Medicare Proposes (and Rejects) New Telehealth Services for 2019

The post Medicare Proposes (and Rejects) New Telehealth Services for 2019 appeared first on Dr. Miltie.

Monday, July 30, 2018

Where Things Stood

Understanding the impact of what we have seen so far this year first requires an understanding of where we were at the end of 2017, with respect to both Medicare reimbursement and provider adoption of telehealth solutions.

Hospitals and health systems have long understood that digital health technologies allow patients to be active participants in their health while also allowing health care providers to intervene before costs and complications escalate. At the close of 2017, direct-to-consumer telehealth companies had matured and were working closely with commercial payors to deliver telehealth services to plan beneficiaries. Reports on digital therapeutic tools, artificial intelligence applications and other digital health tools were in the media daily, and use cases continued to create evidence of both the efficacy and efficiency of digital health tools.

Under value-based reimbursement models, health care providers are penalized when patient care, particularly for chronic conditions, is not effectively managed. In order to manage the population now considered within their scope of care, and in anticipation of the rising care needs of the retiring baby boomer population, in 2017 providers were actively leveraging tools to help them succeed. In fact, a 2017 study reported that 73 percent of health care organizations use technology for monitoring and maintenance, with the most common use being patient monitoring at 64 percent.

Provider action tends to follow reimbursement dollars, however, and while Medicare has reimbursed for telehealth services for many years, the rules and restrictions associated with telehealth reimbursement have resulted in very limited utilization and actual Medicare reimbursement.

Prior to 2018, Medicare covered only real-time, audiovisual consultations with patients for a limited number of Medicare Part B services, and only when certain geographic, provider type and facility type criteria were met, with the exception of federal demonstration programs.  The biggest challenge was that reimbursement could only occur when the originating site (i.e., the patient’s location) was located either in a federal demonstration program, a rural Health Professional Shortage Area or a county outside of any Metropolitan Statistical Area, as defined by the Health Resources and Services Administration and the US Census Bureau.  This geographic restriction limited Medicare reimbursement to services provided to patients of health care facilities located in rural areas, and prevented reimbursement of services to patients outside of a medical facility (e.g., at home or at a workplace) or located in urban areas.  The restriction also undermined the broader implementation of telehealth programs because health systems could only develop programs for these specific use cases.

Indeed, the diversity of telehealth and digital health solutions continues to be one of the most difficult practical challenges associated with broad adoption. So while there is a patient care incentive to utilize digital health tools, there has been very little Medicare reimbursement incentive to provide services using digital health solutions—until now.

2018 and Beyond: A New Era?

In 2018 Medicare reimbursement has undergone massive expansion through a series of rules and laws, including a proposed rule promulgated in July 2018.

Unbundling of CPT Code 9901

CMS took a major step towards aligning patient care expectations with provider reimbursement in the revisions to the Physician Fee Schedule and Other Revisions to Part B for CY 2018; Medicare Shared Savings Program Requirements; and Medicare Diabetes Prevention Program Final Rule (published on November 15, 2017) (Final Rule).  The Final Rule began taking effect January 1, 2018.

Of particular note, CMS unbundled CPT code 99091, which allows providers to bill for remote patient monitoring (RPM), fundamentally changing the scope of Medicare reimbursement for remote care. As the Connected Health Initiative stated, “[u]ntil now, connected health technologies have been effectively locked out of the most important part of America’s healthcare system, Medicare and Medicaid.” With this change, CMS not only provided an added incentive for providers to take advantage of digital health tools to benefit patients, but improved the business case for providers who have already invested in those tools to leverage them for patient care via RPM.

Prior to the adoption of the Final Rule, CMS rules prohibited billing certain remote care tasks for a patient during the same service period as many of the treatments that commonly use RPM services. Specifically, this category includes chronic care management (CCM) codes 99487, 99489 and 99490 (which include management of cardiovascular disease, chronic obstructive pulmonary disease (COPD), diabetes and hypertension, among others); transitional care management (TCM) codes 99495 and 99469 (which include services for the time between a patient’s discharge from the hospital, rehab, nursing or similar facility and the patient’s return home or admission to an assisted living facility); and general behavioral health integration (BHI) code 99484.  Thus, if a provider used RPM for a patient with COPD receiving services billable under any of the above CCM codes, then the provider would receive no reimbursement for the RPM services. However, with the adoption of the Final Rule, RPM services that are billable under 99091 can be billed once during the same 30-day service period as any CCM,  TCM or BHI  codes discussed.

The Final Rule states that CPT code 99091 is for “collection and interpretation of physiologic data (e.g., ECG, blood pressure, glucose monitoring) digitally stored and/or transmitted by the patient and/or caregiver to the physician or other qualified health care professional, qualified by education, training, licensure/regulation (when applicable) requiring a minimum of 30 minutes of time.” Providers can use the code for time spent accessing data, reviewing or interpreting the data, and making any necessary modifications to the care plan that result, including communication with the patient and caregiver and any associated documentation.

CPT code 99091 is payable in both facility and non-facility settings, but there are other specific eligibility requirements. In addition to the requirement that the code be billed once per 30-day service period per patient, the provider must obtain advance beneficiary consent for the service and document the consent in the patient medical record. For new patients or patients who have not been seen by the billing provider within one year, the provider and patient must also have a face-to-face consultation. The unbundled code is applicable to physicians, physician assistants, nurse practitioners, certified nurse midwives, clinical nurse specialists and their teams. The services are ineligible if provided via subcontractor, however, which has discouraged collaborations between health care providers and RPM technology companies that desire to offer remote monitoring services. While providers can take advantage of digital health tools to support their RPM services, the analytic tasks must be provided by the clinical care team. Comments submitted to CMS expressed concern that the current code may not optimally describe the services furnished using current technology. However, CMS indicated that the unbundling of 99091 is an interim measure for reimbursement of RPM services while new, more specific RPM codes are developed. As CMS stated, “separate payment for this code will not mitigate the need for coding revisions.”

Other Notable 2018 Fee Schedule Final Rule Changes

In addition to unbundling code 99091, the Final Rule also expands allowable telehealth reimbursement and permits virtual sessions in certain circumstances under the Medicare Diabetes Prevention Program Expanded Model (MDPP), as we reported here.

New and add-on services

CMS evaluates requests for the addition of telehealth services on the basis of two categories: (1) services that are similar to services already on the list, and (2) services that are not similar to services already on the list. An evaluation of a category 2 service requires CMS to assess, based on the submission of evidence, whether the use of a telecommunications system to furnish the service “produces demonstrated clinical benefit to the patient.”

Upon review of several public requests, CMS determined that the following services met the category 1 requirement:

• Healthcare Common Procedure Coding System (HCPCS) code G0296 – counseling visit to discuss the need for lung cancer screening
• Current Procedural Technology (CPT) codes 90839 and 90840 – psychotherapy for crisis

Payment for these services is conditioned upon the distant site practitioner having the ability to mobilize originating site resources to diffuse a crisis and restore safety, when applicable.

The following four add-on (category 2) CPT and HCPCS codes were also added:

• CPT code 90785 – interactive complexity
• CPT codes 96160 and 96161 – administration of patient-focused health risk assessment instrument, and administration of caregiver-focused health risk assessment instrument
• HCPCS code G0506 – comprehensive assessment or/and care planning for patients requiring CCM services

In instances where CMS is unable to confirm whether all components of a service may be performed via telehealth, an explicit condition of payment may be added alongside the code to ensure that all CPT (or other) prefatory requirements are met.

Medicare diabetes prevention program virtual sessions

MDPP is a “structured behavior change intervention” designed to prevent type 2 diabetes among Medicare beneficiaries with an indication of prediabetes. MDPP consists of 16 sessions that integrate a Centers for Disease Control and Prevention-approved curriculum in an in-person, “group-based, classroom-style setting.” The curriculum provides practical training in dietary changes, increased physical activity and strategies to control weight. Under the Final Rule, MDPP beneficiaries may make up a limited number of sessions “virtually” at the request of the individual beneficiary. The virtual sessions may include furnishing behavioral change programs online (e.g., via a connected smart phone, tablet, computer, laptop); furnishing coaching programs online with other means of support by the coach (e.g., via telecommunications, video conferencing); or distance learning that does not require online connectivity (e.g., via phone). The sessions will be billed using a modifier for CMS’s tracking purposes. MDPP services that are exclusively furnished virtually or using remote technologies (without in-person attendance) will not be reimbursed.

2018 Quality Payment Program Final Rule

In tandem with the Final Rule, CMS released the 2018 Quality Payment Program Final Rule. Physicians and other eligible practitioners who participate in the Merit-Based Incentive Payment System must attest to their participation in two “High” weighted activities and four “Medium” weighted activities, or a combination, to obtain the maximum performance score. By changing the classification of the Improvement Activity Performance Category called “Engage Patients and Families to Guide Improvement in the System of Care” from Medium to High, CMS incentivized providers to use RPM technologies that provide real-time feedback to patients and their care team. The updates require providers to leverage platforms and devices using an active feedback loop to provide real-time, or near real-time, patient-generated health data to the care team or clinically endorsed feedback from the provider to patients.

In combination with the Fee Schedule changes, including changes to CPT code 99091, this change further demonstrates that CMS is getting behind digital health initiatives in a real way.

The Bipartisan Budget Act of 2018

The Bipartisan Budget Act of 2018 passed in February includes significant expansion of direct reimbursement for telehealth services by incorporating provisions of the CHRONIC Care Act, which had, in different forms, passed both houses of Congress in 2016. These provisions represent the first significant legal expansion of Medicare reimbursement of telehealth services since Medicare first started to reimburse telehealth services.

Expanded access to telehealth stroke services

Beginning in 2019, Medicare will reimburse telehealth consultations with neurologists with respect to patients presenting with stroke symptoms at hospitals or mobile stroke units. The provision eliminates the current geographic restriction that limits originating sites to rural areas. This allows distant site providers delivering telestroke services to receive a professional fee for delivering the consultation to patients located anywhere in the United States, provided that the other Medicare telehealth coverage requirements are satisfied (e.g., type of provider, type of technology).

Expanded telehealth services for chronically ill Medicare Advantage enrollees

Beginning in plan year 2020, Medicare Advantage (MA) plans can offer expanded telehealth services as a basic benefit to chronically ill enrollees. MA enrollees would have the option to receive these additional benefits through telehealth or in person. However, a plan that fails to provide in-person access to a certain type of physician specialist cannot meet network adequacy requirements by providing solely telehealth access to such providers. HHS is required to solicit public comment before November 30, 2018, with respect to the types of telehealth services that should be considered and the requirements for providing those services.

Expanded telehealth opportunities for Accountable Care Organizations (ACOS)

Beginning in 2020, certain ACOs will have an increased opportunity to provide Medicare reimbursable telehealth services with the removal various barriers. The changes allow a beneficiary’s home to qualify as an originating site, and eliminate the geographic component of the originating site requirement. Not surprisingly, the provision eliminates the originating site fee if the service is furnished in the patient’s home. This additional telehealth flexibility is available for Next Generation ACOs and for additional ACOs, including MSSP Track II (if the ACO remains at two-sided risk and chooses prospective assignment), MSSP Track III, and two-sided risk ACO models with prospective assignment tested or expanded through the Innovation Center.

The Secretary was asked to study the implementation of this provision and report to Congress before January 1, 2026 with an analysis of the utilization of and expenditures for telehealth services under this section and recommendations for any appropriate legislation and administrative action.

CMS Proposed Rule (Physician Fee Schedule) Released July 12, 2018

CMS’s Notice of Proposed Rulemaking, Revisions to Payment Policies under the Physician Fee Schedule and Other Revisions to Part B for CY 2019 (Proposed Rule) would expand reimbursement for physicians and other qualified health care providers under a variety of specific circumstances. Comments on the Proposed Rule may be submitted until September 10, 2018.

Brief (5–10 minute) virtual visits by qualified providers with existing patients

The Proposed Rule would reimburse virtual care services between visits to determine whether a patient’s condition requires an office visit. Reimbursement for virtual visits would be billed using HCPCS code GVCI1 at a rate of $14 per visit, which is much lower than the cost of an E/M visit, and would be available only with respect to existing patients of the practitioner. This change could potentially result in cost savings to Medicare if it effectively reduces unnecessary office visits by allowing providers to use technology to communicate with their patients to assess their patients’ needs (in a rather common-sense way). Currently, CMS does not separately cover these types of check-ins between providers and patients, but dedicated providers across the country have offered this type of assistance regardless.

If the virtual care service originates from a related E/M service delivered at some point within the prior seven days, the virtual care service would not be separately reimbursable, as the follow-up visit would be “bundled” into the Medicare payment for the previous E/M service. Similarly, if the virtual care service leads to an E/M service with the same physician, the virtual care service would be “bundled” into that E/M service and would not be separately reimbursable.

CMS believes that this approach could be beneficial in a variety of ways. For example, it notes that this could assist in the treatment of opioid use disorders and other substance use disorders “since there are several components of Medication Assisted Therapy (MAT) that could be done virtually, or to assess whether the patient’s condition requires an office visit.” At the same time, CMS recognizes that it may need to address a few concerns. Specifically, CMS is seeking comments on whether a frequency limitation should be imposed and also what sort of documentation regarding medical necessity would be appropriate, among other things.

Review of patient images or video (store and forward)

The Proposed Rule provided that HCPCS GRAS1 code (Remote Evaluation of Pre-Recorded Patient Information) be used for reimbursement for reviewing “recorded video and/or images captured by a patient in order to evaluate the patient’s condition” and to determine whether the patient requires an in-person office visit. This proposed change would apply to all providers, which would be significant given that “store and forward” telehealth services are currently only reimbursed by Medicare in very limited circumstances.

As with the virtual visits described above, this service would not be separately reimbursable if it results from an E/M service provided within seven days prior, or leads to E/M services. CMS is seeking comment on whether this service should be limited to existing patients “or whether there are certain cases, like dermatological or ophthalmological services, where it might be appropriate for a new patient to receive these services.”

Provider-to-provider consultations

Codes 994X6, 994X0, 99446, 99447, 99448 and 94449 may be used to reimburse provider-to-provider consults in the context of care management or care coordination activities. These codes may be used for “assessment and management services conducted through telephone, internet, or electronic health record consultations furnished when a patient’s treating physician or other qualified healthcare professional requests the opinion and/or treatment advice of a consulting physician or qualified healthcare professional with specific specialty expertise to assist with the diagnosis and/or management of the patient’s problem without the need for the patient’s face-to-face contact with the consulting physician or qualified healthcare professional.”

This expansion of reimbursement (away from a service that would otherwise be bundled through face-to-face encounters) is derived from CMS’s recognition that current coding does not accurately reflect trends in medical practice. Specifically, CMS believes that “making separate payment for interprofessional consultations undertaken for the benefit of treating a patient will contribute to payment accuracy for primary care and care management services.” Nonetheless, CMS is concerned about program integrity and is seeking comments on how CMS might be able to evaluate whether the services are reasonable and necessary under the circumstances.

Cost

Crucially, CMS is cognizant of the impacts these changes may have on Medicare cost with respect to utilization and avoidable utilization of other services. Its analysis is that because reimbursement is generally low for these services, utilization will be fairly low, but could increase to upwards of 19 million visits per year. CMS also expects that the number of additional services resulting from these new services will outweigh avoided utilization. Accordingly, CMS expects that the financial impact of paying for the communication-technology-based services will be an increase in Medicare costs. Unfortunately, this does not bode well for reimbursement generally: “In order to maintain budget neutrality in setting proposed rates for CY 2019, we assumed the number of services that would result in a 0.2 percent reduction in the proposed conversion factor.”

CMS Proposed Rule (Home Health) Released July 2, 2018

In an effort to encourage more home health agencies (HHAs) to adopt RPM, the CMS Proposed Changes to the Home Health Prospective Payment System released July 2, 2018, propose the inclusion of RPM costs on the HHA cost report as an allowable cost. Allowing HHAs to report the costs of RPM on the HHA cost report as part of their operating expenses means these costs would then be factored into the costs per visit, which has important implications for purposes of assessing HHA costs relevant to payment, including HHA Medicare margin calculations. CMS is soliciting comments on the proposed definition of remote patient monitoring under the Home Health Agency Prospective Payment System to describe the telecommunication services that are used by HHAs to augment the patient’s plan of care during a home health episode. In addition, CMS has requested comments regarding additional opportunities to use telehealth technologies for consideration in future rulemaking, which further evidences CMS attention to how telehealth can improve the delivery of home health services.

CMS Proposed Rule (Outpatient Hospital Services) Released July 25, 2018

In the CMS Proposed Changes to Hospital Outpatient Prospective Payment and Ambulatory Surgical Center Payment Systems and Quality Reporting Programs released on July 25, 2018, CMS has asked members of the public to submit their ideas on ways to promote the interoperability and electronic information exchange, and potential revisions to CMS patient health and safety requirements for hospitals and other Medicare- and Medicaid-participating providers and suppliers “to fully understand all of these health IT interoperability issues, initiatives, and innovations through the lens of its regulatory authority.” CMS is “particularly interested in identifying fundamental barriers to interoperability and health information exchange, including those specific barriers that prevent patients from being able to access and control their medical records.”

Don’t Get Too Excited

Reimbursement for services delivered via digital health solutions should continue to improve beyond 2018, based on Congress’ and CMS’s desire to identify additional appropriate uses of telehealth and to reevaluate the current Medicare coverage requirements, CMS’s recent expansions of and proposed changes to the list of covered services, and the fact that Medicare and Medicaid payments for telehealth services are at an all-time high. However, this must be understood in context.

First, it is important to note that although Congress has significantly improved the financial environment for telehealth through the Bipartisan Budget Act, it has not altered in any fundamental way the very restrictive structure for telehealth reimbursement. With the exception of broadening the flexibility for MA Plans, the Bipartisan Budget Act essentially creates very specific exceptions to that structure by waiving certain, but not all, of its requirements, and then only under specific circumstances. This seems to be consistent with the approach suggested by the Medicare Payment Advisory Commission in its report to Congress on telehealth issued as required by the 21st Century Cures Act: “[P]olicymakers should take a measured approach to further incorporating telehealth into Medicare by evaluating individual telehealth services to assess their capacity to address the Commission’s three principles of cost reduction, access expansion, and quality improvement.” Accordingly, we should not expect significant or unbridled congressional efforts to expand telehealth coverage under Medicare.

Second, as demonstrated by the reference to a likely fee schedule offset in the Proposed Rule, we should recognize that even though CMS is interested in expanding telehealth reimbursement, it remains focused on the bottom line of Medicare reimbursement as a whole. Accordingly, while digital health reimbursement expansion may be more likely in the future, broad support for these efforts may be tempered by the possibility of financial offset in other reimbursement areas.

Finally, the OIG’s addition of Medicaid and Medicare telehealth payment audits to the 2018 Work Plan and recent reports indicating high billing errors demand that telehealth providers fully understand and develop procedures for complying with the associated regulatory and compliance requirements in advance. One key step in this process requires that providers review and update their corporate compliance programs—particularly billing, coding and documentation policies—to confirm that the provider and any partners properly bill for services, and that the compliance program effectively prevents, identifies and offers pathways for addressing billing compliance issues. With the changes in 2018, this task has simply gotten harder.

Although these comments may reflect a tempering of expectations and a word of caution relative to enforcement, they are also indicative of a very positive trend for telehealth. The Medicare reimbursement regime’s efforts to expand reimbursement for certain telehealth services, focus on its role within larger policy goals and concerns related to fraud also reflect the government’s perspective that these services are no longer a novelty and deserve attention.

The post 2018 Mid-Year Digital Health Report: Focus on Medicare appeared first on Dr. Miltie.

Some very good news for the telehealth community can be found amidst the more than 1,400 pages of the proposed Medicare Physician Fee Schedule for 2019 (“Proposed Rule”) issued by CMS yesterday.  Finally, CMS acknowledges just how far behind Medicare has lagged in recognizing and paying for physician services furnished via communications technology.

Virtual Check-In

The longstanding barriers to Medicare payment for telehealth visits based on the location of the patient and the technology utilized could soon give way to payment for brief check-in services using technology that will evaluate whether or not an office visit or other service is warranted.  CMS proposes to establish a new code to pay providers for a virtual check in. For many telehealth providers, the payment proposal will not go far enough since the new code can only be used for established patients. CMS notes that the telehealth practitioner should have some basic knowledge of the patients’ medical condition and needs that can only be gained by having an existing relationship with the patient.

Store and Forward

In other good news, the Proposed Rule creates a specific payment code for the remote professional evaluation of patient-transmitted information conducted via pre-recorded “store and forward” video or image technology.  CMS recognizes that the progression of technology and its impact on the practice of medicine in recent years will result in increased access to services for Medicare beneficiaries. CMS is seeking comment as to whether these type of telehealth services could be deployed for new patients as well as existing patients.

The Bipartisan Budget Act of 2018

The Proposed Rule also implements important expansions of telehealth services included in the Bipartisan Budget Act of 2018 (“BBA of 2018”) passed last winter. The BBA of 2018 made way for end-stage renal disease patients to receive certain clinical assessments via telehealth beginning in January 2019.  Under the Proposed Rule, CMS proposes to amend its regulations to add in the home of the patient as the “originating site.” Under existing Medicare rules, the patient’s home is not an appropriate “originating site” for a telehealth visit.

Comments on the Proposed Rule are due by September 10, 2018.

The post Telehealth Gets a Boost in Proposed Physician Fee Schedule appeared first on Dr. Miltie.

[Billing Code:  4120-01-P]

DEPARTMENT OF HEALTH AND HUMAN SERVICES

 Centers for Medicare & Medicaid Services 42 CFR Parts 409, 424, 484, 486, and 488 [CMS-1689-P]

RIN 0938-AT29

Medicare and Medicaid Programs; CY 2019 Home Health Prospective Payment System Rate Update and CY 2020 Case-Mix Adjustment Methodology Refinements; Home Health Value-Based Purchasing Model; Home Health Quality Reporting Requirements; Home Infusion Therapy Requirements; and Training Requirements for Surveyors of National Accrediting Organizations

AGENCY:  Centers for Medicare & Medicaid Services (CMS), HHS.

ACTION:  Proposed rule.

SUMMARY:  This proposed rule would update the home health prospective payment system (HH PPS) payment rates, including the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor, effective for home health episodes of care ending on or after January 1, 2019.  It also proposes updates to the HH PPS case-mix weights for calendar year (CY) 2019 using the most current, complete data available at the time of rulemaking; discusses our efforts to monitor the potential impacts of the rebasing adjustments that were implemented in CYs 2014 through 2017; proposes a rebasing of the HH market basket (which includes a decrease in the labor-related share); proposes the methodology used to determine rural add-on payments for CYs 2019 through 2022, as required by section 50208 of the Bipartisan Budget Act of 2018 hereinafter referred to as the “ BBA of 2018” ;

proposes regulations text changes regarding certifying and recertifying patient eligibility for Medicare home health services; and proposes to define “ remote patient monitoring” and recognize the cost associated as an allowable administrative cost.  Additionally, it proposes case-mix methodology refinements to be implemented for home health services beginning on or after January 1, 2020, including a change in the unit of payment from 60- day episodes of care to 30-day periods of care, as required by section 51001 of the BBA  of 2018; includes information on the implementation of temporary transitional payments for home infusion therapy services for CYs 2019 and 2020, as required by section 50401 of the BBA of 2018; solicits comments regarding payment for home infusion therapy services for CY 2021 and subsequent years; proposes health and safety standards for home infusion therapy; and proposes an accreditation and oversight process for home infusion therapy suppliers.  This rule proposes changes to the Home Health Value-Based Purchasing (HHVBP) Model to remove two OASIS-based measures, replace three

OASIS-based measures with two new proposed composite measures, rescore the maximum number of improvement points, and reweight the measures in the applicable measures set.  Also, the Home Health Quality Reporting Program provisions include a discussion of the Meaningful Measures Initiative and propose the removal of seven measures to further the priorities of this initiative.  In addition, the HH QRP offers a discussion on social risk factors and an update on implementation efforts for certain provisions of the IMPACT Act.  This proposed rule clarifies the regulatory text to note that not all OASIS data is required for the HH QRP.  Finally, it would require that accrediting organization surveyors take CMS-provided training.

Proposed Rule Pages 1-200 in .pdf

[pdf-embedder url=”https://drmiltie.com/wp-content/uploads/2018/07/Medicare-and-Medicaid-Programs-CY-2019-Home-Health-Prospective-Payment-System-Update-Proposed-Rule-2018-07-02-pages-1-200.pdf” title=”Medicare and Medicaid Programs – CY 2019 Home Health Prospective Payment System Update – Proposed Rule – 2018-07-02 – pages 1-200″]

Proposed Rule Pages 201-400 in .pdf

[pdf-embedder url=”https://drmiltie.com/wp-content/uploads/2018/07/Medicare-and-Medicaid-Programs-CY-2019-Home-Health-Prospective-Payment-System-Update-Proposed-Rule-2018-07-02-pages-201-400.pdf” title=”Medicare and Medicaid Programs – CY 2019 Home Health Prospective Payment System Update – Proposed Rule – 2018-07-02 – pages 201-400″]

Proposed Rule Pages 401-600 in .pdf

[pdf-embedder url=”https://drmiltie.com/wp-content/uploads/2018/07/Medicare-and-Medicaid-Programs-CY-2019-Home-Health-Prospective-Payment-System-Update-Proposed-Rule-2018-07-02-pages-401-600.pdf” title=”Medicare and Medicaid Programs – CY 2019 Home Health Prospective Payment System Update – Proposed Rule – 2018-07-02 – pages 401-600″]

Proposed Rule Pages 1-600 in .docx

[gview file=”https://drmiltie.com/wp-content/uploads/2018/07/Medicare-and-Medicaid-Programs-CY-2019-Home-Health-Prospective-Payment-System-Update-Proposed-Rule-2018-07-02.docx”]

The post Medicare and Medicaid Programs – CY 2019 Home Health Prospective Payment System Update – Proposed Rule – 2018-07-02 appeared first on Dr. Miltie.

Date

2018-07-02

Title

CMS proposes calendar year 2019 and 2020 payment and policy changes for Home Health Agencies and Home Infusion Therapy Suppliers

Contact

press@cms.hhs.gov

CMS proposes calendar year 2019 and 2020 payment and policy changes for Home Health Agencies and Home Infusion Therapy Suppliers

On July 2, 2018, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule [CMS-1689-P] outlining proposed Calendar Year (CY) 2019 Medicare payment updates and proposed quality reporting changes for home health agencies (HHAs), and proposed case-mix methodology refinements and a change in the home health unit of payment from 60 days to 30 days for CY 2020. This proposed rule also discusses the implementation of temporary transitional payments for home infusion therapy services to begin on January 1, 2019 and includes proposals related to full implementation of the new home infusion therapy benefit in CY 2021.

The proposed rule includes policies that are based on three pillars: empowering patients, increasing competition, and fostering innovation. The focus of the proposed rule is on the patients and their needs, and not on increasing process for process sake. CMS would continue a commitment to shift Medicare payments from volume to value, with continued implementation of the Home Health Value-Based Purchasing Model and the Home Health Quality Reporting Program, as well as a new case-mix adjustment methodology for the Home Health Prospective Payment System (HH PPS) that focuses on the patient’s condition and resulting care needs rather than on the amount of care provided in order to determine Medicare payment. The proposed rule would also modernize Medicare through innovations in home health and the new home infusion therapy benefit, meaningful quality measure reporting, reduced paperwork, and reduced administrative costs.

CMS encourages comments, questions, or thoughts on this proposed rule and will accept comments until August 31, 2018. The proposed rule can be downloaded from the Federal Register at: https://www.federalregister.gov/public-inspection.

Payment Rate Changes under the HH PPS for CY 201

CMS projects that Medicare payments to HHAs in CY 2019 would be increased by 2.1 percent, or $400 million, based on the proposed policies. The proposed increase reflects the effects of a 2.1 percent home health payment update percentage ($400 million increase); a 0.1 percent increase in payments due to decreasing the fixed-dollar-loss (FDL) ratio in order to pay no more than 2.5 percent of total payments as outlier payments (a $20 million increase); and a -0.1 percent decrease in payments due to the new rural add-on policy mandated by the Bipartisan Budget Act of 2018 for CY 2019 ($20 million decrease). The new rural add-on policy requires CMS to classify rural counties into one of three categories based on: 1) high home health utilization 2) low population density and 3) all others. Rural add-on payments for CYs 2019 through 2022 vary based on counties’ category classification.

Modernizing the HH PPS Case-mix Classification System and Promoting Patient-Driven Care

The Bipartisan Budget Act of 2018 requires a change in the unit of payment under the HH PPS, from 60-day episodes of care to 30-day periods of care, to be implemented in a budget neutral manner on January 1, 2020. Also for 2020, Congress mandated that Medicare stop using the number of therapy visits provided to determine payment, because therapy thresholds encourage volume over value and does not acknowledge that all patients aren’t the same, and some patients have complex needs that don’t involve a lot of therapy.

The proposed Patient-Driven Groupings Model, or PDGM, removes the current incentive to overprovide therapy, and instead, is designed to reflect our focus on relying more heavily on clinical characteristics and other patient information to allow payments to more closely coincide with patients’ needs. Using patient characteristics to place home health periods of care into meaningful payment categories is more consistent with how home health clinicians differentiate between home health patients in order to provide needed services. The improved structure of this proposed case-mix system would move Medicare towards a more value-based payment system that puts the unique care needs of the patient first while also reducing the administrative burden associated with the HH PPS.

To support an assessment of the effects of the proposed PDGM, CMS will provide, upon request, a Home Health Claims-OASIS Limited Data Set (LDS) file to accompany the CY 2019 HH PPS proposed and final rules. The Home Health Claims-OASIS LDS file can be requested by following the instructions on the following CMS website: https://www.cms.gov/Research-Statistics-Data-and-Systems/Files-for-Order/Data-Disclosures-Data-Agreements/DUA_-_NewLDS.html, and a file layout will be available.

Additionally, CMS will make available agency-level impacts and a report to congressional committees regarding a technical expert panel’s insights on the proposed PDGM, as well as an interactive Grouper Tool that will allow HHAs to determine case-mix weights for their patient populations. These materials are available on the HHA Center webpage at https://www.cms.gov/Center/Provider-Type/Home-Health-Agency-HHA-Center.html

Fostering Innovation

The Use of Remote Patient Monitoring under the Medicare Home Health Benefit

CMS is proposing to define remote patient monitoring in regulation for the Medicare home health benefit and to include the cost of remote patient monitoring as an allowable cost on the HHA cost report. Studies note that remote patient monitoring has a positive impact on patients as it allows patients to share more live-time data with their providers and caregivers, which will lead to more tailored care and better health outcomes. CMS believes that by defining remote patient monitoring and including such costs as allowable costs on the HHA cost report could encourage more HHAs to adopt the technology.

New Home Infusion Therapy Services Temporary Transitional Payment and Home Infusion Therapy Benefit

For CYs 2019 and 2020, as required by section 50401 of the Bipartisan Budget Act of 2018, CMS proposes the implementation of the temporary transitional payment for home infusion therapy services that would begin on January 1, 2019 and end the day before the full implementation of the new home infusion therapy benefit. Section 5012 of the 21^st Century Cures Act (Cures Act) creates a new separate Medicare benefit category for coverage of home infusion therapy services including associated professional services for administering certain drugs and biologicals through a durable medical infusion pump, training and education, and remote monitoring and monitoring services effective January 1, 2021. This rule solicits comments on elements of the home infusion therapy benefit. In addition, this rule also proposes health and safety standards for home infusion therapy, an accreditation process for home infusion therapy suppliers and an approval and oversight process for the organizations that accredit home infusion therapy suppliers.

Home Health Quality Reporting Program (HH QRP) Provisions

In furtherance of the Meaningful Measures Initiative and to further align with the policies of other CMS quality reporting programs, CMS is proposing to replace our policy for removing previously adopted HH QRP measures with eight measure removal factors. CMS is also proposing to remove seven quality measures beginning in the CY 2021 HH QRP based upon one of these eight proposed measure removal factors. An update on the implementation of certain provisions of the IMPACT Act is also being provided along with a discussion of accounting for social risk factors in the HH QRP. Lastly, CMS is proposing to update its regulations to clarify that only a portion of OASIS data is used to determine whether an HHA has satisfied the HH QRP reporting requirements for a program year.

Home Health Value-Based Purchasing Model

In the CY 2019 HH PPS proposed rule, in addition to providing an update on the progress towards developing public reporting of performance under the Health Value-Based Purchasing (HHVBP) Model, CMS proposes to refine the HHVBP Model. CMS proposes to remove two Outcome and Assessment Information Set (OASIS)‑based measures, Influenza Immunization Received for Current Flu Season Measure and the Pneumococcal Polysaccharide Vaccine Ever Received, from the set of applicable measures; replace three OASIS-based measures with two proposed composite measures on total change in self-care and mobility; amend how we calculate the Total Performance Scores by changing the weighting methodology for the OASIS-based, claims-based, and HHCAHPS measures; and rescore the maximum amount of improvement points.

Regulatory Burden Reduction

The cost impact related to OASIS item collection as a result of the proposed implementation of the PDGM and proposed changes to the HH QRP as outlined above, are estimated to result in a net $60 million in annualized cost savings for home health agencies, or $5,150 in cost savings per HHA per year beginning in CY 2020.

In an effort to make improvements to the health care delivery system and to reduce unnecessary burdens for physicians, CMS is proposing to eliminate the requirement that the certifying physician estimate how much longer skilled services are required when recertifying the need for continued home health care. This proposal is responsive to industry concerns about regulatory burden reduction and could reduce claims denials that solely result from an estimation missing from the recertification statement. We estimate that this proposal would result in annualized cost savings to certifying physicians of $14 million beginning in CY 2019.

We are also proposing to amend current regulations to align them with current sub-regulatory guidance to allow medical record documentation from the HHA to be used to support the basis for certification of home health eligibility, consistent with the Bipartisan Budget Act of 2018.

These burden reduction efforts would allow providers to spend more time on their chief responsibility: improving the health outcomes of their patients.

Advancing My HealthEData: Request for Information from stakeholders

In addition to payment and policy proposals, CMS is releasing a Request for Information (RFI) to obtain feedback on positive solutions to better achieve interoperability or the sharing of healthcare data between providers. Specifically, CMS is requesting stakeholder feedback through a RFI on the possibility of revising Conditions of Participation related to interoperability as a way to increase electronic sharing of data by providers. This will inform next steps to advance this critical initiative.

In responding to the RFI, commenters should provide clear and concise proposals that include data and specific examples. CMS will not respond to RFI comment submissions in the final rule, but rather will actively consider all input in developing future regulatory proposals or future sub-regulatory guidance.

For additional information about the Home Health Value-Based Purchasing Model, visit https://innovation.cms.gov/initiatives/home-health-value-based-purchasing-model.

For additional information about the Home Health Prospective Payment System, visit https://www.cms.gov/Medicare/Medicare-Fee-for-Service-Payment/HomeHealthPPS/index.html.For additional information about the Home Health Quality Reporting Program, visit https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/Home-Health-Quality-Reporting-Requirements.html 

The proposed rule can be viewed at https://www.federalregister.gov/public-inspection.

The post CMS proposes calendar year 2019 and 2020 payment and policy changes for Home Health Agencies and Home Infusion Therapy Suppliers appeared first on Dr. Miltie.

On July 2, CMS proposed significant changes to the Home Health Prospective Payment System (PPS) to strengthen and modernize Medicare, drive value, and focus on individual patient needs rather than volume of care. Specifically, CMS is proposing changes to improve access to solutions via remote patient monitoring technology, and to update the payment model for home health care.

“Today’s proposals would give doctors more time to spend with their patients, allow home health agencies to leverage innovation and drive better results for patients,” said CMS Administrator Seema Verma. “The redesign of the home health payment system encourages value over volume and removes incentives to provide unnecessary care.”

CMS’s proposed changes promote innovation to modernize home health by allowing the cost of remote patient monitoring to be reported by home health agencies as allowable costs on the Medicare cost report form. This is expected to help foster the adoption of emerging technologies by home health agencies and result in more effective care planning, as data is shared among patients, their caregivers, and their providers. Supporting patients in sharing this data will advance the Administration’s MyHealthEData initiative.

As required by the Bipartisan Budget Act of 2018, this proposed rule would also implement a new Patient-Driven Groupings Model (PDGM) for home health payments. The proposed rule also includes information on the implementation of home infusion therapy temporary transitional payments as required by the Bipartisan Budget Act of 2018. In addition, the proposed rule solicits comments on elements of the new home infusion therapy benefit category and proposes standards for home infusion therapy suppliers and accrediting organizations of these suppliers as required by the 21st Century Cures Act.

Physicians who order home health services for their patients would also see administrative burden reduced under this rule. CMS is proposing to eliminate the requirement that the certifying physician estimate how much longer skilled services would be needed when recertifying the need for continuing home health care, as this information is already gathered on a patient’s plan of care.

The proposed rule helps advance the Trump Administration’s Meaningful Measures Initiative. CMS is proposing changes to the Home Health Quality Reporting Program (HH QRP). The cost impact related to updated data collection processes as a result of the proposed implementation of the PDGM and proposed changes to the HH QRP are estimated to result in a net $60 million in annualized cost savings to Home Health Agencies (HHAs), or $5,150 in annualized cost savings per HHA, beginning in CY 2020.

In the proposed rule CMS is releasing a Request for Information to welcome continued feedback on the Medicare program and interoperability. CMS is gathering stakeholder feedback on revising the CMS patient health and safety standards that are required for providers and suppliers participating in the Medicare and Medicaid programs to further advance electronic exchange of information that supports safe, effective transitions of care between hospitals and community providers.

For More Information:

• Proposed Rule
• Fact Sheet
• Home Health PPS website
• HHA Center website
• Home Health Value-Based Purchasing Model webpage
• Home Health Quality Reporting Requirements webpage

See the full text of this excerpted CMS Press Release (issued July 2).

The post CMS Takes Action to Modernize Medicare Home Health appeared first on Dr. Miltie.

The Bipartisan Budget Act of 2018 was recently signed into law. Within the number of provisions is the use of telehealth and reimbursement for Part B Medicare beneficiaries using CPT code 99091.

February 14, 2018 by Cafe Staff

If 2017 ended on a high for telehealth and remote patient monitoring, the start of 2018 also did not disappoint. Indeed, on Feb 9, the Bipartisan Budget Act of 2018 was signed into law. This bill, which provides a budget agreement for 2018-2019, also includes a number of policy provisions in support of telehealth, also opening the door to remote patient monitoring (RPM). This budget deal expands the use of telehealth for patients undergoing home dialysis by allowing Medicare beneficiaries to elect to receive monthly related clinical assessments through telehealth, and to those having suffered a stroke, it expands the possible locations where patients may receive a telehealth consultation. The use of telehealth was also expanded for Medicare Advantage (MA) plans and accountable care organizations (ACOs).

We are advancing to a new “personal health” paradigm.

Beginning in plan year 2020, a MA plan may provide additional telehealth benefits to its enrollees. The bill defines additional telehealth services as those “for which benefits are available under Medicare part B…” and “that are identified for such year as clinically appropriate to furnish using electronic information and telecommunications technology when a physician… or practitioner… providing the service is not at the same location as the plan enrollee.” I had mentioned above that the door was opened for RPM. And, as I reported before, the Centers for Medicare & Medicaid Services (CMS) started reimbursing RPM (code 99091 is now reimbursed in Part B Medicare), as such so that it is “available under Part B” (note the underlined text above) and therefore reimbursable as part of MA. Or, at least, this is our interpretation. In fact, CMS should issue a clarification in this respect to ensure plans start covering RPM.

As to the expansion of telehealth use by ACOs, the bill removes the restrictions (subject to some conditions) set by 1834(m) of the Social Security Act to a Medicare fee-for-service beneficiary of the ACO whereby the home of the beneficiary can be treated as an originating site (similar to the changes presented above for the treatment of stroke patients), and geographic limitations are lifted.

Intel has long believed that the old “mainframe health” paradigm (i.e., centralized, hospital-centric, expert driven, reactive, costly) is giving way to a new “personal health” paradigm (i.e., distributed, data rich, preventive, home- and consumer- centric, and efficiency-driven). An ingredient of this transformation is Intel’s Health Application Platform for remote healthcare. This application software platform enables a variety of remote care usage models. When coupled with an Intel architecture-based design specification, it can enable healthcare solution providers to securely deliver distributed services.

With the passing of this legislation, the US Congress showed bipartisan support for the expansion of technologies that support Medicare’s modernization. Patients will have more choices to access healthcare services, hopefully improving clinical outcomes, which is another step in the right direction for a more nimble, patient centric healthcare framework. Intel lauds this bipartisan agreement and the support for the expansion of telehealth. We will be now looking to CMS’ next steps to bring to fruition the possibilities opened by this legislation.

The post 2018 Bodes Well for Telehealth And Remote Patient Monitoring appeared first on Dr. Miltie.

The Bipartisan Budget Act of 2018 is set to modify health care and the use of telehealth services by increasing access to telehealth stroke services, allowing telehealth opportunities to increase for Accountable Care Organizations ( ACO’s) and expanding the use of telehealth services for Chronically Ill MA enrollees. 

February 12, 2018 by Karen S. Sealander & Lisa Schmitz Mazur

On February 9, 2018 after a brief shutdown, Congress passed and President Trump signed the Bipartisan Budget Act of 2018, a two-year budget agreement that includes funding for the operation of the federal government until March 23, 2018. The law includes significant health care policy changes impacting Medicare, Medicaid and other federal health agencies. In addition to raising federal spending caps enacted in the Budget Control Act of 2011, this legislation includes additional spending for health care priorities. Here we break down some of the changes affecting telehealth.

Expanded Access to Telehealth Stroke Services

The new law expands, beginning in 2019, the ability of patients presenting with stroke symptoms at hospitals or mobile stroke units to receive a timely telehealth consultation with a neurologist in order to determine the best course of treatment. The provision eliminates the current geographic restriction that limits originating sites to rural areas, meaning distant site providers delivering telestroke services could receive a professional fee for delivering the consultation to patients located anywhere in the United States, provided that the other Medicare telehealth coverage requirements are satisfied (e.g., type of provider, type of technology).

Expanded Telehealth Services for Chronically Ill MA Enrollees

The new law allows MA plans to offer expanded telehealth services as supplemental benefits to chronically ill enrollees beginning in plan year 2020. HHS is required to solicit public comment before November 30, 2018, with respect to the types of additional telehealth services that should be considered and the requirements for providing those services. MA enrollees would have the option to receive such additional benefits through telehealth or in person. Including telehealth services and technologies in the package of benefits would not change the requirement that MA plans meet network adequacy requirements. This means that a plan that failed to provide in person access to a certain type of physician specialist could not meet network adequacy requirements by providing solely telehealth access to such providers.

Expanded Telehealth Opportunities for Accountable Care Organizations (ACOs)

This new law provides additional ACOs the opportunity to expand telehealth services by removing various barriers to the provision of telehealth services. The changes (1) allow beneficiaries assigned to an ACO to receive telehealth services in the patient’s home, (2) eliminate the geographic component of the originating site requirement, and (3) allow providers to furnish telehealth services as currently specified under Medicare’s physician fee schedule, with limited exceptions. Reimbursement under Medicare is contingent upon the telehealth services being delivered to a beneficiary at an approved originating site, such as a hospital, or at the beneficiary’s place of residence. Not surprisingly, the provision does require that Medicare provide a separate payment for the originating site fee if the service is furnished in the patient’s home. This additional telehealth flexibility is available now for Next Generation ACOs and for additional ACOs, including MSSP Track II (if the ACO remains at two-sided risk and chooses prospective assignment), MSSP Track III, and two-sided risk ACO models with prospective assignment tested or expanded through the Innovation Center.

The Secretary is directed to study the implementation of this provision and report to Congress before January 1, 2026 with an analysis of the utilization of and expenditures for telehealth services under this section and recommendations for any appropriate legislation and administrative action.

The post Bipartisan Budget Act of 2018 Includes Significant Changes in Medicare, Other Federal Health Programs appeared first on Dr. Miltie.