Policy & Regulation News

CMS Changes Medicare Home Health Prospective Payment System

By Ryan Mcaskill

The new HH PPS for 2015 has a greater focus on efficiency, flexibility, payment accuracy and improved quality.

- The Centers for Medicare and Medicaid Services (CMS) announced this week that it has made changes to the Medicare home health prospective payment system (HH PPS) for the calendar year of 2015. The goal of the changes is to foster greater efficiency, flexibility, payment accuracy and improved quality. In 2013, an estimated 3.5 million beneficiaries received home health services from nearly 12,000 home health agencies. That cost was approximately $18 billion.

The rule implements increases to the national per-visit payment rates, a 2.82 percent reduction to the non-routine medical supplies (NRS) conversion factor and a reduction to the national, standardized 60-day episode payment rate of $80.95 for 2015. These changes are projected to reduce payments to home health agencies by 0.30 percent or $60 million.

This is one of several rules that for 2015 that highlight an Administration-wide strategy to deliver better care at a lower cost by finding better ways to deliver care, pay providers and use data.

“Provisions in these rules are helping to move our health-care system to one that values quality over quantity and focuses on reforms such as measuring for better health outcomes, focusing on disease prevention, helping patients return home, helping manage and improve chronic diseases, and fostering a more-efficient and coordinated health care system,” the press release reads.

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  • Medicare pays home health agencies through a prospective payment system that pays higher rates for services furnished to beneficiaries with greater needs. Payment rates are based on relevant data from patient assessments conducted by clinicians as currently requires for all home health agencies participating in Medicare. The rates are updated annually.

    Examining the rule more specifically

    Face-to-Face Encounter Requirements – The Affordable Care Act requires physicians to have face-to-face encounters with a beneficiary before they certify eligibility for home health benefits.Current regulations require that meeting to happen within 90 days of starting care or up to 30 days after care. The rule changes three things: physicians no longer need to add a narrative to explain why a patient is homebound; a denied HHA claim also cancels a physicians certifying/re-certifying patient eligibility; and reiterating that a face-to-face is required for certification.

    Therapy Reassessment – CMS is eliminating the 13th and 19th visit reassessment requirements. For episodes starting January 1, 2015 a qualified therapist must provide needed therapy service at least every 30 calendar days.

    Home Health Quality Reporting Program – Participants in the program will now be required to submit at least 70 percent of both admission and discharge patients with episodes of care occurring during the reporting period. That threshold will increase to a maximum of 90 percent over the next two years.

    Home Health Value-based Purchasing Model – The goal is to have an HHA VBP model up for testing in 2016. CMS will review all comments received on the project and decided if moving forward is a possibility.