VNAA Leader: Disconnect at CMS Short-Circuits Home Health Innovation

Home health care agencies are staring down the prospect of a $350 million Medicare payment cut in 2016, so they could be forgiven for seeing the Centers for Medicare & Medicaid Services (CMS) as an enemy.

But it’s not quite so simple, according to Tracey Moorhead, CEO and president of the Visiting Nurse Associations of America (VNAA), which represents nonprofit home health care and hospice agencies in over 40 states.

At this week’s VNAA Public Policy Leadership Conference in Washington, D.C., Moorhead sat down with Home Health Care News and spoke about the innovation disconnect at CMS and some of the top issues facing providers, from continuing challenges with physician documentation to the looming ICD-10 transition.

HHCN: The conference began with a session focused on palliative care. Why this topic?

Moorehead: This is a critical issue for us. We see palliative care filling a critical gap between the post-acute care space, which home health is traditionally active in, and hospice.

We know that folks in the last couple years of life, particularly with chronic conditions and case management needs, cycle in and out of the hospital. They may not be eligible or ready for hospice, but they aren’t truly post-acute care. There is a true need for palliative care in this country, and it’s one of our highest priorities to advance that conversation.

HHCN: Legislation like The Palliative Care and Hospice Education and Training Act (PCHETA) is working its way through Congress, and aims to bolster palliative care through workforce development and other initiatives. But in addition to legislative action, is CMS supportive of innovation in this arena and pushing forward with new models?

Moorehead: What I see, and I think what many of my colleagues see, is a disconnect at CMS between folks in the leadership, who understand that new models are necessary and want to test and scale these new models, and the rank-and-file. Particularly in palliative care and hospice.

There’s a desire among the leaders to learn about the interdisciplinary hospice model. That is not reflected at the rank-and-file at CMS. There is a huge disconnect between the people who write the payment rules — if you read the hospice payment rule, it is nowhere near supportive of the interdisciplinary aspect of hospice. And yet, then you have [Acting Administrator] Andy Slavitt and [Deputy Administrator and Director of the Center for Medicare] Sean Cavanaugh and [Deputy Administrator for Innovation and Quality & Chief Medical Officer] Patrick Conway talking about the value of hospice and the value of the interdisciplinary leadership of hospice.

We have to somehow bridge that disconnect and help them understand that these we have continued to evolve, we are a huge and critical resource for health care delivery, for quality improvement and cost reduction, and yet we’re being so shoved down by the payment and administrative policies that the rank-and-file from CMS have implemented in the past couple years. It’s a real problem for the industry.

HHCN: Do you think the disconnect is due to the size of the bureaucracy?

Moorhead: I do. Innovative leaders, in the folks I mentioned by name, understand. They’ve been in some of the most innovative systems in the country. They want to change these things and implement and develop payment structures that reward quality and value and outcomes, and that’s where we want to be at VNA.

But then we get payment rules that go out of their way, it seems, to penalize providers who are doing their best to provide high quality care and to support family members and to improve care in the community.

HHCN: In addition to palliative care, what are the top legislative priorities that VNAA is working on?

Moorhead: With Congress, our key priority right now is addressing the documentation challenge that members of our industry have been struggling with.

Legislation has been introduced in the Senate that would really help the backlog of denials and claims. Our members have lost tens of millions of dollars because of an egregious application of these Medicare documentation requirements. But also, going forward, the legislation would help clarify some of the auditor requirements and education requirements that CMS has for the auditors. Resolving that challenge is our highest legislative priority right now.

HHCN: You’re referring to documentation challenges around physician certification for the home health benefit in Medicare?

Moorhead: The challenge goes back to a provision in the Affordable Care Act that required face-to-face documentation of a physician visit prior to eligibility for home health services.

The problem with the application of that requirement has been that the home health agencies don’t get paid if the physician doesn’t document appropriately. Not for any lack of high quality care provided by the home health agency, it’s because the auditors have deemed that the physician hasn’t signed in the right place or documented in the right place. So, it really has nothing to do with us.

And our industry has really struggled to educate physicians, while at the same time we’re trying to get CMS to better educate the auditors. There’s no consistency in the application of these requirements by the auditors. Our key points in the legislation are to require CMS to better educate the auditors to ensure consistency in the application of the rules. And also to help them educate physicians on the requirements for documentation, so that our agencies aren’t trying to track down a physician’s signature in the exact right spot that they think the auditor is going to require it.

CMS has changed their requirements for this, starting January 1 of this year, but they also have not been enforcing it or conducting audits. October 1 is when they start audits again. So, there’s a lot of uncertainty right now as to what those audits are going to look like. They refer to them as “probe and educate” at the physician level, but our members are very concerned about how that probe and educate process is going to impact them and if we’re going to continue to see the high rate of denials for services already rendered, that were referred effectively by a physician.

HHCN: And when these denials are appealed, I assume they get added to the huge appeals backlog that exists.

Moorhead: Exactly. Hospitals are at the top of the food chain. And we all know there are millions of hospital claims in the system. They’re trying to deal with all of those first, and home health claims that are in the same adjudication system are at the end of the line.

So, our members who are trying to appeal those denials have years ahead of them to try and recoup that money by demonstrating that in fact a physician did effectively refer to a home health agency.

We’ve tried to work with the Hill to say this is a problem for us as well. Unfortunately, at this time, the Hill is really only focused on how to resolve the hospital backlog.

HHCN: And where in the process is the legislation around this issue, is it garnering support?

Moorhead: We have bipartisan sponsorship in the Senate. We’re working on getting additional co-sponsors in the Senate, and talking to folks on the House side about possible introduction. Some strong conversations are going on there.

HHCN: Lastly, the ICD-10 deadline is right around the corner, but there are still big concerns about how home health agencies will be able to implement his new coding system — including that ICD-10 codes only include nine characters and home health needs a tenth. Is this something you’re working on?

Moorhead: The ICD-10 challenges are a big issue for us right now. We’ve not been working it on the Hill so much but behind the scenes at CMS, to help them understand the issue, particularly with that tenth character.

It seemed a couple of weeks ago that a few of the folks at CMS simply didn’t understand what the challenge would be for HHAs with regard to ICD-10. So, we’ve had an education program that’s been happening very quickly in the last few weeks.

Written by Tim Mullaney