By Chase Doscher, Class of 2018; Colbey B. Reagan, Partner at Waller; Daniel Patten, Associate at Waller
Last April, the Center for Medicare & Medicaid Services (CMS) issued a change request making revisions to Chapter 15 (Medicare Enrollment) of the Medicare Program Integrity Manual. Specifically, this change request made significant alterations to Section 220.127.116.11.5 – Electronic Funds Transfer (EFT) Payment and CHOWs. Prior to the change request, when dealing with a change of ownership (CHOW), Medicare Administrative Contractors (MACs) continued to pay the Seller of a healthcare provider or facility until they received the tie-in notice from the CMS Regional Office. MACs would reject any application submitted by either the Seller or the Buyer to change the EFT account or special payment address prior to receiving approval from CMS. The ultimate responsibility for determining payment arrangements was left to the Buyer and Seller while the MAC and CMS processed the CHOW application.
Effective May 15, 2017, when the Seller and the Buyer initiate a CHOW, the provider agreement in existence, alongside the CMS Certification Number (CCN), is assigned automatically from the Seller to the Buyer effective on the transfer date. It is important to note that the Buyer retains the ability to reject the automatic assignment prior to the transfer date. To reject the automatic assignment of the provider agreement, the Buyer must file an initial participation application with the Medicare program. The assigned provider agreement is still subject to all applicable statutes and regulations as well as the terms and conditions under which it was issued. Any contractor will continue to adjust payments to the provider to account for both prior overpayment and underpayment, even if the claims relate to services provided before the CHOW. Additionally, the Buyer in a CHOW may obtain a new National Provider Identifier (NPI) or maintain the existing NPI. Once the CHOW processing is complete, the Seller will no longer be allowed to bill for services furnished after CHOW processing, and only the Buyer is permitted to submit claims using the existing CCN. It is important for parties undergoing CHOW processing to understand that under the implemented changes, any payment arrangement for services furnished during the CHOW processing period is left up to the parties to work out. One primary implication of this is that the Buyer will have some long-term responsibility to bill for services provided by the Seller during CHOW processing.
By Emmie Futrell, Class of 2018; Patsy Powers, Partner at Waller; Daniel Patten, Associate at Waller
On August 17, 2017, CMS published a proposed rule that could bring about significant changes to some of its Innovation Center’s major payment models. Specifically, the Proposed Rule would:
- reduce the number of mandatory geographic area participants of the Comprehensive Care for Joint Replacement (CJR) model;
- cancel the Episode Payment Models (EPMs) and Cardiac Rehabilitation (CR) incentive payment model; and
- increase the pool of practitioners that qualify under the Advanced Alternative Payment Model.
These changes may be surprising to some as these models are still in their infancy. The CJR model started last year, and the EPMs and CRs were not scheduled to begin until January 1, 2018.
Perhaps the most striking element of the Proposed Rule is the removal of 33 geographic areas (of the currently 64 geographic areas) where participation in the CJR model has been mandatory. Instead, CMS proposes that such hospitals participate in the CJR model on a voluntary basis, especially hospitals with low volume or those located in rural areas. These hospitals are provided with a one-time option whereby continued participation in the CJR model will be left to their discretion. CMS believes that moving the CJR model away from a mandatory requirement will increase the likelihood that providers will participate in future voluntary initiatives. Hospitals that choose to continue participation in the CJR model will receive a target price for these procedures from CMS each year, and the proposed rule includes refinements and clarifications to this payment process.
CMS is accepting public comments on these revisions, which can be electronically submitted here, until October 16, 2017.
By Will Blackford, Class of 2017
On January 13, 2017, the Centers for Medicare and Medicaid Services (“CMS”) published in the Federal Register its Final Rule pertaining to the Conditions of Participation (“CoPs”) for home health agencies (“HHAs”). The rule represents the first modernization in over two decades of the fundamental requirements for HHA participation in Medicare and Medicaid, despite efforts in 1997 to revise the entire set of HHA CoPs. With enforcement of the new provisions beginning July 13, 2017, CMS has given HHAs a six-month window for adapting their policies, procedures, and practices to comply with the new standards.
The most significant changes under the Final Rule revolve around four categories:
- Patient Rights. CMS added an expansive CoP that sets forth the specific rights that HHAs owe each patient and the steps they must take to protect such rights.
- Care Planning. The final rule updates the comprehensive patient assessment requirement to focus on all aspects of patient wellbeing. It also requires that a HHA provide its patients with a written copy of the plan of care and utilize an integrated communication system to identify and coordinate care between the HHA and the patient’s physicians.
- Quality Assessment and Performance Improvement. To ensure continual evaluation and improvement of care for patients, CMS will now require that HHAs initiate a data-driven, agency-wide quality assessment and performance improvement (QAPI) program that is capable of measuring improvement in indicators that are linked to improvement in patient outcomes, safety and care quality.
- Infection and Prevention Control. The new infection prevention and control requirement that focuses on the use of standard infection control practices, and patient/caregiver education and teaching.
In addition to the modified care standards, CMS also refined the definition of “Representative” to expressly distinguish between a patient-selected representative and a legal representative with legal decision-making authority under the law. There are numerous updates throughout the Final Rule that are shaped by this two-tiered approach to representation.
To meet these new requirements, HHAs need to familiarize themselves with the Final Rule and analyze their current policies and procedures to formulate a plan for tackling implementation of these significant changes. Agencies that fail to comply with any of the new CoPs by the July 13, 2017 deadline are at risk of penalties ranging from imposition of sanctions for marginal issues, to program termination for major infractions.