call volume during the testing period.

 To obtain more information on acknowledgement testing and how to participate go to MLN Matters Article MM8858 at

OIG Releases 2015 Work Plan

Dianne De La Mare

The US Department of Health and Human Services (HHS), Office of Inspector General (OIG), has released its 2015 work Plan, which summarizes new and on-going OIG reviews, audits and other activities that the agency plans to pursue in FY 2015. OIG was created to protect the integrity of HHS programs and operations and the well-being of beneficiaries by detecting and preventing fraud, waste and abuse; identifying opportunities to improve program economy, efficiency and effectiveness; and holding accountable those who do not meet program requirements or who violate federal health care laws. The FY 2015 OIG Work Plan acts as a guide for AHCA/NCAL membership, identifying the specific areas where long term care and post-acute care providers can expect OIG focus and involvement. For skilled nursing facilities (SNFs), OIG plans to review the following areas:

· Medicare Part A billing by skilled nursing facilities – OIG will describe changes in SNF billing practices from FYs 2011-2013. Prior OIG work has found that SNFs increasingly billed for the highest level of therapy even though beneficiary characteristics remained largely unchanged. Expected issue date of this report is due in 2015.

· Questionable billing patterns for Part B services during nursing home stays – OIG will identify questionable billing patterns associated with SNFs and Medicare providers for Part B services provided to residents during stays not paid under Part A. For example, stays during which benefits are exhausted or the 3-day prior inpatient stay requirement is not met. Expected issue date of this report is due in 2015.

 · State agency verification of deficiency corrections – OIG will determine whether state survey agencies verified correction plans for deficiencies identified during nursing facility (NF recertification surveys. Prior OIG work has found that one state survey agency did not always verify that NFs corrected deficiencies identified during surveys in accordance with the federal requirements. Expected issue date of this report is due in 2015

· Program for national background checks for long-term-care employees – OIG will review the procedures implemented by participating states for long term care facilities or providers to conduct background checks on prospective employees and providers who would have direct access to patients and determine the costs of conducting such background checks. Expected date of this report is due in 2015.

 · Hospitalizations of nursing home residents for manageable and preventable conditions – OIG will determine the extent to which Medicare beneficiaries residing in NFs are hospitalized as a result of conditions thought to be manageable or preventable in the NF setting. Expected issue date of this report is due in 2015.

For assisted living facilities (ALFs), OIG has plans to review Hospices in ALFs settings. For home health (HH) services, OIG has plans to review Home health prospective payment system requirements and Employment of individuals with criminal convictions.

To obtain a copy of the full OIG Work Plan FY 2015 go to

November Journal of the American Medical Association Article on Observation Status

Dana Halvorson 

The November 19, 2014, Vol 312, No. 19 edition of the JAMA Forum includes an article by Diana Mason, PhD, RN, entitled The Unintended Consequences of the “Observation Status” Policy. The article focuses on the unintended consequences of the observation status policy for patients without Medicare Part B coverage, the hospital, and for skilled nursing care, and highlights 4 possible improvements to address the issue.

Mason notes that “whether through legislation or rule-making or actions by hospitals, it’s time to clean up the unintended consequences of this policy.” Hospital stays classified as observation, no matter how long and no matter the type or number of services provided, are considered outpatient. These hospital stays do not qualify patients for Medicare-covered care in a skilled nursing center. For more information about observation stays, please visit the AHCA/NCAL website.

Friday, November 14, 2014

Preparing for Open Enrollment

Dana Halvorson

According to a November 14, 2014, email alert from the Team, there are a few things you can do in order to prepare for open enrollment (or, if you are assisting anyone, help them prepare), which began last weekend on November 15th. If you enroll by December 15th, coverage can begin on January 1st, 2015. Ways you can get ready include:

 · Download this checklist to make sure you have all the documents you’ll need.

· Find out if you could qualify for premium tax credits and other savings this year.

 · See new 2015 Marketplace plans and prices before you apply.

 · Find someone in your community who can sit down with you to answer your questions before you fill out an application.

· Sign up for text message alerts that include updates and reminders so you don’t miss important deadlines.

In addition, and according to a November 14, 2014, email alert from the CMS Office of Minority Health, the Marketplace includes a Small Business Health Option Program (SHOP), designed to give small businesses new health insurance options and a way to cover their employees. The SHOP is available to small employers with 50 or fewer full-time equivalent employees. As of this past Saturday, the SHOP Marketplace is allowing qualifying employers to find, compare, purchase, and enroll in 2015 SHOP health and dental coverage entirely online through Employees will be able to view offers of insurance from their employer and enroll online through Small businesses and their employees can get help from the toll-free SHOP Marketplace call center at 1-800-706-7893 or for TTY, call 711. The hours are Monday through Friday, 9 a.m. to 7 p.m

Wednesday, November 12, 2014

ACA Implementation and Guidance

Dana Halvorson

According to a POLITICO Pro Health Care Whiteboard posting from Marianne LeVine, the Department of Labor’s Employee Benefits Security Administration updated its website on November 6, 2014, with frequently asked questions (FAQs) about the implementation of the Affordable Care Act (ACA) and a guidance on state regulation of stop-loss insurance. The FAQs, focused on the compliance of premium reimbursement arrangements, were prepared jointly by the Departments of Labor, Health and Human Services, and the Treasury. Be sure to check out AHCA/NCAL’s ACA website for information and updates on the ACA.

CMS Releases “Medicare Appeals Process” Podcast

Dan Ciolek and Dianne De La Mare

The CMS “Medicare Appeals Process” Podcast is now available. This 15 minute long MP3 audio podcast is designed to provide education on the five levels of claim appeals in Original Medicare (Medicare Part A and Part B). It includes details explaining how the Medicare appeals process applies to providers, participating physicians, and participating suppliers in addition to including more information on available appeals-related resources.

CMS Announces Plan to Issue New Recovery Audit Contracts For Regions 3 and 5

Dan Ciolek

On November 4, the Centers for Medicare and Medicaid Services (CMS) announced an update on their Recovery Audit Program website announcing plans to issue awards to two Recovery Audit Contractors (RACs) by the end of the year. On the website, CMS discusses that the new contracts for Recovery Auditor Regions 1, 2, and 4 remain under a pre-award protest, which is expected to continue into late summer of 2015. However, the procurement process continues for Region 3 (Part A / Part B claim reviews), which includes Florida, Tennessee, Alabama, Georgia, West Virginia, Virginia, North Carolina and South Carolina; and, for Region 5, which will be the national contract for DMEPOS and Home Health & Hospice claim reviews. CMS discusses on the website that they remain hopeful that these two new contracts will be awarded before the end of this year. However, in direct conversations with AHCA, CMS anticipates that it is quite likely that the new contract awards may receive post-award protests which may further delay the implementation of these new RAC contracts.

Previously, CMS had announced that the current RAC contractors were instructed in late August 2014 to resume conducting limited reviews (which had been on a pause since late February), pending the completion of the new RAC procurement process. To date, therapy manual medical review (MMR) was not part of this limited review resumption, however, AHCA has learned this week that CMS intends to resume limited therapy MMR in the near future. More details will be provided soon.

For more information, contact Dan Ciolek at

2015 Independent Owner (IO) Leadership Conference Makes Big Changes This Year

Christy Sharp

Registration is now open.  Mark your calendars and make your plans to attend the 2015 IO Leadership Conference.

March 11-13, 2015
Westin Beach Resort & Spa
Fort Lauderdale, Florida

AHCA/NCAL has redesigned the format to give you more of all the things you love about this conference.

—More time for networking with your peers

—More discussions on the topics that matter to you

—More opportunities to learn from each other

—More solutions to the challenges you face

You can earn up to 11.75 CEUs in education sessions that will all make use of the ever-popular Town Hall Meeting format so that you can engage fully and make the most of your time.

This year’s theme is How To Survive Medicaid Managed Care As an Independent Owner.

Visit to see the complete agenda and register.
The deadline is February 9, 2015.

Sponsors as of 11/11/2014: eHealth Data Solutions, Kronos, matrixcare, PointRight.

Congress Returns to Washington

Drew Thies

After a nearly two-month-long campaign break, members of the House of Representatives and the Senate return to Washington today to resume legislative business for the remainder of 2014.

Though the Republicans gained control of the Senate and expanded their majority in the House, Speaker John Boehner and Majority Leader in-waiting Mitch McConnell will not be able to exercise their new power until January. The makeup of Congress will remain the same until the end of the year, when Members who are retiring or lost will vacate their Capitol Hill offices.

Rumors abound surrounding what Congress may try to tackle before the 113th session comes to a close in December, but the only must-pass item looks to be another continuing resolution to keep government funded through the holidays.

Additionally, look for the confirmation of President Obama’s new pick for Attorney General, Loretta Lynch, to become a leading issue. With limited floor time for what is sure to be a controversial proceeding, however, the confirmation may get punted to next year as well.

The new members of the new Congress will also be in Washington this week and throughout the end of the year learning the ropes and meeting contacts in D.C. AHCA will continue to work with all members of Congress, old and new, to promote policies that preserve quality care.

ACA Litigation Heads to US Supreme Court

Dianne De La Mare

The US Supreme Court has agreed to review the legal challenge in King v Burwell (most likely in March 2015) and to decide whether or not the Obama Administration is improperly providing tax subsidies to consumers who purchase insurance through the Federal Exchanges (in more than 30 states). This will mark the third time that the US Supreme Court will hear litigation focusing on the Affordable Care Act (ACA), and casts a cloud on the tax subsidies issues as the second round of open enrollment for insurance through the Exchanges is set to begin. In 2012, the US Supreme Court upheld the constitutionality of the ACA but also found the Medicaid expansion provision unconstitutionally coercive to the states, leaving Medicaid expansion optional for the states. Then earlier this year, the Court carved out an exception for providing contraceptive coverage for employers who object for religious reasons.

Now, in agreeing to hear King v Burwell, the US Supreme Court will review the lower court (US Court of Appeals for the Fourth Circuit) decision that upheld the subsidies for the Federal Exchanges. Recall that on the same day that the Fourth Circuit released its decision, a panel of the US Court of Appeals for the District of Columbia (DC) Circuit struck down the subsidies. The full DC Circuit was poised to reconsider this matter in December but now pending the US Supreme Court review, this action has been put on hold. Depending on how the US Supreme Court rules on this matter, their final decision could seriously dismantle the ACA. 

Tuesday, November 11, 2014

Register for the 2015 NCAL Spring Conference

Katherine Preede

Open the door to new possibilities by registering today for the 2015 NCAL Spring Conference! Featuring the theme, “Thriving in a New Health Care Environment,” this extensive conference is exclusively designed to provide tools and strategies for assisted living professionals.

Held March 9-11, 2015 at the Westin Beach Resort & Spa in Fort Lauderdale, Florida, attendees will have the opportunity to earn up to 10.5 CEUs and network with individuals from across the country.

The conference curriculum is second-to-none and features the top experts in senior care. Sessions will cover a variety of topics, including customer satisfaction, workforce stability, dementia care, risk management, quality improvement, care transitions, and emergency preparedness. Dynamic keynote speakers Jeff Havens and Mike Schlappi will deliver not-to-miss inspirational speeches on leadership, motivation and adaptation during times of change.


By registering today you will save $125 off the on-site registration rate! Also consider registering for the AHCA/NCAL Independent Owner Leadership Conference, occurring immediately after this event, March 11-13, 2015, and save on registration fees for both conferences.

Attending the NCAL Spring Conference is a strategic decision you can make to ensure that in this ever-changing world of health care, your organization is ahead of the curve. Make the commitment to yourself and your future today!

Monday, November 10, 2014

Insurance Plans That Fail to Cover In-Patient Hospitalizations Not ACA Compliant

Toni Fatone

The Department of Health and Human Services (HHS) and the Department of the Treasury (IRS) have announced Notice 2014-69 that group health insurance plans that do not cover in-patient hospitalization services and or substantial physician services will not be found to be compliant with the Affordable Care Act (ACA). HHS and the IRS will promptly propose regulations to provide that such plans currently being promoted to employers and that currently achieve compliance on the HHS Minimum Value (MV) Calculator do not provide minimum value under the intent of the law. Employers will not be permitted to use the calculator or any actuarial certification or valuation to defend use of such plans to cover employees under the requirements of the ACA.

These proposed changes will be finalized early in 2015 and will apply to all plans other than those that are dated pre-November 4, 2014. If an employer has entered into a binding agreement to adopt, or has been enrolling employees in a plan without In-Patient hospitalization/Non Physician Services plan prior to November 4, 2014 and the employer relied on the MV Calculator the proposed regulation will not apply before the end of the plan year IF that plan year begins no later than March 1, 2015. An employee offered a Non In-Patient Hospitalization Plan/Non-Physician Services Plan will still be eligible for a premium tax credit regardless of whether that Plan is offered pre-November 4th or not. Additionally, an employer that offers an In-patient/Non-Physician Plan must not state or imply in any disclosures to employees that the offer of coverage for such a plan will preclude the employee from obtaining a premium tax credit. The employer must also “timely correct” any prior disclosures that such Non-In-Patient/Non-Physicians Plan would bar an otherwise tax credit eligible employee from obtaining a premium tax credit. If an employer also offers to its employees a plan that includes hospitalization and physician services and it is “affordable” and provides “minimum value” that employer is permitted to advise employees that the offer of this other plan will or may preclude the employee from obtaining a premium tax credit.

Any questions regarding this may be directed to HHS at 301-492-5153 or IRS at 202-317-7006. Additional information for employers can be found at,, and Also, be sure to check out AHCA/NCAL’s ACA website for important information and updates on the ACA.

MedPAC Update on Site-Neutral

Mike Cheek and Elise Smith

On Friday, November 7th the Commission again addressed site-neutral payment, building upon its June report discussion on orthopedic conditions. The Commissioners reach consensus upon the following action items for staff:

· Move forward with formulation of a site neutral policy which includes certain orthopedic conditions as well as a new 17 conditions discussed, today;
· Set aside the possible inclusion of stroke cases; and
· Flesh out an IRF regulatory relief package and transition plan for site neutral implementation. 

Chairperson Hackbarth expressed a need for the Commission to expeditiously move towards formulation of a site neutral policy recommendation. However, it appears the Commission will hold another site-neutral session before any recommendations are published due to the many questions posed by the Commissioners. Below are key statements from both the June meeting and related report as well as today’s meeting.  

A. MedPAC June Report

 The Commission examined three specific conditions (stroke, major joint replacement, and hip fractures) and concluded the following:

· For select conditions, characteristics of beneficiaries admitted to IRFs and SNFs in the same market were similar; 

· In addition, the prevalence of comorbidities of beneficiaries were similar but patients treated in SNFs were more likely to have several of the comorbidities; and

· Outcomes between IRFs and SNFs were basically the same for the identified conditions: there were no significant differences in risk-adjusted readmission rates between IRFs and SNFs; no significant differences in mobility, and, with respect to self-care there were no significant differences for orthopedic conditions but some higher rates of improvement for IRF patients. 

The Commission concluded that the work on orthopedic conditions were a strong starting point for a site-neutral policy and that MedPAC staff will continue to explore site-neural payment between SNFs and IRFs. 

B. MedPAC November 7, 2014 Meeting

Commission staff reviewed their criteria for to evaluate conditions for site neutral payment: a) frequently treated in lower-cost setting; b) similar risk profiles; and c) similar outcomes. In addition to reviewing June findings, at the request of Commissioners, MedPAC staff followed up on stroke cases and analyzed an additional 17 new conditions for an expanded site neutral policy. The public did not receive a list of the new conditions but, from the discussion cardiac and certain infections appear to be included. 

Staff asked the Commissioners for guidance on the design of a site-neutral policy, both regarding the 17 new conditions and stroke.

The staff noted a site-neutral stroke policy could include a subset of stroke patients who are the: 

· Most severely ill (who generally cannot tolerate intensive therapy) and 
· Least severely ill (who do not need the intensity of an IRF)

However, the Commissioners were spilt on this issue due to the heterogeneity of the population and recovery trajectory. Chairperson Hackbarth concluded a recommendation site–neutral regarding strokes could not go forward.

The Commissioners then discussed the 17 new conditions. Staff noted that the new 17 conditions comprise 20% of the conditions included in the analysis (see table below). In keeping with the Commission’s site neutral analytic criteria, the majority of these cases were treated in SNFs. While a list of these conditions was not provided, a mix of orthopedic, pulmonary, cardiac and infections appear to be included based upon discussion. The conditions comprise 10% of IRF cases and spending. Total IRF payments (including add-on payments) are 64% higher than SNF rates. IRF base rates are 49% higher than SNF rates.

The Commission was in favor of moving forward with development of a site neutral policy which includes both orthopedic conditions as well as the 17 new conditions. A site neutral policy which includes the 17 additional conditions and the orthopedic conditions approved in June (June Report) produces notable savings and is presented in the table, below. 

Effect of IRF Site-Neutral Policy on Medicare Spending
(Assumes No Behavioral Change and Does Not Include Re-Admission Costs)
For 17 new conditions
($309 million)
For orthopedic conditions (June Report)
($188 million)
($497 million)
Impact on total IRF spending

If strokes were included, which appears unlikely, an additional $256 million in savings would be accrued. 

C. AHCA Staff Comment
An underlying issue that we think the MedPAC staff will have to address is a pervasive confusion about therapy intensity and medical intensity. Commissioners repeatedly queried why SNFs treating patients with more co-morbidities and complex medical conditions (and more medical needs) when IRFs must comply with hospital requirements and have physician and nurses on staff 24/7. Such questions were posed in several ways but never answered.   

Twitter Event: Wednesday, November 12th at 8 PM

Katherine Merullo

Care Conversations is a place to come together and talk about choosing the right care options, now and for the future.  Here, you will find information and resources to help you discuss care with loved ones and health care providers.

Join us as we chat about having these important conversations and get some tips on making the right decisions for your loved ones at:

Care Conversations Twitter Party
Wednesday, November 12th from 8:00 to 9:00 p.m. Eastern Time
Where: #CareConvo tag on Twitter

How: Follow party host @ResourcefulMom, sponsor @ahcancal and tweet with the hashtag to participate #CareConvo

And of course, they will be giving away great prizes throughout the evening!

Learn more about the Twitter event & RSVP (not req’d) at:

Updated Kaiser Family Foundation FAQs on the ACA’s Marketplace

Dana Halvorson

Last week, the Kaiser Family Foundation (KFF) released an updated collection of Frequently Asked Questions (FAQs) providing answers for consumers, and the navigators and brokers who assist them, as the Nov. 15 start date nears for the Affordable Care Act's (ACA’s) second open enrollment period.

According to a Nov. 7 email alert from KFF, the searchable collection includes nearly 300 up-to-date responses, answering new questions about plan renewal, cancellations, and continuing financial assistance. The FAQs also offer guidance for understanding 2014 federal income taxes in the context of the health law, addressing potential penalties for not obtaining coverage, exemptions to the individual mandate, and other subjects. The KFF email alert included that answers have been updated to key questions about the law and how it applies to people in different circumstances, including marketplace and Medicaid eligibility, and guidance for immigrants, people with variable incomes and others in special situations.

Additionally, a new issue brief, Explaining the 2015 Open Enrollment Period, provides an overview of what consumers can expect during the ACA's second open enrollment period and the tax filing season that follows. The FAQ compilation is part of a series of new and updated KFF resources to be released in coming weeks to help consumers understand health insurance and navigate open enrollment.

For more information, visit Understanding Health Insurance, and check and @KaiserFamFound on Twitter for an "FAQ of the Day." You can also sign up to receive KFF emails here if you are interested. Finally, be sure to check out AHCA/NCAL’s ACA website for important information and updates relating to the ACA.

MedPAC Meeting on Hospital Short Stay Policy Issues

Dana Halvorson 
On September 12, 2014, the Medicare Payment Advisory Commission (MedPAC) held a meeting on hospital short stay policy issues, and held another meeting on these issues last Thursday, November 6. The Commission meets publicly in Washington, D.C., to discuss Medicare issues and policy questions and to develop and approve reports and recommendations to the U.S. Congress. At these meetings, staff present research and policy options for the Commissioners to discuss.

The November 6 hospital short stay policy issues meeting focused on, among other topics discussed, observation stays, the 3-day stay requirement, Recovery Audit Contractors, one-day inpatient stays, and self-administered drugs. A McKnight’s article that provides a brief overview of the meeting can be found here, while the MedPAC meeting issue brief and the PowerPoint presentation can be found here. More information about the observation stays issue can be found on the AHCA website.      

Next CMS SNF/LTC Open Door Forum

Holly Harmon

The next CMS Skilled Nursing Facilities (SNF)/Long Term Care (LTC) Open Door Forum scheduled for Thursday, November 13, 2014 at 2:00 PM Eastern Time (ET). 
Date: Thursday, November 13, 2014
Start Time: 2:00 PM Eastern Time (ET)
This call will be Conference Call Only. To participate by phone: 
Dial: 1-800-837-1935 & Reference Conference ID: 44426119
For TTY services dial 7-1-1 or 1-800-855-2880. A Relay Communications Assistant will help.
Encore: 1-855-859-2056; Conference ID: 44426119
Encore is an audio recording of this call that can be accessed by dialing 1-855-859-2056 and entering the Conference ID beginning 2 hours after the call has ended. The recording expires after 2 business days.
I. Opening Remarks: Chair – Jeanette Kranacs (Center for Medicare), Moderator – Jill Darling (Office of Communications)
II. Announcements & Updates 
  •  Two Quality Measures, Changing Scale of Quality Measure
  • December 16, 2014 - MLN Connects™ National Provider Call: Certifying Patient Eligibility for the Medicare Home Health Benefit (1:30 pm to 3:30 pm Eastern Time) Participants can find more information here.
  • 2015 Voluntary Payroll Staffing Data Collection Project (email
  • SNF PPS Payment Reform Research Project - Announcement  
III. Open Q&A
For ODF schedule updates and E-Mailing List registration, visit the CMS website at

Wednesday, November 5, 2014

Republicans Take the Senate, Expand Seats in House and Governorships

Drew Thies

Republicans seized control of the U.S. Senate early in the midterms, taking many seats controlled by Democrats and not losing a single seat previously controlled by their party.

The GOP won Senate seats in every state Mitt Romney won in the 2012 presidential election and carved a path into previous Obama strongholds, Iowa and Colorado. Republicans also took seats from Democrats in Arkansas, Montana, North Carolina, South Dakota, and West Virginia. Despite votes still being counted in Alaska and Virginia and a Louisiana runoff scheduled in December, Republicans will control at least 52 seats in the Senate.

The Republicans’ lead was also expanded in the House, where they picked up 13 seats at the time of publication and now hold a nearly 50 seat lead on Democrats in the chamber.

Governorships, which some pollsters thought may be a ray of light for the Democratic party, also stayed mostly Republican, with the GOP picking up new seats in Massachusetts and Illinois while fending off top challengers in other states with embattled incumbents.

Webinar: Improving Integrity in Nursing Centers

Dianne De La Mare

This webinar will highlight AHCA/NCAL's new "Fraud and Abuse Toolkit," and help providers untangle the web of fraud and abuse laws and regulations. The Toolkit focuses on nursing facilities; but much of the information can be helpful to other health care providers, such as assisted living or DD facilities. Provider's comprehensive understanding of the applicable fraud and abuse laws and regulations is important in order to protect patients and payors (including Medicare and Medicaid). Further, an understanding of the fraud and abuse laws and regulations can help facilities protect themselves from potential administrative, monetary, civil and criminal liabilities.

Learning Objectives:
1. Understand how to comply with federal fraud and abuse laws and regulations.
2. Learn how federal agencies and contractors enforce those laws and regulation.
3. Discover what to do when a government inspector walks in the facility door.

Susan Edwards
Reed Smith

Improving Integrity in Nursing Centers
Thursday, November 20, 2014
2:00 PM-3:00 PM Eastern Time (60 minutes)

Webinar: SNF Re-hospitalization Program – Independent Owners Preparing for Implementation

Mike Cheek

The Protecting Access to Medicare Act of 2014 (H.R. 4302; Pub.L. 113–93) included several important provisions for the skilled nursing center industry. Of key importance is a re-hospitalization program. The Centers for Medicare and Medicaid (CMS) will withhold two percent of Medicare fee-for-services payments to skilled nursing centers. In turn, skilled nursing centers will be able to receive these withheld funds by meeting CMS and industry agreed to facility-specific re-hospitalization rates.

1. Basics of the SNF Re-Hospitalization Program
2. Ideas for Preparation Including Use of Long Term Care Trend Tracker
3. Information on How Some Members Are Preparing for Implementation
Wednesday, December 17, 2014
1:00 PM – 2:30 PM Eastern Time
Mike Cheek
Senior Vice President, Medicaid & Long Term Care Policy

David Gifford
Senior Vice President, Quality and Regulatory Affairs

Peggy Connorton
Director, Quality & LTC Trend Tracker

Holly Harmon
Senior Director, Clinical Services

Antipsychotic Drug Use in Nursing Homes: Trend Update from CMS

Holly Harmon

The National Partnership to Improve Dementia Care in Nursing Homes is committed to improving the quality of care for individuals with dementia living in nursing homes. The Partnership has a mission to deliver health care that is person-centered, comprehensive, and interdisciplinary, with a specific focus on protecting residents from being prescribed antipsychotic medications, unless there is a valid, clinical indication and a systematic process to evaluate each individual’s need.

CMS is tracking the progress of the Partnership by reviewing publicly reported measures. The official measure of the Partnership is the percent of long-stay nursing home residents who are receiving an antipsychotic medication, excluding those residents diagnosed with schizophrenia, Huntington's Disease, or Tourette’s Syndrome. In the fourth quarter of 2011, 23.9% of long-stay nursing home residents were receiving an antipsychotic medication. Since then, there has been a decrease of 18.8% to a national prevalence of 19.4% in the second quarter of 2014. Success has varied by state and CMS region, with some states and regions having seen a reduction of greater than 20%. For more information on the Partnership, please send correspondence to  

AHCA’s Skilled Nursing Progress Report for First Quarter 2014 can be found on the Quality Initiative website or by clicking here:

Additional MedPAC Meeting on Hospital Short Stay Policy Issues

Dana Halvorson and James Michel

On September 12, 2014, the Medicare Payment Advisory Commission (MedPAC) held a meeting on hospital short stay policy issues, and will hold another meeting on these issues this Thursday, November 6, from 10:30am – 12:30pm ET.

The Commission meets publicly in Washington, D.C., to discuss Medicare issues and policy questions and to develop and approve reports and recommendations to the U.S. Congress. At these meetings, staff present research and policy options for the Commissioners to discuss. The September 12 hospital short stay policy issues meeting focused on, among other topics discussed, observation stays, the 2-midnight rule, Recovery Audit Contractors, one-day inpatient stays, and beneficiary impacts.

A McKnight’s article that provides a brief overview of the meeting can be found here, while the MedPAC meeting issue brief and the PowerPoint presentation can be found here. The brief for the upcoming November 6 MedPAC meeting can be found here. More information about the observation stays issue can be found on the AHCA website.      

How to Prepare Your Organization as the Industry Moves Toward MCOs, ACOs, and a Bundled Payment System

Adrienne Riaz-Kahn

There are already over 6,000 providers who have volunteered for bundled payment models that rely heavily on post-acute care. As the healthcare industry moves towards this new system, it is critical for long term care and community-based providers to create meaningful partnerships.

Attend this informative webinar hosted by My InnerView by National Research Corporation and discover how to prepare your organization for the changes ahead.

Learning Objectives:· Go beyond experience measurement to position yourself as a favorable care coordination partner
· Find out how to speak the language of ACOs and MCOs and get ahead of the game
· Learn how to improve your reputation and brand equity to forge lasting strategic partnerships. 
Rich Kortum, Director of Business Development, My InnerView by National Research Corp.
Bruce Thevenot, Senior Consultant, My InnerView by National Research Corp.

2:00pm – 3:00pm Eastern Time

Registration Link: