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CMS Open Door Forum Discusses PDGM, Authority to Sanction Providers, and More

The Home Health, Hospice & Durable Medical Equipment Open Door Forum held by the Centers for Medicare and Medicaid Services (CMS) on September 18 covered a variety of issues pertaining to the home health and hospice industry. What follows are the key issues that were presented related to home health:

Provider Enrollment

CMS officials described the new authorities to control fraud and abuse in the Medicare and Medicaid programs provided in the final rule for “Program Integrity Enhancement to the Provider Enrollment Process.”

Under the new rule CMS has the authority to:

  • Deny or revoke a provider or supplier that has a current or previous direct or indirect affiliation with a provider or supplier that has uncollected debt; has been or is subject to a payment suspension under a federal health care program; has been excluded from Medicare, Medicaid, or CHIP; or has had its Medicare, Medicaid, or CHIP billing privileges denied or revoked, (referred to as “disclosable events”).

Affiliations are defined as: A five percent or greater direct or indirect ownership interest that  an individual or entity has in another organization; A general or limited partnership interest (regardless of the percentage) that an individual or entity has in another organization; An interest in which an individual or entity exercises operational or managerial control over, or directly or indirectly conducts, the day-to-day operations of another organization either under contract or through some other arrangement, regardless of whether or not the managing individual or entity is a W–2 employee of the organization; An interest in which an individual is acting as an officer or director of a corporation; Any reassignment relationship.

  • Deny or revoke a provider’s or supplier’s Medicare enrollment if CMS determines that the provider or supplier is currently revoked under a different name, numerical identifier, or business identity, and the applicable reenrollment bar period has not expired.
  • Revoke a provider’s or supplier’s Medicare enrollment –including all of the provider’s or supplier’s practice locations, regardless of whether they are part of the same enrollment –if the provider or supplier billed for services performed at, or items furnished from, a location that it knew or should reasonably have known did not comply with Medicare enrollment requirements.
  • Revoke a physician’s or eligible professional’s Medicare enrollment if he or she has a pattern or practice of ordering, certifying, referring, or prescribing Medicare Part A or B services, items, or drugs that is abusive, represents a threat to the health and safety of Medicare beneficiaries, or otherwise fails to meet Medicare requirements.
  • Increase the maximum re-enrollment bar from 3 to 10 years.
  • Prohibit a provider or supplier from enrolling in the Medicare program for up to 3 years if its enrollment application is denied because the provider or supplier submitted false or misleading information on or with (or omitted information from) its application in order to gain enrollment in the Medicare program.
  • Revoke a provider’s or supplier’s Medicare enrollment if the provider or supplier has an existing debt that CMS refers to the United States Department of Treasury.

CMS stated that they will review each case individually and only take action if it is determined that there is an undue risk for fraud and abuse. Additional information from CMS will be forthcoming.

Follow-up From the Patient Driven Grouper Model (PDGM) Webcast

CMS provide answers to several questions posed during the August 8, CMS webcast on claims processing under PDGM.

  1. CMS made the following correction on slide # 47” 

  The original slide read

  • The OASIS assessment completion date (M0090) is before the PDGM implementation date
  • HH submits 12/30/2019 as the occurrence code 50 date on the PDGM claim
  • Medicare systems will use this date to match to the 2019 assessment and use its functional information to group the claim.

The corrected slide reads:

  • The OASIS assessment completion date (M0090) is reported as 01/01/2020, per one-time OASIS recertification instructions
  • HH submits 01/01/2020 as the occurrence code 50 date on the PDGM claim
  • Medicare systems will use this date to match to the assessment and use its functional information to group the claim.
  1. Agencies under the Review Choice Demonstration will be required to include a separate UTN on each 30 day period claim.

  2. If there are no visits ordered for a 30 days period a request for anticipated payment (RAP) must still be submitted even if there is no subsequent claim. The RAP will auto cancel. The “from” date on the RAP in these situations should be the first date in the period.

Home Health Quality Reporting Program (HHQRP)

Letters notifying those home health agencies (HHAs) that are non-compliant with the HHQRP and are subject to the 2% reduction in their annual payment update (APU) for 2020 will be sent in October, 2019.

An HHA disagreeing with the payment reduction decision may submit a request for reconsideration to CMS within thirty (30) days from the date at the top of the non-compliance notification letter. CMS will not accept any requests submitted after the thirty (30) days deadline. The only method for submitting reconsideration requests is via email. Requests submitted by any other means will not be reviewed for reconsideration. Do not include protected health information (PHI) or other Health Insurance Portability and Accountability Act (HIPAA) violations in the documentation being submitted to CMS for review. CMS cannot review requests including PHI.

Materials and the question and answer document containing responses to questions submitted by providers during the Home Health Quality Reporting Program: Achieving a Full Annual Payment Update (APU)/Market Basket Increase Webinar held on June 19, 2019 are now available in the Downloads section at the bottom of the CMS web page. 

The Home Health Compare refresh is scheduled for October 19, and will include all of the claims-based measures. The update will be the last public reporting of the claims-based measures for Re-hospitalization During the First 30 Days of Home Health and Emergency Department Use without Hospital Readmission During the First 30 Days of Home Health.

Home health agencies are encouraged to periodically check the CMS HHQRP Spotlight page for the most recent HHQRP information.

Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS)

The HHCAPHs quarterly newsletter will be available October 1, and will focus on the HHCAHPS Survey Chart book that is posted on the HHCAHPS website.

(From NAHC)

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