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Advisor Newsletter - September 2017

RCS-1 Reimbursement Crosswalk ModelLooking for Guidance on Jimmo v. Sebeilus?Countdown to Major Home Health Changes



RCS-1 Reimbursement Crosswalk Model
HealthPRO®/Heritage has developed a proprietary, sophisticated RCS-1 Reimbursement Crosswalk Model that will help us work strategically with partners to assess aggregate reimbursement risk and understand the interplay between nursing and therapy reimbursement components. The model is dynamic, allowing behavior changes to be modeled so providers can see the impact of specific elements that significantly drive reimbursement under RCS-1 (e.g.: such as diagnostic coding, cognitive assessment, and ADL scoring).

Importantly, our Crosswalk Model uses MDS data as the source, creating patient-level and aggregate views of impact over time. Data can be imported into the model from the provider’s submission files and affords a more comprehensive view of RCS-1 impact than other available patient-level calculators.
The CMS calculator released in early August merely offers the projected aggregate impact by facility, without any specificity related to reimbursement components or ability to modify behavior. Additionally, CMS has not published the grouper or the MDS assessment criteria. As a result, several unknowns remain. (Our model is subject to change pending CMS' response to the ANPR comments and the final rule.)

Early in Q4 2017, the RCS-1 Reimbursement Crosswalk Model will be offered to all HealthPRO®/Heritage contracted therapy clients free of charge as part of our overall strategic partnership. Providers who are interested in completing the impact analysis can inquire with their Regional Vice President or other HealthPRO®/Heritage contacts.



Looking for Guidance on Jimmo v. Sebeilus?
The landmark Jimmo v. Sebelius lawsuit settled in 2013 continues to cause confusion. This class action settlement served to spotlight whether CMS policy covers therapy services for patients who do not demonstrate improvement or progress towards recovery of prior function. But the policy continues to be either misunderstood or misinterpreted by patient advocacy groups, concerned family members, and even by the community of therapy providers.

With a full understanding how to interpret Jimmo v Sebelius, HealthPRO®/Heritage remains committed to ensuring patients receive the appropriate level of care – when and where they need it – to enhance and maintain their functional capacity and quality of life. Moreover, PAC providers must understand the nuances of CMS policy and apply a rigorous interpretation in order to address situations as they arise in their own communities. Guidance is offered here:

  1. First, the lawsuit forced CMS to clarify policy related to care coverage; it did not change CMS policy. Note: there was no expansion of Medicare coverage resulting from this lawsuit. Instead, the goal of this settlement was to ensure that existing policy was more well-defined and that Medicare beneficiaries receive the full coverage to which they are entitled. (This happened after Medicare contractors in Vermont inappropriately applied an “Improvement Standard” in making claims determinations for Medicare coverage involving skilled care.)
  2. It has always been the case that coverage for therapy services was not dependent upon a patient’s potential for improvement. Instead, the policy states if skilled services are required to prevent further decline/maximize function for a patient, then reasonable and appropriate therapy services are covered by CMS. According to CMS, “Even if full recovery or medical improvement is not possible, a patient may need skilled services to prevent further deterioration or preserve current capabilities.” Furthermore, treating therapists do not have to demonstrate an inherent understanding of the improvement, and restoration potential is not the deciding factor in determining whether skilled services are needed.
  3. Skilled therapy defined: Therapeutic intervention that requires the expertise of a therapist in order to perform/provide treatment. It is therefore critical that therapists provide sufficient documentation to substantiate clearly that skilled care is required.
  4. If an unskilled staff member or family member can be trained to provide the service/treatment, the service is considered “unskilled” and will not be covered by CMS. Be aware that in absence of unskilled staff (or Restorative Nursing Program), maintenance services/treatment provided by therapy will not be covered.

HealthPRO®/Heritage remains committed to assisting our client organizations to better understand regulatory nuances such as the Jimmo v. Sebilius settlement and what it means for day-to-day operations. Our support includes comprehensive training for proper documentation practices (as with accurately capturing skilled services), interpreting how to apply compliance standards (sometimes on a case-by-case basis) and advocating on behalf of patients (especially those with chronic conditions such as Huntington’s Disease, Dementia, Multiple Sclerosis, Parkinson’s Disease) so they receive the much needed services to which they are entitled.



Countdown to Major Home Health Changes
As of January 13, 2018, the home health industry will see significant changes with the first revision to the CoPs (Conditions of Participation) in 20+ years. A focus on “patient-centered, data-driven, outcome‐oriented processes that promote high quality patient care at all times for all patients” is captured in these new and revised CoPs. Home health agencies must be prepared to comply with the following:

Changes in Administrative Processes:

  • Policy and procedure manuals refresh: Significant changes will be required, and all clinicians (as well as your therapy partner) must be informed.
  • Governing body: will be more actively engaged in overall operational management, fiscal oversight, QAPI processes, and regular agency status reviews.
  • PAC (professional advisory committee) requirements: to be eliminated
  • Administrator responsibilities: He/she will be available for patients, representatives, and caregivers for complaints.
  • Administrator requirements: He/she will report to the governing body and must meet minimum educational/experience expectations.
  • “Clinical Manager” position: He/she will be responsible for patient/ personnel assignments, coordinating patient care/ referrals, reassessment of patient needs, assuring development/implementation/updates to individualized plans of care. According to new CoPs, a clinical manager must be on-duty at all times.

New QAPI Program Requirements:

  • Five new standards exist: scope, data, activities, performance improvement projects, and executive responsibility.
  • Estimated implementation cost: ~$30,000 to develop/implement new QAPI program requirements
  • Governing body: will approve frequency, detail of data collection; will review/revise QAPI program quarterly to ensure proper focus, data-driven, and well-documented (through performance improvement plans).
  • Chart audits, record reviews: no longer a QAPI program requirement (but remains as “best practice”)
  • NOTE: Agencies are advised to focus on high-risk, high-volume or problem-prone areas of service (due to high incidence, severity of problems).

Revised Patient Rights:

  • Six standards exist: exercise of rights, rights of patients, transfer and discharge process, investigation of complaints, and accessibility to patients.
  • New / revised rights (via written and verbal notice) include:
    • To have property and person treated with respect
    • To be free of verbal, mental, sexual, and physical abuse including injuries of unknown source, neglect, misappropriation of property, and to be free from any discrimination or reprisal of exercising rights
    • To be advised RE: state hotline and associated government funded agencies that service patient’s geographical area
    • To consent/refuse care in advance and/or during treatment.
    • To be informed RE: changes in care or payment prior to the next visit
    • To refuse discharge
  • Patient notification: all documents/patient rights info available in patient’s preferred language; patients must receive written schedule of all visits, and an updated medication profile and schedule. Patient will be provided contact information for Clinical Manager.
  • Two patient representatives: both (1) a legal representative with health care decision making authority and (2) a patient-selected representative must be informed of home health services provided.
  • Upon admission: clinical documentation to demonstrate discussion of patient rights and projected plan of care including patient’s ability to understand/seek clarification RE: plan of care. Also, process must be in place to ensure the needs of non-English speaking patients are met.
  • Mandatory complaint investigations: every complaint must be investigated, documented and include plan of action/resolution.
  • Transfer / discharge orders: Very specific requirements will exist RE: whether transfer/ discharge can occur with cause. Also, the right to refuse discharge for cause will exist.

Changes in Care Coordination:

  • Safety measures: updated requirements will protect against injury; focus on preventing emergent care and hospital re-admissions.
  • Physician involvement/engagement: orders will now require signature, date, and time. Increased engagement required by physicians in developing/revising care plans (especially when outcomes are not being achieved).
  • Discharge/transfer summaries: 23 new required elements exist.
  •  Home Health aide training /supervision: nine new standards exist.
January 2018 deadline looms on the horizon, and home health agencies may require support/guidance to implement strategies to assure these new requirements are met.

HealthPRO®/Heritage has the bandwidth and resources to ensure our client partners are well-prepared for this transition. In fact, our experts recognize the CoPs as an opportunity for HHAs! Strong execution on these required changes will differentiate our home health partners and serve to establish a competitive advantage while also enhancing the quality of care delivery for patients they serve.


Questions about what you read or ready to partner with HealthPRO®/Heritage?
Contact us today!

Tags: Advisor, Advisor Newsletter, HealthPRO/Heritage, RCS-1, Home Health, Jimmo V Sebelius, Jimmo v. Sebeilus, CMS policy, Crosswalk Model, CMS Calculator, PAC provider, Skilled Therapy