Friday, October 31, 2014

CMS Finally Pays Glenda Jimmo for Her Maintenance Therapy

Dan Ciolek


Per a Center for Medicare Advocacy (CMA) announcement , the Centers for Medicare and Medicaid Services (CMS) agreed to settle the recently filed Jimmo v. Burwell lawsuit on October 29, and will actually cover her home health maintenance therapy provided several years ago, which was previously denied and led to the landmark Jimmo v. Sebilius settlement.

In April 2014, despite the 2012 settlement agreement in which CMS agreed that Medicare cannot deny (Part A, Part B, or Medicare Advantage) payment for therapy or nursing services (provided in home health, SNF, or outpatient settings) merely on the basis that the condition/function was not improving, Ms. Jimmo’s claim was again denied at the 4th level of appeal due to “lack of improvement”, which prompted the new lawsuit settled on October 29.

This is great news in that it affirms that maintenance services are a necessary covered service for beneficiaries with chronic and/or progressive conditions that are at risk for decline in health and function without skilled interventions performed by qualified individuals, and that cannot be safely and effectively be performed by the patient or nonskilled caregivers.

There is one very valuable piece of information in the CMA press release that should not go unnoticed. Despite having a number of chronic health conditions, the press release notes that Ms. Jimmo developed a condition that required temporary SNF care, that she is currently getting SNF therapy services, and that she is expected to return home soon. There are several messages that can be inferred from this story:

1) people with chronic health problems can benefit from maintenance therapy as a covered Medicare benefit,

2) people with chronic health problems can decline without maintenance therapy requiring more costly inpatient services, including the woman who has become the poster child for maintenance therapy, and

3) people with chronic health problems, with recent decline can benefit from skilled nursing facility care, and can return to their home as a result of quality nursing and rehabilitation care.

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 dnh_behavioralhealth@cms.hhs.gov.

AHCA’s Skilled Nursing Progress Report for First Quarter 2014 can be found on the Quality Initiative website or by clicking here: http://www.ahcancal.org/quality_improvement/qualityinitiative/Documents/AP%20Q1_2014%20Progress%20Report_CMS%20numbers.pdf

Important 2015 Marketplace Info

Dana Halvorson

According to an October 31, 2014, email alert from the HealthCare.gov team, there are a few items individuals should be doing now to get ready for November 15th. That is the date in which you can return to HealthCare.gov to find a new health insurance plan or re-enroll in your current plan. The 3 things you can do right now to get ready include:


If you have any questions relating to the Affordable Care Act (ACA), please submit them to dhalvorson@ahca.org, and be sure to check out AHCA/NCAL’s ACA website.

Wednesday, October 29, 2014

Important Post-Convention Information

Jon Patrick Ewing

If you attended the AHCA/NCAL 65th Annual Convention & Expo, please note this important information.

Complete the Convention & Expo Survey: Please take a moment to give us your feedback by taking the Post-Convention Survey. When you send back a completed survey, you will automatically be eligible to win a $200 cash card. The deadline to complete the survey is Friday, November 7.

Claim Your CEUs for 2014: AHCA/NCAL Convention & Expo attendees can retrieve their CEU certificates by clicking on the following link:
http://www.retrievemyleads.com/rml_login.php?AliasType=attendee&ShowID=ahcass14 

User ID: Please use your first and last name – all one word – all lower case (i.e.: johndoe)
Password: Please use the email that you used to register for convention (i.e.: johndoe@ahca.org)

If you find a mistake in your certificate, please email the issue to Adrienne Riaz-Khan (ariaz-khan@ahca.org). Please provide a detailed description of what needs correcting. For example, “I attended the closing general session but missed my out scan”. Certificates were emailed to attendees yesterday. This link will be live for one year should you need to reprint or did not get your certificate.

Session Evaluations: In addition, we ask that you complete convention education session evaluations by going to the following link: http://data.express-evaluations.com/eval/36690/2014/main.php

Event Photos: All events are available in the AHCA/NCAL Convention & Expo 2014 Folder on Flickr. There are multiple albums with different event names to view your selections.
https://www.flickr.com/photos/ahcancal/collections/72157648906224891/

Claim Your CEUs for 2014

Teresa Eyet


AHCA/NCAL Convention & Expo attendees can retrieve their CEU certificates by clicking on the following link:

http://www.retrievemyleads.com/rml_login.php?AliasType=attendee&ShowID=ahcass14 

User ID: Please use your first and last name – all one word – all lower case (i.e.: teresaeyet)
Password: Please use the email that you used to register for convention (i.e.: teyet@ahca.org)

If you find a mistake in your certificate, please email the issue to Adrienne Riaz-Khan (ariaz-khan@ahca.org). Please provide a detailed description of what needs correcting. For example, I attended the closing general session but missed my out scan.

Certificates were emailed to all attendees October 28, 2014. This link will be live for one year should people need to reprint or did not get their certificates. 

Registration open for free NPUAP webinar

Holly  Harmon

On November 20 at 2:00 PM Eastern, in honor of World Wide Pressure Ulcer Prevention Day, the NPUAP is pleased to offer a FREE webinar, hosted by Dr. Nancy Bergstrom, titled “Repositioning as a Pressure Ulcer Prevention Strategy: A Multi-site Clinical Trial.” Dr. Bergstrom will introduce findings from the TURN Study conducted at UT Health School of Nursing, where researchers looked at optimal frequency of patient repositioning for pressure ulcer prevention.

This webinar is only open to the first 1,000 registrants so register today!

For more information on the webinar and how to register please view website.

Medicare “Improvement Standard” Returns to Courts

Dan Ciolek and Dianne De La Mare


In a landmark court agreement in 2012, the Centers for Medicare and Medicaid Services agreed to settle a class-action lawsuit filed by Glenda Jimmo, a 78 year old woman from Vermont who was denied Medicare coverage due to a “lack of improvement”. In the settlement agreement, and in subsequent updates to Medicare policy manuals, CMS agreed that beneficiaries cannot be denied coverage based solely on the lack of improvement in health or function. Coverage instead is based upon the need for skilled care, and that the care can only be safely and effectively be performed by qualified nursing or therapy professionals.

In the settlement agreement, beneficiaries that were previously denied care due to the improper “improvement standard” were offered an opportunity to appeal claims denied only due to lack of improvement. In April 2014, Ms. Jimmo received a decision from the Medicare Appeals Council (the 4th level of appeal) which upheld the earlier denials agreeing with the original medical review decision that her condition was not improving. As reported in Kaiser Health News, Ms. Jimmo with the support of the Center for Medicare Advocacy (CMA) have filed a lawsuit (Jimmo v. Burwell) seeking a reversal of Medicare’s decision to deny coverage.

AHCA continues to monitor this situation. For more information, contact Dan Ciolek dciolek@ahca.org or Dianne De La Mare ddelamare@ahca.org.       

Tuesday, October 28, 2014

Submit Your Posters

Urvi Patel

Have a story to share? Have an outstanding practice? Have stellar results?

Come share your success with your peers! Submit a Poster Session Proposal for the 2015 AHCA/NCAL Quality Symposium.

We are particularly interested in proposals showing how improvements in the Quality Initiative Goals have led to positive business outcomes.

Safely Reducing Hospital Readmissions
Safely Reducing Off-Label Antipsychotic Drug Use
Reducing Staff Turnover
Improving Customer Satisfaction

The deadline to submit is November 17th, 2014. Applicants will be notified on December 15th, 2014.

For questions contact Urvi Patel at upatel@ahca.org.

White House Prepares Upcoming Conference on Aging

 The Obamas on South Lawn (Official White House Photo by Pete Souza)
Drew Thies

The White House continues to prepare for its Conference on Aging, set to be held in Washington next year. The conference, which occurs every 10 years, is hosted as an opportunity for those in aging and care-giving communities to provide advice and policy recommendations to the executive departments and beyond on how to secure a better future for aging Americans.

AHCA/NCAL is happy to announce that we have already had contact with the administration about the subject matter of the conference. We will continue to work with the White House to showcase the skilled nursing profession during this event.

White House staff has met with advocates nationwide to develop a framework for the series of events. Topics covered will focus broadly on preserving finances as Americans age, maintaining healthy aging, providing the appropriate support to the disabled and elderly, as well as protecting aging Americans from negligence and exploitation.

Specific dates for the conference have not yet been set, but we will continue to update members with news as we work with the administration. You can learn more about the White House Conference on Aging at their website.  

Our Quality Award Journey

By Lori Cooper, Administrator, Stonebrook Healthcare Center
2014 Gold Quality Award Recipient

 (L to R) Neil Pruitt, Jr,, AHCA Immediate Past Chair, Lori Cooper, Len Russ, AHCA Chair 
As an independent facility, taking the Quality Award journey is one of the best decisions we ever made. We utilized the criteria and feedback at every stage to identify, develop and implement systems to make us a high performing organization and a leader in our marketplace. Like most independent facilities, Stonebrook has limited resources for the various layers of consulting that can be found in multi-operations. This did not prevent us from making a commitment to quality. To address this challenge, we assigned champions to each category of the application. These champions became experts in their assigned areas.   

We soon realized there are numerous advantages to participating. We learned about our organization; the good, the bad and the ugly. With that information, we were able to identify what we do best and identify areas where we needed to improve our processes. We came to understand the importance and value of being a data-driven organization. The quality award process prompted us to look at our outcomes as compared to our competitors. By being willing to address the areas where we were not as good as our competitors, our results improved over time.  

For us, the benefits of participating in the Quality Award Program are evident in every aspect our organization. Here are the top five benefits for us:

1. We now have an engaged leadership team that understands the need to focus on our strategy and customers. Our leadership team sets the direction for our organization and seeks out future opportunities. They understand the importance of creating a culture that delivers a consistently positive experience for our customers that is in alignment with our mission. This level of leadership keeps our operations current and responsive to the needs of our stakeholders.

2. We have systems and processes in place that can be replicated. In the event that we would lose a key employee or knowledge holder, we would be able to continue our day-to-day functions with minimal impact. As an independent organization, this continuity is vital for us to survive and thrive long-term.  

3. The Quality Award Program made us aware of the importance of listening to our customers and stakeholders. The communication throughout the organization has become essential to us. We listen to our customers and use their feedback to make improvements to our processes. As a result, our customer satisfaction scores are consistently in the top 10 percentile of the My InnerView national data base.

4. The morale, unity and engagement of our employees have been positively impacted by our participation in the Quality Award Program. We purposefully focus on our employees and their work environment and well-being. We used the criteria as a tool to identify workplace factors that could enhance our workplace environment. For the past three years, our organization has been recognized as a “Top Workplace” in the San Francisco Bay Area out of all industries.

5. By achieving the Gold Quality Award, our independent organization has earned more credibility, an enhanced reputation and increased marketability in the local area. This is imperative to us as we do not have the deep pockets for advertising. We are able to attain a higher market share based on our reputation.  

Our journey through the Quality Award Program has had a dramatic impact on our organization. It proves that independent operators can achieve and maintain the highest level of performance. I encourage every independent operator to take the journey with us. You won’t be sorry.

Submit your Intent to Apply for the 2015 AHCA/NCAL National Quality Award Program by November 13, 2014!

ACA Employer Requirements-Are You Ready for January 1, 2015


Since the enactment of the Affordable Care Act (ACA) in 2010, there have been some administrative delays and a number of regulations published, making it at times challenging for employers (including long term and post-acute care providers) to keep up and comply with the relevant employer shared responsibility provisions that go into effect on January 1, 2015. As an employer, a key aspect of the health reform law is understanding and complying with these provisions. Nicole Fallon of CliftonLarsonAllen will explain what these provisions are, and what you need to do to ensure you are prepared. A timeline of key ACA requirements will be provided, and you will have the opportunity to get your pressing questions answered. 

 
Tuesday, December 2, 2014
2:00 PM- 3:00 PM Eastern Time

Learning Objectives:

· Review and gain a better understanding of key employer reporting requirements
· Learn more about the employer “shared responsibility” penalties and IRS reporting requirements
· Receive a better understanding for determining when an employee is full-time
· Learn about key ACA compliance dates

Speaker:
Nicole O. Fallon, Consultant/Director Health Care, CliftonLarsonAllen LLP. 

"Medicare Quarterly Provider Compliance Newsletter Volume 5, Issue 1” Released

Dan Ciolek
The “Medicare Quarterly Provider Compliance Newsletter [Volume 5, Issue 1]” Educational Tool (ICN 909051) is now available. This newsletter is designed to provide education on how to avoid common billing errors and other erroneous activities when dealing with the Medicare Program. It includes guidance to help health care professionals address and avoid the top issues of the particular Quarter. Two articles specific to SNF services include: 1) RAC findings on SNF level of care review (pages 6-7), and 2) CERT findings on SNF certifications and re-certifications (pages 15-17).

Mass Adjustment of Selected SNF Claims

Dan Ciolek

Since August 25, 2014, the Medicare claims processing system has been incorrectly calculating the expenses subject to deductible for Skilled Nursing Facility (SNF) inpatient claims (Type of Bill (TOB) 22x with Healthcare Common Procedure Code (HCPC) 97116. As a result, these claims have been overpaid. Once the system is fixed on October 27, Medicare Administrative Contractors (MACs) will adjust claims received on or after August 25, 2014, through October 27, 2014.





SHOP Coverage Online

Dana Halvorson
 
According to an Oct. 24, 2014, email alert from the HealthCare.gov team, new online features are coming to the Small Business Health Options Program (SHOP) Marketplace on HealthCare.gov in November. These changes will make it easier for small employers to find, purchase, and have their employees enroll in SHOP coverage. SHOP was created in the Affordable Care Act (ACA), and is a new way for small businesses to buy health insurance for their employees. According to the email alert, here are few things employers need to know about renewing or changing SHOP coverage for 2015: 
  • Beginning November 15th, you’ll be able to renew or change SHOP coverage online. You’ll no longer be able to renew your SHOP coverage directly with an insurance company or have to use a paper application.
  • Once you make your online offer of coverage to your employees, they‘ll also be able to renew or change their coverage online.
  • You’ll need to give your employees at least a week to decide if they want to accept your offer for 2015 SHOP coverage. If they enroll by December 15th, their coverage will take effect as early as January 1, 2015.
  • If you had 1-50 full time equivalent employees in 2014, but have added more employees after beginning your coverage - you may still be eligible to renew or change your SHOP coverage in 2015.
You can learn more about renewing or changing your SHOP coverage here. If you have any questions relating to the ACA, please submit them to insurancecoverage@ahca.org, and be sure to check out AHCA/NCAL’s ACA website.

Registration is now open for the 7th Annual AHCA/NCAL Quality Symposium

Jon Patrick Ewing

Registration is now open for the 7th Annual AHCA/NCAL Quality Symposium. The symposium will be held in Austin, Texas, February 23-25, 2015.  
  
The AHCA/NCAL 7th Annual Quality Symposium: It’s Time to Roar, builds on a tradition of providing high level, extremely targeted quality improvement programming. The quality call to action has grown from a persistent chorus of voices to an industry-wide roar. Be sure your voice is among those contributing to the roar that drives change, and progress, and outcomes. Register now for the premier quality education and networking event in the long term and post-acute care. Earn up to 15.5 CEUs for administrators. Nurse hours are also available.
 
 
What's in store for this year’s attendees?
 
· NEW! Provider magazine will curate a series of talks called AHCA/NCAL LED Talks and modeled after the popular TED Talk concept. These talks will inspire you to LEAD, ENGAGE, and DISCOVER.
 · NEW! Sponsor supported education sessions with CEUs featuring content presented by our sponsor partners.
 · Opening General Session with Terry Barber. Barber is the author of The Inspiration Factor. Known as America’s Chief Inspiration Officer. Barber’s mission is to equip and empower leaders, companies, and nonprofits organizations to be intentional about becoming inspiring from the inside out. 
· 20 concurrent education sessions over three days
· Moderated Poster Gallery
· Quality Initiative Recognition Program (QIRP): The Quality Symposium is also a time for celebration. At the Quality Initiative Recognition Program Ceremony, we will celebrate the incredible success of the over 7,000 nursing center or assisted living communities that have met one or more of the AHCA and NCAL Quality Initiative goals.
· Choose from one of four Symposium Intensives:
  1. Improving Transitions of Care through Consortiums or Partnerships
  2. Creating a Dynamic Work Environment
  3. Looking Ahead with Food First: Using QAPI to Change a Culture
  4. INTERACT for Assisted Living
 · Plus lots of networking opportunities to connect with quality professionals from across the country
Watch your mail next month for your invitation to attend. For immediate information and to register, visit qs.ahcancal.org. Registration is now open for the 7th Annual AHCA/NCAL Quality Symposium

Challenge: Bring on the Fiesta at your Place

Tom Burke


“Bring on the Fiesta” is the theme for National Nursing Home Week (NNHW) May 10-17, 2015. For those living or working in a care center the week’s focus will be on celebrating “Family, Life, and Love” in an embracing atmosphere of encouragement and support.

So plan on having a Fiesta in May 2015 and watch for the special “Planning Guide and Product Catalogue” that will be available early next year with exclusive ideas and themed-products. Be sure your activities staff knows about this so they can begin to get excited about all the fun everyone will be having. If you have any great Fiesta! ideas, such as cultural performances, exhibitions, or competitions, be sure to email suggestions to tburke@ahca.org.

Wednesday, October 22, 2014

Members of Congress Learn Value of Skilled Nursing Therapy

Drew Thies

AHCA/NCAL members have been hard at work this year showing their Representatives in Congress the value of therapy services in a skilled nursing setting. Several Members of Congress from across the country visited AHCA skilled nursing buildings in order to learn specifically how therapy services are given in a SNF setting.

The Members of Congress, including Rep. Joe Garcia (D-FL), Rep. Patrick Murphy (D-FL), and Rep. Peter Roskam (R-IL), listened to patients as they explained their stories, many of which involved a return to their communities and families within a month of starting therapy. Click here for a video of the tours and conversations. 

Skilled nursing centers provide an efficient rehabilitation environment, with a combination of physical, occupational, and speech/language therapy, to people who have lost normal functionality due to an injury, a stroke, surgery, and even a progressive disease such as arthritis. These cost-e­ffective services help avoid costly hospital and post-acute admissions and readmissions, and often facilitate the return to community-based living for beneficiaries.

Existing Medicare payment policies, however, focus on phases of a patient’s illness defined by a specific service site, rather than on the characteristics or care needs of the Medicare beneficiary. This system fails to encourage collaboration and coordination across multiple sites of care and provides few incentives that reward efficient care delivery.

AHCA supports a payment system for post-acute care focusing on patients rather than their setting of care. Medicare Payment Advisory Commission (MedPAC) found that outcomes between SNFs and other similar care settings were basically the same for conditions usually requiring rehabilitative service, such as strokes or hip fractures. Increasing utilization of SNF rehabilitative services by grouping patients by clinical condition and severity of injury would provide high-quality care in a setting that could save billions in Medicare spending over the next decade.

For more information about skilled nursing rehabilitative service or if you are interested in having a Member of Congress tour your own skilled nursing or assisted living center, please contact Drew Thies at dthies@ahca.org.

Tuesday, October 21, 2014

Basic Health Program Funding Methodology Proposed Notice


According to an Oct. 21, 2014, fact sheet sent out by the Centers for Medicare & Medicaid Services (CMS) Media Relations, the Agency issued yesterday a proposed notice establishing the methodology for determining federal funding for the Basic Health Program in program year 2016. The Basic Health Program provides states with the option to establish a health benefits coverage program for lower-income individuals as an alternative to Health Insurance Marketplace coverage under the Affordable Care Act (ACA). This voluntary program enables states to create a health benefits program for residents with incomes that are too high to qualify for Medicaid through Medicaid expansion in the Affordable Care Act, but are in the lower income bracket to be eligible to purchase coverage through the Marketplace. According to the CMS fact sheet, this proposed notice is substantially the same as the final notice for program year 2015, and includes the following key provisions.  
 
Key Provisions in the Proposed Notice: 
CMS proposes to use the same payment methodology for program year 2016 as established for 2015, along with updated values for several factors. 
  • The proposed methodology calculates monthly payment rates for each state for various rate cells, which are defined by age, geographic area (county), income, household size, and the number of persons in a household enrolled in the program. The proposal also makes adjustments for American Indians and Alaska Natives enrolled in the program.
  • The proposed methodology calculates payment rates based on the premium tax credit amount and the cost-sharing reductions. The premium tax credit is calculated by estimating the average premium tax credit that persons would have received for each rate cell, which is the difference between the second lowest cost silver plan premium available and the amount of income that a household would be required to pay if the members of the household were enrolled in the second lowest cost silver plan in the Marketplace. Cost-sharing reductions are calculated by estimating the average advance cost-sharing reductions payment that would have been provided to persons for each rate cell. 
  •   The proposed methodology gives states the option to use either the 2016 Marketplace premiums or the 2015 premiums projected forward by an estimated trend rate to calculate the Basic Health Program payment rates. States would also have the option to propose a methodology to calculate the difference in health status between the Basic Health Program population and persons enrolled in the individual Marketplace.
     
  • The proposed methodology calculates payments quarterly. Payments will be based on the last quarter of enrollment (or estimated enrollment for states that implement a new Basic Health Program) and reconciled once enrollment data is submitted for each quarter. 
The proposed notice can be found here, and will be posted on https://www.federalregister.gov/

CMS "Medicare Secondary Payer Provisions” Web-Based Training Course — Revised

Dan Ciolek
The Centers for Medicare and Medicaid Services (CMS) “Medicare Secondary Payer Provisions” Web-Based Training Course (WBT) was revised. This WBT is designed to provide education on Medicare Secondary Payer (MSP) provisions. It includes information on identifying the MSP provisions; recognizing when Medicare is a primary or secondary payer; identifying MSP compliance provisions, and identifying CMS MSP resources. Continuing education credits are available to learners who successfully complete this course. See course description for more information. To access other CMS WBT courses, go to MLN Products and click on “Web-Based Training Courses” under “Related Links” at the bottom of the web page.





CMS “Reading the Institutional Remittance Advice (RA)” Booklet — Released

Dan Ciolek
The Centers for Medicare and Medicaid Services (CMS) “Reading the Institutional Remittance Advice (RA)” Booklet (ICN 908326) is now available in downloadable format. This booklet is designed to provide education on the institutional remittance advice (RA). It includes screen shots of an institutional RA with an explanation of what you will find on each screen.

Hospital Observation Status Consumer Notification Act Passes in PA

Dana Halvorson


Due to the advocacy efforts of the Pennsylvania Health Care Association/Center for Assisted Living Management and its members, the PA Senate recently passed unanimously HB 1907 (the Hospital Observation Status Consumer Notification Act). The bill now heads to the Governor’s desk to be signed into law. The legislation requires hospitals to provide oral and written notice to a patient if he or she is receiving care as an “outpatient” under “observation status” rather than being admitted as an “inpatient” after 23 hours in the hospital. It also requires hospitals to explain the ramifications of the observation status to the patient. The Act will take effect within 180 days of becoming law. If you have any questions about HB 1907, please don’t hesitate to contact Russ McDaid at 717-221-7930 or rmcdaid@phca.org.

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.

Key Dates for the Health Insurance Marketplace

Dana Halvorson

As noted in Capitol Connections last week, the next Health Insurance Marketplace Open Enrollment Period is right around the corner. Open Enrollment is the time when an individual can apply for a new Marketplace plan, keep their current plan, or pick a new one. According to the HealthCare.gov blog, there are 4 key dates to keep in mind:
 
  • November 15, 2014. Open Enrollment begins. Apply for, keep, or change your coverage.
  • December 15, 2014. Enroll by the 15th if you want new coverage that begins on January 1, 2015. If your plan is changing or you want to change plans, enroll by the 15th to avoid a lapse in coverage.
  • December 31, 2014. Coverage ends for 2014 plans. Coverage for 2015 plans can start as soon as January 1st.
  • February 15, 2015. This is the last day you can apply for 2015 coverage before the end of Open Enrollment. 
To buy Marketplace insurance outside of Open Enrollment, you must qualify for a Special Enrollment Period due to a qualifying life event like marriage, birth or adoption of a child, or loss of other health coverage. If you have any questions relating to the Affordable Care Act (ACA), please submit them to insurancecoverage@ahca.org, and be sure to check out AHCA/NCAL’s ACA website.

Information for Employers about Their Responsibilities Under the ACA

Dana Halvorson

The following information comes directly from a recent IRS Tax Tips email alert sent on October 16, which you can sign up for on the IRS website here. In Issue Number: HCTT-2014-21 titled "Information for Employers about Their Responsibilities Under the Affordable Care Act" the following update about the ACA was sent:

If you are an employer, the number of employees in your business will affect what you need to know about the Affordable Care Act (ACA). Employers with 50 or more full-time and full-time-equivalent employees are generally considered to be “applicable large employers” (ALEs) under the employer shared responsibility provisions of the ACA. Applicable large employers are subject to the employer shared responsibility provisions. However, more than 95 percent of employers are not ALEs and are not subject to these provisions because they have fewer than 50 full-time and full-time-equivalent employees.

Whether an employer is an ALE is determined each calendar year based on employment and hours of service data from the prior calendar year. An employer can find information about determining the size of its workforce in the employer shared responsibility provision questions and answers section of the IRS.gov/aca website and in the related final regulations. In general, beginning January 1, 2015, ALEs with at least 100 full-time and full-time equivalent employees must offer affordable health coverage that provides minimum value to their full-time employees and their dependents or they may be subject to an employer shared responsibility payment. This payment would apply only if at least one of its full-time employees receives a premium tax credit through enrollment in a state based Marketplace or a federally facilitated or Marketplace. Also, starting in 2016 ALEs must report to the IRS information about the health care coverage, if any, they offered to their full-time employees for calendar year 2015, and must also furnish related statements to their full-time employees.

For 2014, the IRS will not assess employer shared responsibility payments and the information reporting related to the employer shared responsibility provisions is voluntary. In addition, the employer shared responsibility provisions will be phased in for smaller ALEs from 2015 to 2016. Specifically, ALEs that meet certain conditions regarding maintenance of workforce size and coverage in 2014 are not subject to the employer shared responsibility provision for 2015. For these employers, no employer shared responsibility payment will apply for any calendar month during 2015 (including, for an employer with a non-calendar year plan, the months in 2016 that are part of the 2015 plan year). However these employers are required to meet the information reporting requirements for 2015. The employer shared responsibility provision questions and answers section of the IRS.gov/aca website and the preamble to the employer shared responsibility final regulations describe the requirements for this relief in more detail. Both resources also describe additional forms of transition relief that apply for 2015. 

Small employers, specifically those with fewer than 25 full-time equivalent employees, may be eligible for the small business health care tax credit. Regardless of the number of employees, if an employer sponsors a self-insured health plan, it must report to the IRS certain information about its health insurance coverage plan for each covered employee.

You can find out more about the small business health care tax credit, applicable large employers, the employer shared responsibility provision, information reporting requirements and the premium tax credit at IRS.gov/aca, and more about the health care law in general can be found at HealthCare.gov. If you have any questions relating to the ACA, please submit them to insurancecoverage@ahca.org, and be sure to check out AHCA/NCAL’s ACA website.

Public Forum on the Status of Medicare Appeals Backlog to be held on October 29

Daniel Ciolek and Diane De La Mare
AHCA members that have Medicare Part A and Part B claims tied up in the appeals system, particularly at the third level of appeals, the Administrative Law Judge (ALJ), may be interested in the upcoming public forum on October 29 to learn about the current status of the appeals backlog, and ongoing government efforts to address the problem. The session runs from 10:00 AM- 3:00 PM Eastern time and there are only a limited number of seats available onsite in Washington, DC. However, this event is also is being offered via webex. Please see below for the event details which can also be found here.       

 Important links:
· Invitation from the Chief Administrative Law Judge (for all registrants)

· Registration link to Email form (for on-site registration)

· Attendee Information link to Downloadable PDF (for on-site attendees)

· Webinar Information (for webex registration)

Event Information:

The Office of Medicare Hearings and Appeals (OMHA) will host the second OMHA Medicare Appellant Forum on October 29, 2014, to provide updates to OMHA appellants on the status of OMHA operations and relay information on OMHA and CMS initiatives designed to mitigate the Medicare appeals backlog at the OMHA-level of the administrative appeals process.

Meeting Date: The OMHA Medicare Appellant Forum will be held on Wednesday, October 29, 2014 from 10:00 a.m. to 3:00 p.m. Eastern Standard Time (E.S.T.), with a 1-hour recess for lunch. Check-in will begin at 9:00 a.m. E.S.T. Please allow sufficient time to clear building security.

Meeting Location: The OMHA Medicare Appellants Forum will be held in the Cohen Auditorium of the Wilbur J. Cohen building located at 330 Independence Ave. SW, Washington D.C. 20024.

Deadline for Registration of Attendees and Requests for Special Accommodation: The deadline to register to attend the OMHA Medicare Appellants Forum and request a special accommodation, in accordance with the Americans with Disabilities Act, is 5:00 p.m., E.S.T. on Tuesday, October 28, 2014. Individuals who need special accommodations should contact staff listed in the FOR FURTHER INFORMATION CONTACT section of this notice below.

Due to limited space available to accommodate in-person attendance, each organization is limited to sending two representatives. In addition, a toll-free phone line and/or live stream technology and/or webinar will be available. Information on these options will be posted on this website once a determination has been made.

FOR FURTHER INFORMATION CONTACT: RenĂ©e Johnson, (703) 235-8269, renee.johnson@hhs.gov . Alternatively, you may forward your requests via email to OSOMHAAppellantForum@hhs.gov; please indicate “Request for information” or “Request for special accommodation” in the subject line.

Thursday, October 16, 2014

Webinar: Communicating with Familes, Addressing & Documenting Outcomes

Holly Harmon

The University of Iowa's School of Social Work is offering a free webinar “Communicating with Families: Addressing and Documenting Outcomes” on Tuesday, October 21st 2PM-3PM ET.

Presenters are Paige Hector, LMSW (Paige Ahead Healthcare Education & Consulting, L.L.C) and Tra Beicher, RNC, ARM, HRM, CWS, Author of the book, “Defensive Documentation for Long-term Care: Strategies for Creating a More Lawsuit-proof Resident Record”.

To register, click here http://clas.uiowa.edu/socialwork/nursing-home/current-and-upcoming-webinars

 To access recordings of past webinars, click here http://clas.uiowa.edu/socialwork/nursing-home/webinars/recordings-past-webinars

Wednesday, October 15, 2014

DOL Final Rule on $10.10 Hourly Federal Contractor Minimum Wage and Webinar on New Obligations of Government Contractors

Dana Halvorson

As noted in previous editions of Capitol Connection, on February 12, 2014, President Obama signed Executive Order 13658, Establishing a Minimum Wage for Contractors. The Executive Order raises the hourly minimum wage paid by contractors to workers performing on covered Federal contracts to: (i) $10.10 per hour, beginning January 1, 2015; and (ii) beginning January 1, 2016, and annually thereafter, an amount determined by the Secretary of the Department of Labor (DoL) in accordance with the Order. On October 1, 2014, DOL published the final rule implementing the provisions of Executive Order 13658.

Executive Order 13658 applies to new contracts and replacements for expiring contracts with the Federal Government that result from solicitations issued on or after January 1, 2015, or to contracts that are awarded outside the solicitation process on or after January 1, 2015. It is long-standing policy that Medicare (Parts A and B) or Medicaid providers are not considered to be federal contractors. However, if a provider currently has VA patients, they are considered to be a federal contractor. As noted in Capitol Connection last week, if you are considering entering into a VA contract once 2015 begins, Executive Order 13658 will be applicable to you as you will be a federal contractor. The $10.10 wage rate will apply to all new contracts executed on or after that date. AHCA received further clarification recently on the final rule regarding those with existing VA contracts. The $10.10 rate will not apply to existing contracts unless there is a bilateral negotiation that modifies the contract, thus deeming it as “new”. Automatic rate increases issued at the annual renewal of the option years does not deem a contract as “new”. Service Contract Act wage determinations for existing contracts will not reflect the $10.10 rate, but will reflect wage rates prior to the rule. That being said, if you have a VA contract, you will want to visit with your legal counsel or local or regional VA contact on how this minimum wage increase will impact you at the time of the renewal of your contract option year. It is also important to note that under the VA Provider agreement proposed rule AHCA has been working to finalize, providers would not be considered federal contractors, and would therefore not have to follow complex federal contracting and reporting rules. AHCA is currently awaiting the release of the final rule, and will keep its members posted on any updates relating to this matter.  

For more information, including a fact sheet and FAQ on the DOL final rule, please visit the Wage and Hour Division’s Executive Order 13658 web page at http://www.dol.gov/whd/flsa/eo13658/.

You might also be interested to know about a webinar that the law firm of Jackson Lewis will be offering complimentary on October 29, 2014, on the number of new legal obligations government contractors must follow according to President Obama’s executive orders. In addition to the minimum wage, these obligations include “Pay Transparency” Requirements, Annual “Equal Pay Report” Filing with the OFCCP, LGBT Anti-Discrimination, and Required Reporting of Labor and Employment Law Violations. You can register for the webinar being held from 2-3:30pm EDT here.

If you have any questions, please contact AHCA’s Dana Halvorson or Dianne De La Mare.

Tuesday, October 14, 2014

2014 AHCA/NCAL Convention & Expo a Great Success

Jon-Patrick Ewing 

Please take a moment to give us your feedback by taking the Post-Convention Survey. When you send back a completed survey, you will automatically be eligible to win a $200 cash card. The deadline to complete the survey is Friday, November 7. 

In addition, we ask that you complete convention education session evaluations by going to the following link: http://data.express-evaluations.com/eval/36690/2014/main.php


AHCA/NCAL would like to thank all of this year's attendees for participating in the 65th AHCA/NCAL Annual Convention & Expo! We hope you had an incredible time, made new connections, and took away lots of valuable information.

Electronic Funds Transfer Upgrades to the Internet-based PECOS System

Dan Ciolek


Over the last year, CMS listened to provider feedback about Internet-based Provider Enrollment, Chain, and Ownership System (PECOS) and made improvements to increase access to more information. PECOS is easier to use than ever with Electronic Funds Transfer (EFT) upgrades that are now available. If a provider/supplier wishes to submit a change to the EFT information, they should select "Perform a change of Information to Current Enrollment Information.” Note: All EFT changes must be made through the Change of Information scenario.

Providers/suppliers are able to edit all EFT Information, except the Routing Transit Number and/or Depositor Account Number, once entered and saved. Once saved, if a provider/supplier needs to update the Routing Transit Number and/or Depositor Account Number, the providers/supplier must delete all information and reenter new information. PECOS will now collect an EFT Effective Date and Termination Date to capture the time frame when the Financial Information is valid. The Effective Date is the date on which funds will be directed to the account information entered. The Termination Date is the date on which funds will no longer be directed to the account information entered. PECOS has also been updated to display the most current CMS-588 form which now collects the Financial Institution’s Street Address and Financial Institution’s Zip Code under “Financial Institution Information.”

New Outreach & Education Page at CMS.gov


CMS recently redesigned the Outreach & Education page to make it faster and easier for providers to find information. These changes allow providers to find:   
  • Program updates, educational materials, and outreach events without needing to understand how CMS is structured
  • All of the CMS training and events in one place 
  • Outreach and education materials organized by topic or provider type 
Providers are encouraged to check out the changes and let CMS know what you think by contacting them at Outreachandeducation@cms.hhs.gov.

CMS Dual Eligibles Fact Sheet Revised

Dan Ciolek
The CMS “Dual Eligible Beneficiaries Under the Medicare and Medicaid Programs” Fact Sheet (previously titled “Medicaid Coverage of Medicare Beneficiaries (Dual Eligibles) At a Glance”) (ICN 006977) was revised in September 2014. This fact sheet is designed to provide education on dual eligible beneficiaries under the Medicare and Medicaid Programs.

It includes the following information: 
  • the Medicare and Medicaid Programs;
  • dual eligible beneficiaries;
  • assignment;
  • and prohibited billing.
 

2015 Health Insurance Marketplace Coverage

Dana Halvorson

Starting on November 15, individuals will be able to apply and enroll in 2015 Health Insurance Marketplace coverage. According to an email alert from the HealthCare.gov team, if you already have 2014 Marketplace coverage, you’ll be receiving important information about how to keep your coverage for 2015. In addition, the email noted that there are some things you can do now to get ready for November 15th:

 Learn about important dates and deadlines for Marketplace coverage
Download this Marketplace checklist to gather the documents you’ll need to apply
Find someone in your community to help you apply and answer your questions
Sign up for timely text message updates and connect on social media

If you have any questions relating to the Affordable Care Act (ACA), please submit them to insurancecoverage@ahca.org, and be sure to check out AHCA/NCAL’s ACA website.

SHOP Marketplace Enrollment Online

Dana Halvorson

 According to an email alert from the HealthCare.gov team, for the first time starting on November 15, you will be able to enroll your Small Business through the Small Business Health Options Program (SHOP) Marketplace entirely online. SHOP was created in the Affordable Care Act (ACA), and is a new way for small businesses to buy health insurance for their employees. You can complete an application, choose coverage, and enroll yourself or you can work with an agent or broker. There are a few things you can do now to get ready to enroll for health coverage in the SHOP Marketplace:

Learn more about SHOP coverage and talk to your employees to find out their health coverage needs.
Use the SHOP Full-time Equivalent Employee Calculator to see if you qualify based on your employee count.
Use the SHOP Tax Credit Estimator Tool to find out if you may be eligible for a tax credit and how much the credit could be worth to your Small Business.
See 2014 plans and get premium estimates now.

If you have any questions relating to the ACA, please submit them to insurancecoverage@ahca.org, and be sure to check out AHCA/NCAL’s ACA website.

Webinar: How Can I get Beyond the Basics of Hospital Readmission and Become a Preferred Provider?"

Adrienne Riaz-Khan

How Can I get Beyond the Basics of Hospital Readmission and Become a Preferred Provider?*
Presenter: Kim Barrows, Director of Clinical Services at Health Care Management Group

*This pre-recorded webinar is available with slides for viewing at your convenience. Obtain the free webinar here.

Summary:

The program briefly explains the impact that Healthcare Reform is having on the healthcare industry on both the acute and post-acute care side. There is a strong emphasis on the importance of accurate data analysis and on implementing potential solutions for facilities. The clinical programs along with the use of cutting edge technology have shown to improve clinical outcomes, allowed centers to become preferred providers for local hospitals and have significantly reduced unnecessary hospital readmissions.


Learning Objectives:

1. Discuss the history of hospital readmission and its impact on the industry.

2. Discuss and analyze the types of data necessary to appropriately measure hospital readmission rates.

3. Describe potential solutions within your center that will positively affect clinical outcomes.

4. Describe how progress is measured after implementation.

5. Discuss measures to ensure continuous quality improvement.


This webinar will be offered on-demand, the pre-record date is October 27th, and will be available for viewing on October 29th. If you have any questions Adrienne Riaz-Khan can be reached via email or at 202-898-6332.

Mark Parkinson Joins President Obama at White House Signing Ceremony for IMPACT Act




Abigail Horn

Last week, AHCA/NCAL President & CEO Mark Parkinson joined President Obama at the White House for the signing of the Improving Medicare Post-Acute Care Transformation (IMPACT) Act of 2014 into law. 

This important legislation builds an important framework for future debates and discussions regarding the payment models for post-acute care providers and supports AHCA’s Quality Initiative.

IMPACT will: 

· Incorporate standardized assessment into existing assessment tools (like the CARE tool) across PAC providers and acute care hospitals for pressure ulcers, functional status, cognitive status and special services; 

· Develop public reporting of common quality measures, such as rehospitalizations and pressure ulcers, across settings;

· Provide quality measures to consumers when transitioning to a PAC provider; and 

· Require HHS and MedPAC to conduct several studies on alternative PAC payment models.

“The signing of the IMPACT bill by President Obama closes one process and opens new opportunities to enhance the quality care we deliver every day,” said Parkinson. “I applaud him and the Administration in this critical step forward in improving lives for millions of Americans.”

Tuesday, October 7, 2014

Establishing a Minimum Wage for Contractors and the VA

Dana Halvorson and Dianne De La Mare 

As noted in previous editions of Capitol Connection, on February 12, 2014, President Obama signed Executive Order 13658, Establishing a Minimum Wage for Contractors. The Executive Order raises the hourly minimum wage paid by contractors to workers performing on covered Federal contracts to: (i) $10.10 per hour, beginning January 1, 2015; and (ii) beginning January 1, 2016, and annually thereafter, an amount determined by the Secretary of the Department of Labor (DoL) in accordance with the Order. On October 1, 2014, DOL published the final rule implementing the provisions of Executive Order 13658.

According to the DOL press release, “key provisions of the final rule include:

It defines key terms used in the Executive Order, including contracts, contract-like instruments, and concessions contracts.
It provides guidance for contractors on their obligations under the Executive Order.
It establishes an enforcement process that should be familiar to most government contractors and will protect the right of workers to receive the new $10.10 minimum wage.
It confirms that approximately 200,000 workers will benefit from the Executive Order.”


Executive Order 13658 applies to new contracts and replacements for expiring contracts with the Federal Government that result from solicitations issued on or after January 1, 2015, or to contracts that are awarded outside the solicitation process on or after January 1, 2015. It is long-standing policy that Medicare (Parts A and B) or Medicaid providers are not considered to be federal contractors. However, if a provider currently has VA patients, they are considered to be a federal contractor. If you have a VA contract, you will want to visit with your legal counsel or local or regional VA contact on how this minimum wage increase will impact you at the time of the renewal of your contract option year. If you are considering entering into a VA contract once 2015 begins, Executive Order 13658 will be applicable to you as you will be a federal contractor. You will need to pay the $10.10 rate. That being said, under the VA Provider agreement proposed rule AHCA has been working to finalize, providers would not be considered federal contractors, and would therefore not have to follow complex federal contracting and reporting rules. AHCA is currently awaiting the release of the final rule, and will keep its members posted on any updates relating to this matter.  


For more information, including a fact sheet and FAQ on the DOL final rule, please visit the Wage and Hour Division’s Executive Order 13658 web page at http://www.dol.gov/whd/flsa/eo13658/. If you have any questions, please contact AHCA’s Dana Halvorson or Dianne De La Mare.

AHCA Refreshes LTC Trend Tracker

 help@LTCTrendTracker.com


On Monday, October 6, AHCA revealed a new and improved online platform for LTC Trend TrackerSM. An exclusive benefit for AHCA members, LTC Trend Tracker has transformed how skilled nursing providers maximize their quality improvement efforts and their operational performance. This more modern, user-friendly version gives more information up-front, allows the creation of custom reports, and offers additional options in choosing peer comparisons.

Current users of LTC Trend Tracker received new, personalized login credentials for the new platform on October 6 from AHCA. Members not yet signed up for LTC Trend Tracker should utilize this exclusive member benefit and register today!

 LTC Trend Tracker offers AHCA members a central place to access all the data CMS collects on skilled nursing centers. Additionally, it includes exclusive, in-house measures to help members gain insight on hospital readmissions and discharges to the community. Members can also upload their RUG data, and use a simulator to help identify how to possibly increase their Five-Star rating.

Visit www.LTCTrendTracker.com for more information or watch the video.

For any questions, please contact the LTC Trend Tracker team.

Key Educational Day-Long Programing Events Held at Convention for AHCA/NCAL’s LTC Providers

Dana Halvorson, Rachel Reeves and Daniel Ciolek


AHCA/NCAL’s 65th Annual National Convention & Expo in DC this week, AHCA/NCAL held a variety of day-long educational programming events for its long term and post-acute care providers. On Sunday, Oct. 5, a day was held specifically for NCAL members, Intellectual and Developmental Disabilities (ID/DD) providers, and Therapy providers.

NCAL Day welcomed more than 250 assisted living owners, operators and vendor partners to discover ways to enhance leadership skills as well as person-centered care. Beyond keynote speakers and education sessions geared specifically for assisted living providers, participants celebrated the 2014 NCAL Award Program winners at a special ceremony.

Those participating in a day for ID/DD providers had the opportunity to hear from a Centers for Medicare and Medicaid Services (CMS) expert on the Agency’s work on the Intermediate Care Facilities for Individuals with Intellectual and Developmental Disabilities (ICF/IID) program, and from a Department of Justice expert on the Department’s work on policies and issues impacting ID/DD Residential Services Providers.

During a day for therapy providers, jointly presented by AHCA and the National Association for Long Term CARE (NASL) on Sunday, October 5, clinicians, managers, operators were provided an intensive and interactive program covering current therapy-related Medicare issues. In addition, CMS and other experts discussed various alternative payment models being proposed and tested, and the various important quality and policy research activities that AHCA and its members are undertaking to support such efforts. 

A day for Not for Profit Providers was held on Tuesday, Oct. 7, and participants heard from both CMS and VA experts on policies and issues impacting the LTC world.

Be sure to mark your calendars for AHCA/NCAL’s 66th Annual National Convention & Expo being held next year from October 4-7, 2015, in San Antonio, TX.  

Friday, October 3, 2014

CMS Issues Documents Regarding COT OMRA Changes for FY 2015

Holly Harmon

CMS has posted two document related to MDS 3.0 changes effective for Fiscal Year 2015. The first is a memo which describes the transition guidelines for the changes to the COT OMRA, outlined in the FY 2015 SNF PPS final rule (79 FR 45647 through 45649). The second is a memo which clarifies certain issues and scenarios related to these COT OMRA changes. Click here to view these documents on the CMS website.

ICD-10 Updates

Dianne De La Mare

The US Department of Health and Human Services (HHS), Centers for Medicare & Medicaid Services (CMS) is sponsoring a conference call with CMS subject matter experts to discuss ICD-10 implementation, opportunities for testing and other resources on Wednesday, November 5, 2014 from 1:30-3:00PM, ET. The agenda includes discussion of: 1) HHS’ rule finalizing Oct. 1, 2015, as the new compliance date for ICD-10 for all health providers; 2) Medicare Fee-for-Service (FFS) testing; 3) Medicare Severity Diagnosis Related Grouper (MS-DRG) Conversion Project; 4) Partial code freeze and annual code updates; 5) Plans for National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs); 6) Home health conversions; and 7) Claims that span the implementation date. To register go to http://www.eventsvc.com/blhtechnologies

CMS also has just made available the 2015 ICD-10-CM Official Guidelines for Coding and Reporting on the 2015 ICD-10-CM and GEMs web page and also on the Centers for Disease Control and Prevention website. Note that within the report text the: 1) narrative changes appear in bold text; 2) items underlined have been moved within the guidelines since the FY 2014 version; and 3) italics are used to indicate revisions to heading changes. To review the complete document go to http://www.cms.gov/Medicare/Coding/ICD10/Downloads/icd10cm-guidelines-2015.pdf.

Lastly, during the week of January 26-30, 2015, a sample group of providers will have the opportunity to participate in ICD-10 end-to-end testing with Medicare Administrative Contractors (MACs) and the Common Electronic Data Interchange (CEDI) contractor. The goal of end-to-end testing is to demonstrate that: 1) providers and submitters are able to successfully submit claims containing ICD-10 codes to the Medicare FFS claims systems; 2) CMS software changes made to support ICD-10 result in appropriately adjudicated claims; and 3) Accurate remittance advices are produced. Approximately 850 volunteer submitters will be selected to participate in the January end-to-end testing. To volunteer as a testing submitter you had to complete forms available on your MAC website by October 3, 2014. Testers will be notified by both the MAC and CEDI that they were selected by October 24, 2014.

District Court Approves FCA Extrapolation in NFs

Dianne De La Mare

In a recent decision, the US District Court, Eastern District of Tennessee, has held that the federal government can extrapolate from a small sample of billing statements to hold a nursing facility (NF) operator liable for Medicare fraud under the False Claims Act (FCA). This litigation is important because to date, there are relatively few cases that discuss the question of whether or not extrapolation is appropriate under the FCA.

Further, extrapolation can significantly increase the number of claims considered fraudulent without individualized proof. In this case, the NF operator is alleged to have billed for unnecessary care from 2006 to 2012. The federal government has now received permission to examine a random sample of patient admissions and extend its findings of false billing to more than 50,000 additional admissions. The Judge made this determination based on the fact that “If Congress intended to preclude statistical sampling from being used in this context, it has had ample opportunity to have that intention reflected in the language of the FCA.”

Noting that FCA cases often involve substantial amounts of billing, the Judge also said that it would be too burdensome to force the government to develop a distinct case for every allegedly false claim. AHCA will continue to monitor this important litigation. (US Ex Rel Martin v Life Care)

Fraud Accusations for Delays in Refunding Medicaid Overpayments

Dianne De La Mare

In a recent federal action, the US Department of Justice (DOJ) has intervened in a False Claims Act (FCA) whistleblower (qui tam) suit in the US District Court for the Southern District of New York. The suit, originally filed by a former hospital employee, alleges that the hospital group submitted hundreds of improper claims to Medicaid in 2009 and 2010 through a computer problem that improperly coded private Medicaid Managed Care Organization (MCO) claims for submission to Medicaid for additional reimbursement. Under the Medicaid reimbursement laws, traditional Medicaid excludes providers paid by private MCO plans from any additional payments through Medicaid.

Despite being made aware of the problem in late 2010 by the former employee, the hospital group failed to take appropriate steps to repay the claims, and in fact dragged out full repayment to the government for over two years. Under the ACA, “overpayment” is defined as any funds that a person receives or retains under the Medicare or Medicaid programs that he/she is not entitled. Retaining an identified overpayment is an “obligation” under the FCA, which means that the government can pursue civil penalties against anyone who retains those overpayments as “reverse false claims.” The complaint requests the maximum penalty under the FCA of $11,000 for every improperly retained overpayment, in addition to treble damages. All totaled, a complete victory by the DOJ could result in $30million in fines for the hospital group.

AHCA will continue to monitor this important litigation. (US Ex Rel Kane v Continuum Health Partners).

CMS Annual RAC Report Released

Dianne De La Mare

The US Department of Health and Human Services, Centers for Medicare & Medicaid Services (CMS) has just released its annual Recovery Auditor (RAC) report, Recovery Auditing in Medicare for Fiscal Year 2013, to Congress as required under the Social Security Act. In FY 2013, Recovery Auditors (RACs) identified and corrected over 1.5 million claims for improper Medicare and Medicaid payments, resulting in $3.75 billion in payment errors. CMS collected $3.65 billion in overpayments and reimbursed providers and suppliers $102.4 million in underpayments. The Medicare Fee-for-Service (FFS) Audit program returned over $3 billion to the Medicare Trust Fund after considering all fees, costs and first level appeals (note: there are five levels in the Medicare Appeals Process). The report notes that the $3 billion in savings do not take into account program costs and administrative expenses incurred at the third (Office of Medicare hearings and Appeals [OMHA]) and fourth (Medicare Appeals Council within the Departmental Appeals Board [DAB])levels of the Medicare appeal process because these programs do not receive RAC Program funding for those appeals.  

Recovery Auditor reviews were initially implemented on a post-payment basis.  However, in late FY 2012, CMS implemented a demonstration to use RACs for reviewing claims before they were paid. FY 2013, was the first full year of the RAC Prepayment Review Demonstration. The demonstration started on September 1, 2012 and is scheduled to continue for 3 years (2015) in 11 states (FL, CA, MI, TX, NY, LA, IL, PA, OH, NC and MO). The goal of the demonstration is to lower the number of improper payments for those claims, which are shown through the Comprehensive Error Rate Testing (CERT) reports and other data analysis to have high rates of improper payments.

Since the beginning of the demonstration, RACs have prevented $22.3 million in improper payments, and CMS is currently evaluating the demonstration’s effectiveness and including additional error-prone services for review. CMS uses the results of RAC audits to identify program vulnerabilities and to take appropriate corrective actions to prevent future improper payments. CMS hosts regular meetings with RACs, Medicare Administrative Contractors (MACs) and CMS staff to discuss best practices, as well as particular vulnerabilities and future corrective actions.  

Interesting to note is the skilled nursing facility (SNF) overpayments collected $1.84 million; underpayments restored $19,567 and total amount of corrected $1.86 million (Appendix F1, page 35); resulted in only a small percentage of the total $3.75 billion recovery. However, this could be more of a reflection that RACs were focusing on short-stay hospital admission claims in FY 2013, and that there is no assurance that SNF claims will not be under increased scrutiny in the future.   


Additionally, there is no data provided in the report specific to the congressionally mandated therapy Medical Manual Review (MMR) process, in which RACs assumed the complex medical review function on April 1, 2013. We presume that since outpatient therapy data is stored in the CMS “Outpatient” claim type file for facility based Part B therapy claims, and “Physician” claim type file for office based physician and therapist in private practice, that the therapy MMR data represents a portion of the $46.6 “Outpatient” and a portion of the $56.8 million “Physician” overpayments collected identified in Appendix F1. AHCA has requested more detailed information from CMS pertaining to the therapy MMR RAC audits.


To obtain a copy of the complete report go to : http://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Recovery-Audit-Program/Downloads/FY-2013-Report-To-Congress.pdf. The CMS Recovery Audit Program webpage is available here.