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Public Policy Committee: CMS Update

Posted on: 7/11/2016

By Patricia Velky, RN, BSN, MS, MBA, CPHQ, FAACM, FABC, ACM

The Centers for Medicare and Medicaid Services (CMS) continues to pursue a proactive stance to protect both the Medicare trust fund and improve outcomes for beneficiaries. CMS recently held a second Open Door Forum (ODF) call to provide additional details regarding a three-year Medicare pre-claim review demonstration for home health services set to begin in the states of Illinois, Florida, and Texas in 2016, and in the states of Michigan and Massachusetts beginning in 2017.

As noted on the website “CMS is testing whether pre-claim review improves methods for the identification, investigation, and prosecution of Medicare fraud occurring among Home Health Agencies (HHAs) providing services to people with Medicare benefits. Additionally, CMS is also testing whether the demonstration helps reduce expenditures while maintaining or improving quality of care.”

CMS representatives assured callers that the pre-claim review process does not create new documentation requirements, would not delay access to care or alter the Home Health benefit. A key component of the demonstration project is that the documentation to support payment will be submitted earlier in the process. Direct feedback will be provided to the agency on deficiencies in the submitted documentation thus avoiding improper payments to and potential appeals from the Home Health agencies. Specific turnaround times are spelled out in the Operational guide and CMS stressed that this pre-claim review process should not be a barrier to the start of care for any Medicare beneficiary.

For more information, visit CMS.gov or click the link to the fact sheet below: https://www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Pre-Claim-Review-Initiatives/Downloads/Pre_Claim_Review_Fact_Sheet.pdf

Additionally, on July 6, 2016, CMS released the Calendar Year (CY) 2017 Hospital Outpatient Prospective Payment System (OPPS) and Ambulatory Surgical Center (ASC) Payment System proposed rule (CMS-1656-P). Among other things it has key language to implement Section 603 of the Bipartisan Budget Act of 2015, which impacts the way Medicare pays for certain items and services furnished by certain off-campus outpatient departments of a provider. This is often referred to as “site neutral payment.”

Another key component receiving media attention is the proposed removal of the Pain Management dimension of the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey for purposes of the Hospital Value Based Purchasing Program. Changes to the incentive program for EHRs and changes to definitions/documentation requirements for organ procurement agencies are outlined. As always the annual update to the Medicare Inpatient Only (IPO) List (addendum E) is included. For CY 2017, CMS is proposing to remove six procedures from the IPO list. The procedures include four spine procedures as well as two laryngoplasty procedures. The proposed rule also includes for the second year in a row a comment solicitation regarding whether total knee arthroplasty (TKA) should be removed from the IPO list in a subsequent year.

For more information, visit CMS.gov or click the link to the fact sheet below: https://www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2016-Fact-sheets-items/2016-07-06.html

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