Today, CMS issued significant rule changes, waivers of certain conditions of participations, and a series of interpretations of hospice and home health requirements designed to relieve
pressures and increase flexibilities during the pandemic crisis. All told, the outcome is a mixed bag. That means there is still a lot of work to do to break down the barriers to efficient and effective care.
Here is a summary list of the changes. NAHC will be providing more detail in the coming days.
We start with the disappointment. CMS issued an emergency interim final rule that addresses the industry-wide priority of increasing flexibility
in the use of telehealth. The goal was to gain opportunities to provide telehealth as a means to maximize the availability of staff for in person visits when no alternative was possible, reduce demand on PPE, increase discharges from inpatient hospitals to
free up needed beds, reduce exposures of patients and caregivers, and mitigate concerns or virus transmissions that have led to patients refusing needed care. To do all that, HHAs simply asked to get paid for telehealth services.
CMS recognized the high value of telehealth and the potential to achieve significant outcomes such as the ones referenced above. However,
CMS determined that the law did not allow it to pay HHAs for telehealth. That means we must go back to Congress to change the law or we must change CMS’s view of the law. In the meantime, HHAs should see expanded telehealth as a means to reduce episode
costs. CMS, in fact, offered an illustration of how physician-ordered telehealth might reduce the need for in-person visits while not triggering a reduction in reimbursement as the LUPA threshold was met. As such, CMS sees telehealth not as something to pay
for, but rather something to reduce HHA costs. We strongly disagree with CMS that payment for telehealth is not warranted. We vow to fight on!
The CMS policy does allow HHAs to record the cost of all telehealth services in the cost report. Big deal! That might affect reimbursement rates five years from now. However, we do
very much appreciate that CMS sees great value in telehealth. The discussion of such in the rule is a clear indication that CMS understands and accepts the value of telehealth provided buy HHAs.
As a side note, CMS does pose a limited option for HHAs. That option would have the HHA contract with a physician or NPP to provide the telehealth to patients. The physician or NPP
would then bill for the telehealth service and pay the contracted rate to the HHA. CMS cautions though that such action may be a concern if it is done within a home health services covered episode.
HHAs have long recognized that telehealth could reduce visit volume needs. CMS now also recognizes that outcome. Going forward, CMS wants HHAs to use more telehealth. A key is that
it must be physician ordered rather than the HHAchoosing to substitute telehealth when in person visits are ordered.. Still, it will not add any reimbursement. It will only have the potential reduce costs. NAHC fully intends to continue an aggressive push
to the real change that is needed—payment for telehealth..
The changes do have a
number of significant upsides. Those are
HOME HEALTH SERVICES
1.
A definition of the home health “homebound” requirement that means that any individual determined by their physician to be at high risk of contracting Covid-19 virus due to a compromised health condition, meets the homebound
requirement because it is “medically contraindicated” to leave the home.
2.
A waiver of numerous Conditions of Participation, including:
a.
Onsite visit for home health aide supervision
b.
In person initial patient assessments. Instead, HHAs can provide these assessments remotely or by record review
3.
Utilizing enforcement direction to permit non-physician practitioners (NP, PA, and CNS) to certify eligibility for the home health benefits and to establish and manage the Plan of Care provided such is allowable under state
practice laws. This change was mandated at part of the CARES Act enacted into law last week. However, CMS has been able to accelerate its implementation through its enforcement discretion authority.
4.
Suspend all medical review audits other than in cases of fraud investigation
5.
Suspend the Review Choice Demonstration program. HHAs will have the choice to continue with pre-claim review if they wish. Other claims will be subject to possible post-payment review. RCD will not expand into Florida and
North Carolina as originally planned for May. No new date has been set for that expansion.
HOSPICE SERVICES
1.
Allowance to use telehealth for the physician face-to-face encounter requirement. This was mandated as part of the CARES Act. However, CMS determined it had the authority to make that change under its own authority. Effectively,
this action speeds up the implementation.
2.
Permit the billing of telehealth services by hospice physicians
3.
Waive the requirement for hospices to use volunteers
4.
Waive timeframes for updating comprehensive patient assessments extended the deadline from 15 to 21 days
5.
Waive the non-core services requirements that include physical therapy, occupational therapy, and speech-language pathology
6.
Waive the 14 day home health aide in-person supervisory requirements same as in home health
7.
Suspend all medical review audits other than in cases of fraud investigation
These changes are in addition to those earlier announced that include the establishment of an Accelerated and Advance Payment program, permitting home health F2F encounters by telehealth,
and suspending the auto-cancellation RAP program. CMS also permitted allowances for extending appeal deadlines and some provider enrollment requirements.
All told, there are many positives in today’s actions by CMS. Still, we have more to do. We especially are not finished with telehealth reform advocacy. Stay tuned on that.
These changes can be found at:
https://www.cms.gov/about-cms/emergency-preparedness-response-operations/current-emergencies/coronavirus-waivers
https://www.cms.gov/newsroom/press-releases/trump-administration-makes-sweeping-regulatory-changes-help-us-healthcare-system-address-covid-19
https://www.cms.gov/files/document/provider-burden-relief-faqs.pdf.
Good night.
Bill
William A. Dombi, Esq.
President
National Association for Home Care & Hospice
228 7th St, SE
Washington, DC 20003
202-547-7424(ph)
202-547-7382 (fax)
wad@nahc.org