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The Pulse: December 2013



Featured News

Message from President Jeff Lycan

*** Hospice Public Policy / Leadership Webinar Call ***
December 12, 10AM – 12:00PM
More information will be provided later this week.  Make plans to participate!

Entering the final stages of fall, an outlook I recently read for winter described it as a long cold season due to the early snow laden northern Canadian prairies. As we leave one season, the next looks to be a bit tougher than the present. Speaking metaphorically as our industry prepares for the new 2014 season and beyond it appears that healthcare will continue to provide many challenges. Understanding the variables that influence the forces which drive change is a critical management skill. This is a skill that develops with experience, over time, requires study as well as the accumulation of information from a variety of sources and of a broad scope.

You, our membership, have communicated to Midwest Care Alliance that a major component of the association is to synthesize such information and produce products and services that assist the development of appropriate change and response. The federal legislative/regulatory activity during 2013 put into motion many critical changes for the hospice and home care industry that will impact providers and patients for the rest of this decade. While Thanksgiving and seasonal holidays often create a philosophical break for most of us, this year our focus at MCA shifts towards issues occurring immediately at the state level.

Both, the legislature and state regulatory bodies, continue to push change at a non-stop pace. Throughout the month of November and December staff have been involved in meetings and advocacy work to support our positions. Just a cursory review this list includes: HB 332 and Opiate guidelines; RapBack & Criminal Background checks, Direct Service Workers & training/educational requirements; Medicaid waiver rule updates; Medicaid hospice rules; Hospice Licensure rules and MOLST. A “load of work” at any time of the year but the timing and push to complete certain items within the month of November and December raises some concerns.

In this edition of the PULSE you will receive information on HB 332 along with related talking points and a FAQ document MCA has developed. Hot off the Legislative Service Commission (LSC) press are two additional opiate related bills; HB 341 (To prohibit a controlled substance that is a schedule II drug or contains opioids from being prescribed or dispensed without review of patient information in OARRS) and HB 366 (To establish procedures for hospice programs to prevent diversion of controlled substances that contain opioids). Needless to say we are gearing up for a busy year-end push and January charge. First thing to focus on is HB 322 and MCA strongly encourages members to have your Medical Directors write letters to identified committee members as well as their personal legislator. It is critical we maintain the exemption for terminal conditions. We will also share the proposed hospice rule language changes. MCA is currently working on a response to these rules, both the Licensure Rules and Medicaid Hospice Benefit Rules. There are also multiple updates on other important issues as mentioned above, such as HHPPS realities as well.      


 ****ALERT ****

Prescription Drug abuse is ravaging parts of Ohio and the state legislature is intent on taking steps to curb this crisis.  Ohio began to strongly combat this issue with the passage of HB 93 in 2011.  Since that time many efforts and different committees have been working on ways to prevent “Pill Mills” from operating and to stop the use of prescription drug abuse in our state.  OARRS is the automated system that all prescribers in Ohio should be using to report suspicions of drug seeking, diversion, abuse, and/or check patient usage reports.  HB 93 made some changes in how prescribers are to interact with this system as well as redefined pain clinics.

During the time that HB 93 was being debated and continuing within the broader discussion around opiate abuse, Midwest Care Alliance has worked to maintain protections for terminally ill patients.   However, three weeks ago a House Bill (HB 332) was introduced (See previous December Alerts) which doesn’t currently have the exemption for terminal conditions language and this could have unintended consequences affecting the definition of “Chronic Pain” in Ohio. Ohio statute and rule regarding “Chronic Pain” currently has “terminal condition” identified as an exemption for certain activities and procedures.  Changing this definition could eventually lead to broader changes and implications in how our patients receive Scheduled II prescriptions. MCA believes it is critical to prevent that from occurring.

In response to HB 332 MCA has identified talking points, a Frequently Asked Question document and is working to identify best practice guidelines for our hospice providers. MCA strongly encourages members and their Medical Directors to write letters that support adding the exclusion for “terminal condition” into HB 332. Review the talking points and FAQs to help craft this letter. At this point the letter should go to Representative Ryan Smith, Chair of the Health & Aging Sub-Committee on Opiates. We would also recommend a copy go to your House Representative and if you have contact with your Senator inform them as well. Currently the bill is in the House for review and testimony. However, making sure our position is well known is critical.

Included below is a listing of the HB 332’s sponsor’s along with the representatives of the Health & Aging Committee. If one of your Representatives is specifically on the committee, inform MCA of your communications.

Bill Sponsors and Co-Sponsors:
Sponsors: Wachtmann (R) Napoleon
                 Antonio (D) Lakewood

Co-Sponsors:  Sprague (R) Findlay
                        Sheehy (D) Oregon

Bill is referred to the Health & Aging Committee:

Lynn Wachtmann (Chair) Napoleon
Anne Gonzales (Vice Chair) Westerville  
Tim Brown – Bowling Green                          Brian Hill - Zanesville    
Ron Hood – Athens                                      Jay Hottinger – Newark
Terry Johnson – Portsmouth                         Matt Lynch – Bainbridge
Ron Maag – Lebanon                                   Kirk Schuring – Canton
Barbara Sears – Sylvania                             Ryan Smith - Gallipolis                                  

Nickie Antonio (Ranking Minority)
John Barnes, Jr. – Cleveland                         Heather Bishoff – Blacklick
John Carney – Clintonville                             Robert Hagan – Youngstown
Dale Mallory – Cincinnati                               Dan Ramos - Lorain

MCA expects to have best practice guidelines ready by the first of the year. MCA believes it is desired that our prescribers be most diligent in their assessments and evaluations in identifying concerns around the use of these medications and when questionable to fall back on using the newly identified state guidelines

The association promotes the use of OARRS to check on patients when certain “red flags” occur.  OARRS is a strong tool that has a database capable of tracking all scheduled II prescriptions dispensed through a pharmacy. OARRS can identify scripts, to patients, from prescribers, to pharmacies dispensing, etc.  If our industry is a large user of these medications then we need to demonstrate awareness of the issues and prudent use of the tools in our efforts to control suspicious/aberrant behavior.

We expect HB 366 to be introduced which is meant to amend the hospice statute and would require hospice care programs to establish procedures to prevent diversion of controlled substances that contain opioids. We are watching this very closely and will alert the membership on next steps.



Hospice Licensure Rule Updates Coming

Hospice licensure rule updates are coming in 2014. MCA is reviewing a first swipe at the draft rules which can be found on the Ohio Department of Health website here. Search under rules then draft. One will find several different rules on this page. 3701-19 Hospice Rules are listed. ODH is making a major overhaul of the rules, moving language around and combining other sections. The department is also developing a document for the rule set titled Interpretative Guidelines as it removes language in the current rules that gives direction or examples of intent.

MCA is also reviewing Medicaid Hospice rules as updates are being made to address changes in the Medicaid program. More information on these rules will be addressed during the Hospice Public Policy / Leadership webinar on the 12th.  Make plans to participate.



Home Health HHPPS Teleconference Recordings

There are two NAHC recorded programs providing more information on the home health payment rate rule. MCA will publish information on the second program as it is available. The first program is the NAHC teleconference that occurred on November 26th. This teleconference provided information on how to get prepared for the changes in the payment rule. You can access the recording as follows: 

Conference Number: 5663971

Conference Date:    Tuesday, November 26, 2013

Replay Information:Start Date – November 26, 2013

End Date – December 26, 2013 at 6:36 pm

Replay Dial-In Numbers: (719) 457-0820 or (888) 203-1112

Passcode: 481323205

Don’t miss Dave Macke and Anne Shelley as they present the HHPPS Final Rule Webinar on December 12. This webinar will provide information on the financial and clinical aspects of the HH 2014 PPS Final Rule and provide instruction on what the impact of the rule will be for agencies. Click here for registration information.


Patient Confined to the Home

In October CMS published a new Transmittal (172) which clarifies the definition of the patient as being "confined to the home." This instruction is to more accurately reflect the definition as articulated at Section 1835(a) of the Social Security Act. In addition, vague terms, such as "generally speaking", have been removed to ensure clear and specific requirements of the definition.

CMS states “These changes present the requirements first and more closely align the policy manual with the Act.” (Rev.172, Issued: 10-18-13, Effective: 11-19-13, Implementation: 11- 19 -13) Click here for a copy of the transmittal. The language appears to tighten up the homebound status requirements as it specifies more strict language in the second criteria used to determine confined to the home status.


Home Health - CMS News: Stiffer Sanctions, Tougher Surveys and Harsher Penalties

Reviewing the nuances of survey certifications and enforcement procedures may not make anyone's top 10 list of most exciting workshops – however, attendees at this year's NAHC session said it was high on their list of most important sessions. 

Patricia Sevast, RN, of CMS's Survey and Certification Group, walked participants through a bureaucratic minefield with a mouthful of a title: CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES SUBCHAPTER G—STANDARDS AND CERTIFICATION, PART 488—SURVEY, CERTIFICATION, AND ENFORCEMENT PROCEDURES, Alternative Sanctions for Home Health Agencies With Deficiencies

Sevast explained that, as challenging as it may be to interpret the requirements, agencies must be able to demonstrate they are in "substantial compliance" with federal and state law, with the emphasis on continued rather than cyclical adherence. Surveyors have a lot of leeway when it comes to imposing sanctions on agencies found to be deficient, depending on specific problems discovered. Immediate termination procedures will begin only in the most severe circumstances – such as when patients are in imminent harm – but alternative sanctions may be imposed when deficiencies exist at condition level but do not pose immediate jeopardy. 

Sanctions last for up to six months and may include a combination of civil money penalties, suspension of payment for new admissions, directed in-service, directed plan of correction, or temporary management replacement. Subpart J - the regulation - went into effect on July 1, 2013. Civil money penalties, informal dispute resolution and suspension of payment for new admissions go into effect next July. (The complete set of regulations are available online here

Alternative sanctions offer incentive to come back into compliance quickly in a time period not to exceed six months, until compliance is attained or the HHA is terminated, Sevast explained. Agencies must not only establish policies that correct deficient practice but must also ensure that corrections are long lasting. "You have to take the initiative and responsibility for monitoring staff performance to maintain compliance," she stressed. "Or they will just come and shut you down." 

It is more often careless office procedures or sloppy paperwork than intentional fraud that raises red flags. The Face-to-face document may be missing a physician signature. A plan of care may not be placed in the patient file. A patient complaint may not be promptly investigated or properly documented. Each could signify more serious patient care issues. 

"We know there are things that can slip through the cracks," Sevast continued. "What we don't want to see is a repeated non-compliance, or inattention to procedures or regulations." Little errors can quickly multiply into big problems. If patterns of substandard care or situations that put patients in immediate jeopardy are found "you will find yourself on a 90-day track to termination." (November 13, 2013, by Liz Seegert)


Increased Scrutiny Coupled with Lower Payments

If monitoring daily compliance with Medicare regulations is not enough to keep agency owners awake at night, remember that they must also keep abreast of coming payment modifications for Medicare and Medicaid. Many of these changes are underway now or will begin by January 1. Topping the list is the reality of shrinking bottom lines due to rebasing. 

Mary Carr, NAHC's Associate Director for Regulatory Affairs prepped attendees for what rebasing may hold over the next four years. The Affordable Care Act requires changes in the nature of services provided during a 60 PPS episode along with recapture of what CMS perceives as "overpayments" for services. That means a 3.5 percent rate decrease each year, resulting in a net 13.63 percent reduction.

170 diagnosis codes have been eliminated for care that is either considered too acute or does not require home health intervention. Additionally, there is to be no increase in resource utilization, no changes in the wage index – the labor and non-labor portions – and no change in outliers.

NAHC strongly opposes these CMS modifications, said Carr. "Their formula relies on proxies for payment and cost determinations, even though real figures are readily available from cost report data." Just as bad, she said, is "a failure to factor in the wide range of revenue and cost per episode from geographically disparate HHAs, serving very diverse patient populations."

Nor are all current costs considered, in particular new regulatory compliance costs and permitted use of clinical technologies and services. "Rebasing also neglects to factor in the essential need for operating capital," Carr added. She also explained numerous regulatory changes affecting face-to-face encounter documentation and certification, safety data sheet standards, PECOS, Medicare Advantage and clarification of the definition of homebound. 

Another key area which agencies must adequately address are HIPAA provisions and breaches. "Stolen and lost laptops are our largest vulnerability," Carr warned. "If you don't have encryption safeguards in place, you're opening yourselves up to potentially serious breaches." 

©2012 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology One copy may be printed for personal use; further reproduction by permission only.

Second Year ObamaCare Enrollment Period Pushed Back a Month

HHS announced the delay late Thursday, saying it allows insurers more time to set rates after assessing their 2014 experience. The decision, first reported by Bloomberg, means sign-ups for the 2015 plan year would begin on Nov. 15, 2014 and end on Jan. 15, 2015 instead of the Oct. 15-Dec. 7 window previously announced. The date change, which also lengthens enrollment period by a week, gives companies more opportunity to account for individuals, particularly young adults, who come in late during the plan's first year. Read more….



ODH OASIS Winter Reflections

Click here for the Winter edition. The OASIS Manual was last updated December 2012 and will be updated again this December. The manual is available on line and a link is provided in the winter edition of OASIS Reflection. You will also find information on: Basic OASIS-C training offered in 2014, eligible patients, a number of frequently asked questions, correction policy, deletion forms, link to CMS quarterly Q&A and more.


Midwest Care Alliance Tracked Bills

MCA monitors and tracks bills at the state level monthly to determine their impact on our industry. Click here to view the bills we are currently tracking. 


State Review

Elections 2014
Democratic gubernatorial candidate Ed FitzGerald rolled into Columbus with his new running mate, Sen. Eric Kearney (D-Cincinnati), after a statewide tour introducing their ticket, and with new unemployment numbers not looking good for Ohio, FitzGerald said his likely opponent Gov. John Kasich isn't giving Ohioans what he promised. FitzGerald told Democratic Party faithful at the party's Columbus headquarters that people around Ohio have concerns that the current administration is running state government "for the benefit of a very small group of people”.

A new poll released Tuesday by Quinnipiac University shows Gov. John Kasich going into his re-election year up 7 percentage points over a challenger that is still unrecognizable to many Ohioans. But his lead over Cuyahoga County Executive Ed FitzGerald was cut in half since the June Quinnipiac survey.

Ohio's unemployment rate has been steadily rising since August, going from 7.3 percent to 7.4 percent in September, and to 7.5 percent in October, the Ohio Department of Job and Family Services (ODJFS) said Friday. The unemployment numbers for both September and October were released Friday, with the September numbers coming nearly a month late because of the federal shutdown in early October. The state now officially has an unemployment rate higher than the national rate, which was 7.3 percent in October.

Health & Human Services
Two Democrats Tuesday criticized the decision by the Ohio Department of Job and Family Services (ODJFS) to not seek a waiver of work requirements in order to get federal food assistance, saying they will introduce legislation that will require ODJFS to ask the federal government for a waiver.

The State Medical Board of Ohio on Monday permanently revoked the medical license of Dr. Lorenzo S. Lalli, a physician from Cleveland. According to a press release from the board, Lalli voluntarily surrendered his medical license to avoid any additional board action regarding allegations concerning his prescribing practices.

The Ohio Department of Health received a check from the U.S. Department of Housing and Urban Development (HUD) for $2.5 million Tuesday to re-up the Healthy Homes and Lead Poisoning Prevention Program for another three years. That figure was augmented by an additional $230,000 from the Ohio Housing Finance Agency and Ohio Development Services Agency (DSA).

Medicaid Expansion/Reform
The Ohio Supreme Court shouldn't consider a lawsuit challenging Medicaid expansion because the litigants, among them state legislators, fail to show standing or properly invoke justices' jurisdiction, the Kasich administration argued Monday.

The House Finance and Appropriations Committee continued testimony on Medicaid reforms Tuesday and announced plans to address the overlap in House and Senate proposals. Chairman Ron Amstutz (R-Wooster) said his HB208, jointly sponsored by Rep. Vernon Sykes (D-Akron), will be narrowed to focus solely on strategies to help connect Medicaid beneficiaries to services that help them find work and leave the public assistance program.

In the wake of an inspector general's report that criticized the way the Ohio Department of Taxation (ODT) handled overpayments of certain taxes, Gov. John Kasich said Monday that he will seek legislation codifying its current practices of refunding any overpayments even if the business is unaware of the overpayment and even if it does not ask for a refund.

The long-awaited substitute version of SB58 (Seitz) makes a laundry list of changes to the proposed energy overhaul, including a sizeable expansion of utility resources qualifying as advanced energy, renewable energy and alternative energy -- the latter now including any "behavior or practice" that reduces energy losses. They will not be enough to placate the bill's critics, which include a coalition led by the Ohio Consumers' Counsel (OCC) and the Ohio Manufacturers. (Barnes & Thornburg LLP, Mitzi Matheney  


CMS and Palmetto Related News

ICD-10 Medicaid

The linked communication below was created by ODM and the Ohio Medicaid Managed Care Plans (MCPs).  The communication is intended to give Ohio Medicaid providers information regarding the implementation of the ICD-10 code set.  ODM would like this communication to reach as many Ohio Medicaid providers as possible and has posted this information to the ODM ICD-10 webpage under the “Updates” section.  Additionally, the MCPs will be disseminating this information to their provider networks by various means.

Medicaid Provider Q&As on ICD10

To reach an even larger audience, ODM would appreciate your assistance by providing this information to your providers and/or members.  Possible modes of distribution are:

1) Include or attach to provider newsletters

2) Email blasts to providers

3) Load document or add a link to your webpage

4) Distribute at provider events/seminars

If you, or your providers, have any questions or wish to be removed from Ohio Medicaid’s ICD-10 stakeholder list, please direct your communications to and they will respond in a timely manner.