CMS: States Must Screen High-Risk Medicaid Providers

According to new guidance from CMS, states have until the end of July to begin screening high-risk Medicaid and Children's Health Insurance Program (CHIP) providers.

These screenings would involve fingerprint-based criminal background checks and would occur after a state Medicaid agency has been deemed high risk, or susceptible to improper payments. Providers considered high risk by Medicare are also be considered high risk by state Medicaid agencies. Background checks must be completed by June 1, 2016.

Those who would be required to undergo background checks include the high-risk provider as well as anyone with a 5 percent or more direct or indirect ownership interest in the provider.

To read the guidance, click here.

CMS Releases Electronic Staffing System Specs; System Becomes Mandatory In 2016

CMS has posted technical specifications showing long-term care facilities how to submit electronic staffing information that will be used by the Nursing Home Compare website and Nursing Home Five Star Quality Rating System to help consumers better understand staffing levels.

The submission system is known as the Payroll-Based Journal, or PBJ. PBJ allows staffing and census info to be collected on a regular and more frequent basis than it is currently collected, according to CMS, and it will also be auditable to ensure accuracy. All LTC facilities will have access to the system at no cost.

CMS plans to start collecting staffing and census data using PBJ on a voluntary basis beginning October 1, 2015. Using the system will become mandatory on July 1, 2016. Electronic submission was required under Section 6106 of the Affordable Care Act.

To view the specs on CMS's website, click here.

CMS Issues Proposed Mental Health Parity Rule for Medicaid, CHIP

CMS has issued a proposed rule that would "align mental health and substance use disorder benefits for low-income Americans with benefits required of private health plans and insurance," according to a press release from the agency.

The proposed rule would apply certain provisions of the Mental Health Parity and Addiction Equity Act of 2008 to both Medicaid and the Children's Health Insurance Program (CHIP).

Under the proposed rule:

• All beneficiaries who receive services through managed care organizations (MCOs) or alternative benefit plans would receive access to mental health and substance use disorder benefits, regardless of whether services are provided through MCOs or another service delivery system
• Plans must make the criteria for medical necessity determinations for mental health and substance abuse disorders available to beneficiaries and contracting providers 
• States would be required to make available to enrollees the reasons for any denial of reimbursement or payment for services related to mental health and substance use 
• States would still have flexibility in providing services through managed care delivery mechanisms other than Medicaid MCOs and must ensure that Medicaid MCO enrollees receive parity in services from these groups

To read the press release, click here.

CMS Beefs Up Five-Star Rating System

CMS today enacted several previously announced changes to the Five Star Quality Rating System on the Nursing Home Compare website.

The changes, which were initially announced in October, include the following:

• Antipsychotic use is now calculated into star ratings
• Improved calculations for staffing levels
• Higher standards for nursing homes to achieve a high rating on the quality measure dimension on the website 

The agency notes that star ratings allow consumers to see important differences in quality among nursing homes to help them make better care decisions. Nursing homes are rated on three categories: results from onsite inspections, staffing levels and performance on certain quality measures.

To learn more, click here.

CMS FY 2015 Requests Additional $49 Million for Surveys

CMS' proposed budget for fiscal year 2015 includes a $424.4 million request for Medicare survey and certification activities, a $49 million jump from the 2014 allocation. The agency said it needs the additional funds because of additional providers in the program and "improved CMS standards." CMS estimates that 91 percent of the funds would go toward surveys at LTC and home health agencies.

CMS also notes that their survey costs are being driven up by their involvement in "addressing issues of national importance" such as rates of antipsychotic medication prescription and pressure ulcers in nursing homes.

To learn more, click here.

OSHA: Heavily Soiled Linens Are Not Regulated Waste

OSHA has confirmed that LTC facilities and other healthcare providers are not required to dispose of contaminated linen as "regulated waste" and that OSHA's regulatory standard governing regulated waste is not meant to apply to linens that are laundered and reused.

OSHA examined the issue after it was brought to the agency's attention by the Association for Linen Management (ALM) and American Reusable Textile Association (ARTA). They were concerned about the practice of placing heavily soiled linens in red bags, which is a sign to laundry operators that the bags must go to a waste department for disposal.

Rather than placing the linens in red bags, the ALM recommends that facilities place heavily soiled linens in impermeable bags so that they do not leak on the way to the laundry.

ALM noted that some facilities place linens contaminated by residents with C. diff in the red bags because they believe the infection is so virulent that the linens must be destroyed rather than washed. This is not the case, according to the ALM. Instead, the linens can be laundered using the requirements set by CMS.

To learn more, click here.

CMS: Hospice Medication Claims Will Face Increased Scrutiny

CMS announced that Medicare claims for hospice medications will face heightened scrutiny from the agency in light of widespread inappropriate claims.

Medications for hospice patients should by and large be billed to Medicare Part A, with Medicare Part D only covering drugs that are needed for reasons unrelated to residents' terminal conditions. CMS believes that this guidance has been misinterpreted, resulting in Part D paying out $12.9 million in hospice claims for analgesics. These claims typically came from for-profit, new and/or rural hospice providers and half of the claims were for individuals receiving hospice care in nursing facilities.

To help remedy this, CMS plans to place prior authorization requirements on all hospice medication claims.

To learn more, click here.

CMS Sprinkler Requirement Now In Effect

CMS's automatic sprinkler requirement for nursing homes is now in effect. As of August 13, all nursing homes must be fully sprinklered in order to participate in Medicare or Medicaid.

The sprinkler requirement was first announced in 2008. Facilities were given a five-year window to become compliant.

CMS notes that it does not have authority to allow extensions for this deadline. While the agency issued a proposed rule on February 7 that would grant a limited extension of the due date for some facilities, that rule has not been finalized.

To learn more, click here.

AHCA: Keep QIOs State-Based

The AHCA is urging CMS to keep using state-based quality improvement organizations, or CIOs, for Medicare oversight. They are joined in their support by nearly 50 medical societies.

The groups oppose the potential replacement of state-level QIOs with regional ones and argue that doing so would damage the relationships that SNFs have built with their QIOs over the past decade. They also argue that it would be difficult to form relationships with an organization several states away.

To learn more, click here.

Survey: Residents Happy, But Food and Activities Still Lacking

A new study found that while nursing homes with more staff and fewer deficiencies tend to have happier residents, they're still coming up short when it comes to food and activities. The results of the study were based on three years' worth of satisfaction surveys in Massachusetts.

The researchers also found that non-profit and government-owned facilities tended to score better than their for-profit counterparts.

The researchers hope that their findings will help CMS decide whether to make consumer surveys a part of national nursing homes' report cards.

To learn more, click here.

CMS Plans to Share MDS Info with Health Plans

In an effort to fight fraud, CMS plans to share provider-specific MDS information with health plans. The MDS is one of 23 records systems affected by the new "routine use" defined by CMS.

According to CMS, sharing this information is meant to "prevent, deter, discover, detect, investigate, examine, prosecute, sue with respect to, defend against, correct, remedy or otherwise combat fraud, waste or abuse in such programs."

This sharing would, for example, show if a scammer is billing multiple insurance providers for a full day's worth of care on the same day.

Disclosures would be coordinated by the Data Sharing Partnership Group of CMS.

To learn more, click here.

Revised Survey Guidelines Give ROs More Discretion In Handling IJs

According to revised guidelines from CMS, regional authorities will now have the authority to decide whether to conduct full surveys of deemed providers that are cited for Immediate Jeopardy. Deemed status is available to certain long-term care providers, including hospices, home health agencies and rehabilitation agencies.

The revised guidelines, which were released on April 19, state that providers are subject to full surveys if a complaint investigation finds that they are exhibiting condition-level noncompliance (that is, care that poses a serious health or safety risk to residents, including Immediate Jeopardy citations). However, full surveys might not be necessary for all instances of condition-level noncompliance. Instead, CMS Regional Offices (ROs) will be tasked with deciding whether a full survey is needed on a case-by-case basis. CMS notes that this policy should improve efficiency and effectiveness. 

ROs will take the following into consideration when deciding whether a full survey is warranted (this list is not all-inclusive):

• The manner and degree of noncompliance (determined by the complaint investigation) 
• The provider's/supplier's complaint history
• Recent changes to ownership or management
• Whether the resources required to conduct a full survey are available in the timeframe needed
• The length of time since the provider's/supplier's last accreditation survey

If the RO determines a full survey is not needed, the provider/supplier will be placed on a 23- or 90-day termination track from the Medicare and Medicaid programs. Facilities that receive an IJ citation that isn't remedied while the surveyor is on-site will be placed on the 23-day track, but the RO will have the the option to conduct a revisit instead of a full survey prior to the 23-day deadline. 

To learn more, click here. 

CMS Group Releases Report on Criminal Employment at Nursing Homes

The Long-Term Care Criminal Convictions Work Group, which consists of CMS employees and volunteers from 11 state agencies, has released a report that urges providers and states to agree upon what a "direct access employee" is and whether a person with a criminal background should be allowed to work in a nursing home.

According to a March 2011 report from the Department of Health and Human Services, 92 percent of nursing homes employ at least one person with a criminal conviction.

To learn more, click here.

CMS Alters Survey Procedures In Light of Sequestration Cuts

In a memo released on Tuesday, CMS announced plans to alter some nursing home survey procedures related to life safety codes as a result of sequestration budget cuts. The CMS Survey & Certification budget has been reduced 5 percent from 2012.

The changes are as follows:

• Life Safety Code (LSC) Survey Focus: To help surveyors meet the August 13, 2013 deadline for all nursing homes to install automatic sprinklers, CMS has created a Short Form survey process. 
• Efficiency and Effectiveness: The agency hopes that the Short Form will help surveyors work more efficiently in light of the budget cuts. It should allow them to spend less time at facilities that have demonstrated compliance with codes in the past and more time at facilities with less-than-stellar records. 
• State Option: States will be given the option to implement a Short Form Fire Safety Survey for a limited number of specified facilities that have demonstrated superior compliance with life safety codes and are fully sprinklered. 
• Training: Surveyors in states using the Short Form must be trained during a special training event before utilizing the new process. 

Beginning in FY2013 and at the beginning of each year thereafter, CMS will send each state a list of facilities that qualify to use the Short Form survey process. 

To read the memo, click here.

CMS Clarifies Which Tasks Can Be Delegated by Physicians

CMS has released a brief that clarifies which tasks may be delegated by physicians to other practitioners caring for Medicare beneficiaries in skilled nursing facilities. It can be downloaded here.

The brief focuses on which tasks can be delegated to non-physician practitioners (NPPs), such as nurse practitioners, physician assistants or clinical nurse specialists.

2% Medicare Cuts, Part of Sequestration, Began on April 1

The 2 percent cut to Medicare payments that are part of sequestration took effect on Monday.

As a result of the cut, providers will be reimbursed 98 cents on the dollar for Medicare fee-for-service claims with dates of services or dates of discharge on or after April 1, 2013. The payment adjustment will be applied to all claims after determining coinsurance, any applicable deductible and any applicable Medicare Secondary Payment adjustments.

The impact will begin to be evident in mid-April. The payment reductions are on track to cost skilled nursing facilities about $782.5 million in fiscal year 2014.

CMS Posting More Deficiency Data Online

In a memo released on March 22, CMS announced that it will begin to make additional information about nursing home deficiencies available in April. 

The agency currently posts deficiency report information on the Nursing Home Compare and Five-Star Nursing Home Quality Rating System websites. The information is based on data from Form CMS-2567, Statement of Deficiencies and Plan of Correction, and goes back for 15 months. 

Beginning in April, the agency will make older information available and will provide more detail about the deficiencies cited in the reports. 

CMS does not plan post plans of correction online, but they can be requested from CMS State Survey Agencies or directly from facilities. Federal law mandates that these reports must be provided upon request. 

To read the memo from CMS, click here. 

SNFs Fall Short on Antipsychotic Reduction Goal, But Still Making Progress

The bad news: Skilled nursing facilities are expected to fall far short on the goal of reducing off-label use of antipsychotics by 15 percent.

The good news: They're still making progress.

CMS and the American Health Care Association teamed up with the goal of reducing off-label antipsychotic use by 15 percent by the end of 2012. According to CMS, facilities have only averaged around a 4 percent reduction. The good news, she noted, is that use is going down steadily in every region, even if the goal wasn't met.

Some facilities are meeting the goal, however, and have even reported up to a 50 percent reduction in the use of antipsychotics.

According to a 2010 CMS quality indicator report, 39.4 percent of residents nationwide who had cognitive impairment and behavioral issues but no diagnosis of psychosis or related conditions received antipsychotic medications.

To learn more, click here.

Midwest SNFs Would Be Hit Hard By Sequester

If the government sequester goes into effect, skilled nursing facilities in the Midwest could pay a big price.

The sequester would cut Medicare reimbursement by 2 percent, which would amount to $782.5 million in fiscal year 2014. While California would take the biggest hit, Illinois, Ohio and Michigan are also on the list of the 10 states that would be most impacted.

To learn more, click here.

White House Supports States' Rights to Slash Medicaid Payments

In a court brief filed Monday, the White House said it supports the states' ability to reduce Medicaid payments to long-term care operators and other healthcare providers. The related court case was brought by California providers over the state's proposed payment cuts.

The White House specifically noted that it supports California's right to cut Medicaid payments to a number of providers by 10 percent. The reductions were also approved by CMS in October of 2011.

The White House's court brief also said that states have wide discretion in setting payment rates and that rates can and should be evaluated "to avoid the perpetuation of payment rates that are unnecessarily high."

To learn more, click here.