HHS Outlines Preparedness for Global Climate Change

HHS has released two reports on how it is preparing to respond to climate change. Climate change has been identified as one of the top public health challenges of our time according to HHS. One report, HHS Climate Adaptation Plan, describes how HHS can provide better health services and preparedness for changing health issues as a result of climate change. The second report; HHS’ 2014 Strategic Sustainability Performance Plan describes what HHS is doing to mitigate the agency’s impact on global climate change.

Health Impacts

“Recent reports from the U.S. Global Change Research Program and Intergovernmental Panel on Climate Change indicate that climate change is already negatively affecting human health in the United States, and that it is likely to have greater harmful effects on human health in the future,” according to a statement from HHS. In its Climate Adaptation Plan, HHS identified increased respiratory stress from poor air quality including diminished lung function, increased risk of asthma and premature deaths as one of the main impacts of climate change on human health. Other impacts include increases in plant based allergens, increased exposure to toxic air pollutants, and increased respiratory and asthma conditions from an increased amount of fungus and molds resulting from extreme rainfall and rising temperatures. Conditions sensitive to extreme heat like cardiovascular disease, heat stroke, and respiratory disease could also increase as a result of global warming stated HHS.

Specific Populations

HHS is also worried about the impact of climate change on specific populations of people like the elderly, children, and those with chronic conditions. “Climate change is anticipated to have its greatest impact on people whose health status is already at risk and who have the fewest resources to address or adapt to climate change,” said HHS. Seniors are more at risk from extreme heat waves and have more underlying diseases that increases their health risks and morbidity. HHS pointed out that lower-income people have higher rates of asthma, diabetes and other chronic disease that maybe exasperated by global climate change.

Emergency Preparedness

Increasing the emergency preparedness of the health care system was a large component of HHS’ Climate Adaptation Plan. The objective of a Proposed rule issued in December of 2013 is to establish consistent emergency preparedness requirements for health care providers participating in Medicare and Medicaid and was proposed with global climate change in mind. The Proposed rule would require emergency plans, policies and procedures, communications plans, and training and testing by providers and suppliers who participate in the Medicare and Medicaid programs (see Proposed rule would create emergency preparedness requirements for Medicare, Medicaid, December 27, 2013). Some of the greatest threats to health as a result of global climate change will come from more frequent and severe weather events like heat waves, drought, wildfires, heavy rainfall and flooding and CMS’ main goal is prepare for these natural disasters, said HHS.

In addition HHS is preparing additional reports to assist local health care planning and delivery agencies respond to national disasters, and increasing awareness and participation of volunteer medical groups like the Medical Reserve Corps which is an organization of 200,000 volunteers organized in almost 1,000 local units. These groups and groups participating in the Health Care Coalitions are committed to strengthening public health; reducing vulnerabilities; improving local preparedness, response and recovery capabilities; and building community resilience.

HHS’ Footprint

HHS’ Strategic Sustainability Report describes the agency’s efforts to reduce its impact on global warming. HHS reports that it has reduced its greenhouse gas emission by 12.3 percent when compared to 2008 by reducing energy use and employee travel. The report acknowledges that HHS is not meeting its target in using sustainable buildings. Only 0.73 percent of new and existing buildings are in compliance with Guiding Principles for Federal Leadership in High-Performance and Sustainable Buildings when it had a target of 15 percent of its leased buildings being in compliance with these guiding principles. The report goes on to describe HHS’ efforts at more efficiently using waters, electricity, renewable energy, and fleet management. HHS reports that in 2013 it awarded $40.9 million in contracts to improve energy savings and other efforts to reduce its impact on global climate change. HHS issued its first strategic sustainability report in 2010.

CMS Releases Home Health Rate Update for 2015

CMS has issued an advance release of its Final rule to update Medicare’s Home Health Prospective Payment System (HH PPS) payment rates and wage index for calendar year (CY) 2015. The regulations, which will take effect on January 1, 2015, update the national, standardized 60-day episode payment rates, the national per-visit rates, and the non-routine medical supply (NRS) conversion factor under the Medicare prospective payment system for home health agencies (HHAs). The updates represent the second year in a four year rebasing adjustment required by the Patient Protection and Affordable Care Act (ACA) (P.L. 111-148). Among other provisions, the Final rule, which is set to be published in the Federal Register on November 6, 2014, also makes changes to the face-to-face encounter regulatory requirements and home health quality reporting program requirements.

Adjustments

Beginning in 2014, CMS was obligated, under section 3131(a) of the ACA to make adjustments to home health payment rates over a four year phased in period. Under the law, the rate increases over the four year period must be made in equal increments that cannot exceed 3.5 percent of the 2010 payment rates. Through the 2014 HH PPS Final rule (78 FR 72256), which sets the adjustment for 2014 through 2017, CMS finalized a fixed-dollar reduction to the national, standardized 60-day episode payment rate at $80.95 per year. Additionally, the 2014 Final rule adjusted the per-visit payment rates with upward adjustments that ranged from $6.34 for medical social services on the high end to $1.79 for home health aide services on the low end. Additionally, the non-routine medical supply (NRS) conversion factor was set to reduce by a factor of 2.82 percent per year. The 2015 Final rule continues with the adjustments adopted in the 2014 Final rule. Also in accordance with an ACA mandate, taking into account a multifactor productivity adjustment, under the 2015 Final rule, the HH market basket is being updated 2.1 percent (see, Home health rates to be cut by 0.30 percent in CY 2015, July7, 2014).

Face-to-Face

In addition to making changes related to the ACA requirement, the Final rule discusses how CMS is monitoring the impacts of the rebasing adjustments. The update also includes simplifications to the ACA-mandated face-to-face encounter requirement. In particular, the Final rule eliminates the narrative requirement for certification of eligibility for home health services. Among other implemented rules, the changes establish procedures for obtaining documentation to establish that a patient is eligible for the home health services and demonstrating that a face-to-face encounter with a patient is related to the reason the patient requires home health services.

Other Changes

The Final rule also makes updates to the home health wage index using a 50/50 blend of the existing core-based statistical area (CBSA) designations and the new CBSA designations outlined in a February 28, 2013, Office of Management and Budget (OMB) bulletin. Additionally, changes are made under the Final rule to the quality reporting program for home health providers. Specifically, the quality changes include the establishment of a minimum threshold for submission of Outcome and Assessment Information Set (OASIS) assessments for purposes of quality reporting compliance and the creation of a policy that will assist in the adoption of changes to measures that take place in between rule making cycles.

Costs and Benefits

CMS projects that new requirements associated with certifying patient eligibility for home health services will result in a reduced burden of $21.5 million. However, the overall economic impact of the Final rule is estimated to be $60 million in decreased payments to home health agencies.

Kusserow on Compliance: HHS OIG Releases Work Plan for FY 2015

On October 31, 2014, the HHS Office of Inspector General (OIG) issued its fiscal year (FY) 2015 Work Plan. This comes at the beginning of the FY, which began October 1, 2014. The 2015 Work Plan was released three months earlier than last year’s, which was not done until January 31, 2014, into the second quarter of the FY. This posting will provide a quick look at the Plan and will be followed by more detailed analysis of various sections in following postings. The Work Plan is part of the OIG oversight of more than 300 programs, although an extensive amount of effort and resources are focused on the Medicare and Medicaid programs and their beneficiaries. The OIG operates through four major divisions: Office Audit, Office Evaluation and Inspection, Office of Investigations, and Office of Counsel to the IG. The first two represent the bulk of the plan in that they provide information about intended areas of work, whereas the investigators and attorneys primarily respond to legal issues as the arise, although the Work Plan speaks to several initiatives that involve these functions.

Accomplishments Reported

  • Expected recoveries of $4.9 billion, including $4.1 investigative receivables (of which $1.1 were Medicaid) and $845 million audit receivables
  • $15.7 billion in estimated savings as result of actions taken on prior OIG recommendations
  • Over $5.8 billion in investigative receivables
  • 4,016 individuals and entities excluded from participation in federal healthcare programs
  • 971 criminal actions taken against individuals or entities (crimes against HHS programs)
  • 533 civil actions, which include false claims and unjust-enrichment lawsuits and others

Quick Glance at the Work Plan

The Work Plan outlines new and continuing OIG operations and reviews. Most of work plan items reflect continuation of work previously reported in prior plans. New items are denoted by “(New)” after the project title. New projects are followed by the year the project will begin, and a report may be issued in the same year or the following year. Ongoing projects are followed by the year a report is expected to be issued. For each planned review, the OIG provides: (1) an internal identification code; (2) the year in which the OIG expects to issue results; (3) information as to whether the work is a continued or a new focus. The OIG posts all issued reports to its website.

As expected, the OIG will continue include to review entities, including hospitals, nursing homes, hospice, and home health services. Examples of Work Plan items for FY 2015 include:

  • New inpatient admission criteria;
  • Medicare oversight of provider-based status;
  • Duplicate graduate medical education payments;
  • Outpatient evaluation and management services billed at the new-patient rate;
  • Oversight of hospital privileging;
  • Questionable billing patterns for Part B services during nursing home stays;
  • Hospice general inpatient care;
  • Home health prospective payment system requirements;
  • Diagnostic radiology-medical necessity of high-cost tests; and
  • Selected independent clinical laboratory billing requirements.

It is the intention of the OIG, as part of its policy of open transparency, to let everyone know about its plans. The OIG does this so that individuals and entities will be able to review the Work Plan and use it to compare issues identified by the OIG to their own organization. This will allow time to help everyone “bring their house” in better order. As such, all those entities that are involved in HHS programs should examine the OIG Work Plan and review risk areas related to their areas of operation so as to permit, where needed, corrective actions to avoid OIG enforcement actions.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

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Copyright © 2014 Strategic Management Services, LLC. Published with permission.

Kusserow on Compliance: OIG Calls for Re-Examination of Critical Access Hospital Payment System

  • Medicare Beneficiaries Pay Half of the Costs for Outpatient Services at CAHs
  • Beneficiaries Pay Two to Six Times More than for Same Services at Acute Care Hospitals

The HHS Office of Inspector General’s (OIG) Office of Evaluation and Inspection (OEI) released a report on critical access hospitals (CAHs), calling for modification of how coinsurance is calculated for outpatient services received at CAHs that would reduce the current reimbursement amounts. The OIG cited higher costs Medicare beneficiaries pay when services are received at a CAH, than for the same services at acute care hospitals. This follows another OIG report from last year. Now these two reports stand back to back with a call for a review of critical access criteria for hundreds of small rural hospitals across the nation. Needless to note, there will be a lot of reaction from rural healthcare providers on this subject, as there was when the first report came out.

CAH Background

The CAH certification was created to ensure that rural beneficiaries would have access to hospital services, with Medicare reimbursing them 101 percent of “reasonable costs.” This is instead of payments made at the predetermined rates set by the Outpatient Prospective Payment System (OPPS). The system that Medicare uses to calculate outpatient coinsurance amounts for beneficiaries who receive services at CAHs differs from that used for beneficiaries who receive services at acute care hospitals. Beneficiaries who receive services at CAHs pay coinsurance amounts based on CAH charges, whereas beneficiaries who receive services at acute care hospitals pay coinsurance amounts based on OPPS rates. CAH charges are typically higher than the reasonable costs associated with CAH services or the OPPS rates that acute-care hospitals receive.

OIG Findings

The OIG reviewed claims data to calculate the percentages and amounts of coinsurance that Medicare beneficiaries paid toward the costs of outpatient services at CAHs. This data was compared to what it would be if beneficiaries paid at acute-care hospitals for the 10 most common outpatient services provided at CAHs. The OIG found that as result of coinsurance amounts being based on charges, Medicare beneficiaries paid nearly half the costs for outpatient services at CAHs. Because coinsurance amounts were based on charges, Medicare beneficiaries paid a higher percentage of the costs in coinsurance for outpatient services received at CAHs than they would have paid at hospitals under OPPS. For the 10 frequently provided outpatient services at CAHs, beneficiaries paid between two and six times the amount in coinsurance that they would have for the same services at acute care hospitals.

OIG Recommendations

To reduce the percentage of costs that Medicare beneficiaries pay in coinsurance, the OIG recommended that CMS seek legislative authority to modify how coinsurance is calculated for outpatient services received at CAHs. The OIG offered suggestions as to how CMS could modify how coinsurance is calculated for such services. These included:

  1. Computing coinsurance so that it is based on interim payment rates rather than charges, and
  2. Processing claims for outpatient services at CAHs as if they were paid under OPPS for the purpose of calculating an OPPS equivalent coinsurance.

CMS neither concurred, nor non-concurred with the OIG recommendation, preferring to sit on the sidelines for the time being; however, it is likely that CMS will eventually have to re-examine how CAH qualifications are defined and its current system of payments for CAHs.

Richard P. Kusserow served as DHHS Inspector General for 11 years. He currently is CEO of Strategic Management Services, LLC (SM), a firm that has assisted more than 3,000 organizations and entities with compliance related matters. The SM sister company, CRC, provides a wide range of compliance tools including sanction-screening.

Connect with Richard Kusserow on Google+ or LinkedIn.

Subscribe to the Kusserow on Compliance Newsletter

Copyright © 2014 Strategic Management Services, LLC. Published with permission.