Delta Connect Blog

Certifying Physicians Edits for Home Health Agencies

Posted by Lorraine Lodigiani on Apr 17, 2014 4:13:10 PM

CMS has issued a special edition Medicare Learning Network® article which confirms that both the certifying physician and the attending physician will be subject to the Provider Enrollment, Chain and Ownership System (PECOS) edit when listed on the claim.

Effective July 1, 2014, HHAs are required to report the NPI of the physician who certifies/re-certifies the patient’s eligibility (Certifying Physician). This is in addition to reporting the NPI and name of the physician who signs the patient’s plan of care (Attending Physicians) when the attending physician is not the same physician who certified/recertified the patient’s eligibility to receive services under the Medicare home health benefit. This will occur when the acute or post acute care physician is the physician who documents the face to face encounter, certifies the patient for home health services, and hands off the patient to the community physician who will sign the plan of care. 

Therefore, for episodes that begin on or after July 1, 2014, the certifying physician and the attending physician must be enrolled in PECOS or have validly opted out.

If the Certifying and Attending physicians are different, both physicians are subject to the ordering and referring denial edits.

If the Certifying and Attending physicians are the same, the edits will only be applied to the “Attending” field.

The denial edits will serve as validation and verification that the attending and/or certifying physician that is ordering/referring services listed on the billing provider claims is eligible and enrolled in Medicare in an approved or opt out status.

To view the full article, click here.


From the NAHC Report article 


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Keep Up Advocacy Efforts for Home Health and Hospice During Congress’ April Recess

Posted by Lorraine Lodigiani on Apr 15, 2014 1:08:36 PM

Members of Congress are out for their two-week April recess and will not return to Washington until April 28.  This would be a good time for home care and hospice advocates to be in touch with their Members of Congress back home about home care and hospice issues. 

An effective idea is to invite your legislators to accompany representatives of your agency on a home visit as a compelling way to ensure Members of Congress are informed about the benefits of home care and hospice.  Senator Susan Collins (R-ME) said at NAHC’s recent March on Washington that a home visit with a home care provider was a transformative experience for her.   Home care and hospice advocates should also attend legislators’ public appearances over the recess for a chance to speak up about the importance of home care and hospice issues. 

Helpful when planning such a contact or visit, many legislators now list their schedules on their website, or this information can be obtained by calling the Member’s district office and requesting an itinerary.  To obtain contact information for your Members of Congress, go here: Contact Your Elected Officials.  

One of the important messages to deliver is to urge lawmakers to reject proposals that would impose home health and hospice copays and payment cuts to offset the cost of fixing the flawed Medicare physician payment formula (SGR), to reduce the deficit, or for other purposes.  Here are links on NAHC’s Legislative Action Network to background information and to send a message online.  

For home health -- Write Your Legislators;

For hospice -- Write Your Legislators

NAHC is also seeking to include an amendment in any Medicare legislation which would provide relief from CMS’ home health rebasing final rule.  For a description of this amendment and why it is needed, go here: Rebasing Reform Proposal Talking Points.  To send a message online asking that lawmakers support this amendment, go here Write Your Legislators

Home care and hospice advocates may raise other important issues during the Congressional Easter recess, either by visiting with their lawmakers back home or by sending a message through the NAHC Legislative Action Network:

  • Reform the face-to-face physician encounter requirement for home health services -- Write Your Legislators.
  • Modify the employer responsibilities in the Affordable Care Act (ACA) to address home care specific needs --Write Your Legislators.
  • Preserve the companionship services exemption --Write Your Legislators.
  • Permit Nurse Practitioners and Physician Assistants to sign home health plans of care (Home Health Care Planning Improvement Act (S.1332;H.R.2504)) -- Write Your Legislators.
  • Offer incentives for the adoption of telehomecare technologies (Fostering independence through Technology Act (S.596)) --Send a letter to your Senator.
  • Refine hospice face-to-face requirement, require demonstration of hospice payment reform, and increase hospice survey frequency (Hospice Evaluation and Legitimate Payment Act (S.1053;H.R.2302)) -- Write Your Legislators.
  • Define full-time for purposes of the ACA employer mandate as 40 hours a week (S. 1188; H.R.2575; H.R. 2988) -- Write Your Legislators.

For talking points on other priority issues for home care and hospice providers, you may go here--2014 NAHC March on Washington Resources—and here - Legislative Priorities.


From the NAHC Report article


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CMS Holds Special Open Door Forum on Hospice and Medicare Part D

Posted by Lorraine Lodigiani on Apr 11, 2014 7:42:57 AM


CMS held a Special Open Door Forum (ODF) on the topic of Medicare Part D and Hospice on April 8, 2014.  This ODF was an opportunity for providers to ask questions of CMS subject matter experts on the Part D Payment for Drugs for Beneficiaries Enrolled in Hospice – Final 2014 Guidance.  This guidance was released on March 10, 2014 and is effective May 1, 2014.  Because previous Part D guidance was ambiguous, and there were no objective criteria for sponsors to use in making Part A vs. Part D coverage and payment decisions, the policy will be applied prospectively.

During the ODF CMS reminded providers that, per statute, Medicare excludes from coverage under Part D any drugs that are available under Parts A or B.  Since hospice is a Part A benefit, drugs covered under the hospice benefit for an individual can not be covered under Part D. 

In order to avoid duplicate payments for drugs covered under hospice or waived through the hospice election, CMS directed Part D sponsors to place beneficiary-level prior authorization (PA) requirements on all drugs presented to Part D for payment for beneficiaries who are receiving hospice services.  More detailed information is found in the Part D Payment for Drugs for Beneficiaries Enrolled in Hospice – Final 2014 Guidance, which can be accessed here.

A summary of the Special ODF highlighting frequently asked questions is below:

What is the PA process, and can the hospice initiate it?

The Part D sponsors will use the existing standard PA process, which means a reject code will be generated by the Part D sponsor for any medications presented for payment for beneficiaries receiving hospice services.  This reject code is not a denial.  It is a rejection.  This means the sponsor needs more information before the claim can be processed. Only the beneficiary/representative or the prescriber can request the PA.  The reason for this is related to the regulations pertaining to Part D plans. The PA is a determination of payment.  The hospice, the Part D plan sponsor, or the beneficiary is determined to be responsible for payment.

Although the hospice cannot initiate the PA process, it can provide information.  Both CMS and NAHC urge hospices to proactively communicate with the patient’s Part D plan sponsor.  This includes notifying the plan sponsor of the beneficiary’s hospice election (by filing the NOE as soon as possible), providing a list of prescriptions that will be presented for Part D payment and an acceptable explanation of why the medication is unrelated; as well as notifying the sponsor of a patient’s revocation or discharge.  This communication will expedite the filling of prescriptions and minimize delays for beneficiaries.  In most cases the hospices can provide this information via the plan sponsor’s pharmacy hotline.

Can the plan sponsor deny the medication even after the explanation is provided?

When a coverage determination is requested, again by the beneficiary/representative or the prescriber, the plan sponsor should contact the prescriber or the hospice and accept a verbal or written explanation of why the drug is unrelated.  It is CMS’ expectation that the plan sponsor will accept the explanation; however, this is not enforceable because there is not a regulation requiring this acceptance. However, CMS believes that the plan sponsors will comply, essentially stating that there is not an incentive for the sponsor to deny the claim after an acceptable explanation is received.  CMS stressed that an adequate explanation is a “coherent clinical explanation”.  A statement that the medication is unrelated is not acceptable and the sponsor can deny payment of the medication if there is not an adequate explanation. It is incumbent on the hospice or the provider to be clear about why the medication is unrelated to the terminal illness and related conditions.  There are other legitimate reasons why the sponsor could deny payment such as the dispensing pharmacy being out of network or the medication requires prior authorization under the sponsor’s utilization management program and those requirements have not been met

There will be no dispute resolution process in 2014, so the PA documentation will support coverage of the drug under Part D.  This policy does not affect beneficiary appeal rights. Beneficiaries retain the right to appeal Part A coverage decisions through the Medicare fee-for-service process and Part D coverage decisions through the Part D appeals process.

We are calling the Part D plan sponsor to proactively provide communication, but the sponsor states they are not aware of the PA process.

CMS reminded listeners that the sponsors just became aware of this policy on March 10, 2014 just as the hospices did.  So, it may take a little more time for all the sponsors to have adopted and implemented the policy.  CMS is hopeful that some of the problems hospices and beneficiaries have encountered, i.e. long wait times on telephone calls, etc., will improve as time goes on.  CMS recently held a call for the Part D plan sponsors on this topic which provided some answers and clarification to the Part D plan sponsors which will help with this as well.

What happens when medications are paid for by the Part D plan sponsor (after receiving an acceptable explanation), after a patient has elected hospice?  Will the sponsor chase the hospice for payment of the medications?

If the sponsor has paid for drugs after the hospice election, but before receiving notification, the sponsor should contact the prescriber or hospice for a retrospective determination of payment responsibility for the drugs. 

When a drug is determined to be the hospice’s (or beneficiary’s) responsibility, the sponsor should negotiate directly with the responsible party to recover payment.

Additional information is found in the slides used for the special ODF that can be accessed from the Hospice Center webpage

Questions can also be submitted to  Please include “Hospice” in the subject line.

From the NAHC Report Article 



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Effort Led by NAHC’s Hospice Association of America and 40 State Associations Yields Positive Change in CMS Hospice Vaccine Billing Requirements

Posted by Lorraine Lodigiani on Apr 9, 2014 10:30:37 AM

As reported previously, NAHC’s Hospice Association of America (HAA) and members of the Forum of State Associations (FSA) recently joined together to urge the Centers for Medicare & Medicaid Services (CMS) to change existing policies that require hospice organizations to enroll as Part B suppliers in order to bill preventive vaccines for hospice patients.

HAA and FSA members recommended an alternative policy: allowing hospices to bill for vaccine services on an institutional claim.

In a joint letter to CMS, HAA and the state associations cited regulatory burdens and inconsistency in policies as justification for reconsideration of current policies.

On April 7, 2014, HAA received a response from CMS indicating that CMS agrees with the recommendations made in the joint letter: 

“We agree that it is both feasible and beneficial to the Medicare program to make the changes you have proposed.  In addition to reducing administrative burden for hospices, such a change would provide increased consistency within the Medicare program and a reduction of enrollment workload for our contractors.” 

As a result, the letter goes on to state, “We plan to issue a future transmittal which will add billing instructions to the Medicare Claims Processing Manual to reflect these changes.” 

The letter clarifies that under the changes, CMS envisions:

“Billing instructions mirroring those in place for hospice pre-election evaluation and counseling services.  The vaccine services would be submitted on an institutional claim using a hospice type of bill code (081x or082x), but only the vaccine and vaccine administration revenue codes could appear on this claim.  In this way, Medicare systems will be able to identify the claims for separate Part B payment.” 

At this time CMS anticipates inclusion of the change for hospice billing of vaccines in its January 2015 Medicare systems release, although this time frame may be subject to change depending on CMS priorities.

A copy of CMS’ April 7 to HAA letter is available here.

From the NAHC Report article


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Topics: Hospice

Defining Full Time Employment as Forty Hours

Posted by Rachel Alden on Apr 4, 2014 3:15:51 PM

The House of Representatives recently voted 248-179 to define full-time employment for purposes of the Affordable Care Act (ACA) employer mandate to provide health insurance for full time workers or pay a penalty as forty hours a week.  Eighteen Democrats joined with all voting House Republicans who supported the measure. The ACA as it was written defined a full-time employee as someone who works only thirty hours a week.

The President has threatened to veto the bill.  The legislation will now go to the Senate, where its fate is uncertain. As this is a prominent issue for home health and private duty providers, NAHC is continuing its campaign to build support by encouraging Senators to cosponsor the bipartisan companion legislation, the “Forty Hours Is Full Time Act” (S.1188), introduced by Senators Susan Collins (R-ME) and Joe Donnelly (D-IN).

For more on S.1188 and NAHC’s efforts to build support for this legislation, please see NAHC Report, March 31, 2014.

The more cosponsors the Senate bill gets – particularly by increasing Democratic cosponsors - the greater the chance that the Senate will take up and pass this legislation.  To send a message to your Senators urging them to support S.1188, please click here.

From a NAHC Report article.


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Topics: Affordable Care Act

ICD-10 Delayed to October 1, 2015

Posted by Lorraine Lodigiani on Apr 1, 2014 12:16:24 PM

It's April Fools Day, but there is no joke in the Senate. The U.S. Senate voted to pass the Protecting Access to Medicare Act of 2014, which both pushes back the compliance deadline for ICD-10 and perseveres the pay rate for doctors treating Medicare patients. Senators moved the bill along by a vote of 64 to 35.

As was the case in the House hearing last Thursday members of Congress spoke passionately about how problematic the bill and the process of cramming it through have been.

“We need to restore sanity to the Medicare payment system,” said Majority Leader Harry Reid, D-NV,  at the beginning of the debate. “The fact remains this legislation is not perfect, it’s not ideal.”

Later, Sen. Orrin Hatch, R-Utah, added: “I’m not going to make the perfect the enemy of the good. I plan to vote in favor of the SGR bill today.”

Hatch, as it turned out, was in the majority. Whereas the provision to delay ICD-10 may go largely unnoticed in the general citizenry, it isparked something of an uproar in the healthcare realm — where the code set conversion is among the most contentious issues. 

“This idea of bundling a ‘bad thing’ with a ‘good thing’ in a bill that is sure to pass because of the ‘good thing’ is sort of crazy,” said healthcare technology consultant Steve Sisko.  

Joe Lavelle, founder of Results First Consulting, which works with healthcare systems, added that “the way the vote went clearly indicates to me that back door, big-time political forces are at work.”

On Monday the American Health Information Management Association took to Twitter with the #NoDelay hashtag, calling on senators including Sens. Reid and Ron Wyden, D-Ore., who by virtue of taking over the Senate Finance Committee 16 days ago found himself at the center of the feisty debate, to vote down the bill or pull out the ICD-10 provision.

Lavelle said that among his clients the payers and most health systems would have been ready by Oct. 1, 2014 and that they will take advantage of the extra year, particularly for testing and dual-coding.

“We will not slow down this time — lesson clearly learned last time,” Lavelle added.

Lavelle estimated that another yearlong delay will cost his clients anywhere from $500,000 to $3 million each, depending primarily on the organization’s size.

“If we simply delay without addressing the reasons for delay (procrastination, lack of testing, etc),” Lavelle explained, “then we will be back in the same place next year.”

The bill also serves as the 17th patch of the so-called “doc fix” or SGR, which was the overriding reason for the heated debate Monday afternoon. SGR is the rate that the Centers for Medicare & Medicaid Services pays physicians for treating Medicare patients. The rate of pay was slated for a 24 percent reduction effective April 1. By passing this bill, the Senate voted to postpone that reduction for another 12 months.

“Parties could not come to agreement on what a permanent [SGR] fix should be,” Sen. Reid explained. And he represented what just about every senator who spoke Monday said when he added, “I hope it’s our last patch.”

From the Healthcare IT News article written by Tom Sullivan, Editor, Government Health IT


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Home Care Aides Demanding Better Pay

Posted by Rachel Alden on Mar 31, 2014 9:20:50 AM

According to WWLP Boston, caregivers in Massachusetts are asking the state for better pay, saying that increased wages will inspire more people to join the profession to care for the elderly.

Personal and home care aides are among the fastest growing jobs in the nation, but if they don’t work for the state, many of these caregivers barely get paid enough to survive.

Caregivers protect the state’s most vulnerable people, but their average wage is just $10 per hour.

Senior care managers make around $35,000 per year, while a state worker doing the same exact job gets paid $14,000 more annually. State funding for senior care services has been frozen for the last five years, and a group of caregivers who gathered on Beacon Hill this week say that if they don’t get a raise, no one will be left to defend the elderly.

“They deserve to be taken care of and treated with dignity and compassion, and a lot of times they don’t have a voice, so it’s our job to be there to advocate for them,” senior caregiver Carolyn O’Brien said.

There are about 17,000 people in Massachusetts employed as elder caregivers, and many of them are leaving the field for higher-paying jobs in health care and human services.

Caregivers are asking the state for $9 million in fiscal 2015 for a salary increase, which they say will create more incentives for people to become home care aides.

From a WWLP article.


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Topics: caregivers

House passes 1-year SGR fix that would delay ICD-10

Posted by Lorraine Lodigiani on Mar 28, 2014 10:01:34 AM

Providers could have one more year to prepare for ICD-10 after the U.S. House of Representatives today voted "yes" via voice vote to a 12-month sustainable growth rate (SGR) patch bill that included an ICD-10 delay by at least one year to Oct. 1, 2015.

The bill has to go to the Senate, and a spokesperson for the Senate Finance Committee said today that it has not received the bill and doesn't expect to before tomorrow. Speaker of the House John Boehner, R-Ohio, has said he and Senate Majority Leader Harry Reid, D-Nev., had reached a deal on the legislation.

Some kind of short-term fix is needed to prevent a mandated 20.1% SGR cut to physicians' Medicare pay April 1. The last legislative patch, which prevented the cut through March 31, was passed in January (PBN 1/6/14).

The AMA came out against the bill. Accusing the authors of "cherry-picking" cost-savings provisions from previous, full-repeal SGR bills that had been proposed, AMA President Ardis Dee Hoven, M.D., said the new bill "actually undermines future passage of the permanent repeal framework."

"Full repeal of the SGR is the answer to strengthening the Medicare program, not another patch," said Hoven. Hoven's statement was supported by several other medical groups, including the Medical Group Management Association, American College of Physicians and American Academy of Family Physicians.

The new bill would hold off the cut until April 1, 2015. Some features would ostensibly save the Medicare program money to pay for the patch, in the short and the long term – for example, a section "Ensuring Accurate Valuation of Services Under the Physician Fee Schedule" would save $4 billion from 2014 to 2024, according to a Congressional Budget Office (CBO) scoring of the bill.

From Home Health Line Breaking News


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March on Washington Gets Underway with Opening Legislative Update

Posted by Lorraine Lodigiani on Mar 26, 2014 8:11:59 AM

NAHC's annual March on Washington got underway on Sunday with a general session that highlighted the many issues that the home care and hospice community face, and why this year is so critical for the industry overall to be in Washington as advocates. With SGR negotiations getting underway in Congress, proposals to add copayments to home care and hospice benefits on the table in some proposals, ongoing concern over the face-to-face and companionship rules, CMS’ misguided rebasing Final Rule and ongoing confusion over the ACA employer mandate, the opening session’s panel of experts from NAHC provided updates to attendees on all of these issues, as well as on the political, legislative and regulatory climate in Washington. DC.  

The General Session’s panel included many of NAHC’s own legislative, legal and policy experts - NAHC President Val J. Halamandaris; NAHC Vice President for Law Bill Dombi; NAHC Vice President for Hospice Policy and Programs Theresa Forster; NAHC Vice President for Government Affairs Jeff Kincheloe; NAHC Vice President for Technology Policy Richard Brennan; NAHC Vice President for Regulatory Affairs Mary Carr; Colin Roskey, NAHC Counsel and Mary Langowski, NAHC Counsel – who provided their insight, analysis and percpective on a range of issues.

While the panel helped to outline in clear terms what is at stake for the home care and hospice community - and why it is so important for lawmakers to hear from their constituents who work in the home care and hospice fields – there were some areas of good news. “We could be getting good news from the CBO on our rebasing rule soon,” said NAHC Vice President for Law Bill Dombi. “Just to have the CBO score it is an accomplishment.”

Another area where there were positive developments were in health IT for home care and hospice providers. “There is finally alignment between Congress and the Adminsitration when it comes to healthcare spending and how health IT can play a role in containing those costs,” said NAHC Vice President for Technology Policy Richard Brennan. “There is a bright future ahead for home care and hospice telehealth, but we need support from Congress.”

Panelists also went into detail about a range of Medicaid, Medicare and hospice issues, reminding attendees of some of the key messages to share with lawmakers. “Remind lawmakers that CMS is predicting that close to 50 percent of home health agencies will be under water because of the rebasing rule,” said Mary Langowski. “Tell the people you meet with what that means for their district and humanize what it is you do.”

In offering a summary of the home health and hospice community’s successes in the past year and challenges ahead, NAHC President Val J. Halamandaris offered, “we have been pretty successful recently playing strong defense, but it’s time for us to go on the offense, and that’s what we’re going to do…The biggest threat facing us now is that we don’t work together to overcome these challenges.”

The opening general session was also being “live tweeted.” Attendees are encouraged to join the conversation via social media by using the #MoW2014 hash-tag throughout this year’s March on Washington.

From the NAHC Report article 



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Ensuring High Quality Home Care

Posted by Rachel Alden on Mar 21, 2014 1:42:21 PM

This week, posted an article entitled "We All Want to Live at Home in Old Age, But Know Nothing About the Quality of Care We Will Get There." In the article, Howard Gleckman outlines concerns about the lack of quality measures and reporting for non-Medicare certified home care, specifically for long-term home care funded by Medicaid, private pay home care, and home care provided by family or friends.

He lists three dangers with a lack of knowledge about the quality of home care aides:

  • It is difficult for families to pick good caregivers without some benchmarks to help define quality. What makes a good aide for someone with long-term chronic illness, and how does any given aide measure up?  Most consumers have no idea.
  • Government is pushing Medicaid-based care out of nursing facilities and into the community. But if this change is going to improve the quality of life for those with chronic conditions, we need to identify the flaws in the way we deliver home care and fix them. Government regulators focus on Medicare skilled nursing facilities, not on supports and services delivered at home.
  • It is hard to advocate for better caregiver training without evidence that both paid aides and family caregivers need this preparation. I’ve seen great caregiving training programs (the Schmieding Center in Arkansas is one of the best) but making them widely available will take resources and a public commitment that won’t be forthcoming until policymakers realize how serious the need is.

In the private duty industry, several organizations have led the way to fill this gap. Home Care Pulse has been offering quality management programs with satisfaction research, quality assurance consulting, proof of quality awards, and industry benchmarking reports. Leading Home Care's affiliate Caregiver Quality Assurance helps home care companies improve caregiver retention and reduce turnover costs.

By participating in these programs, home care agencies can display proof of quality or participation information on their marketing materials, helping families find agencies who meet quality standards.

What do you think? What else does the industry need to do to ensure that high quality care is provided to our loved ones?


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Topics: caregivers

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