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Pelosi Indicates Interest In More HCBS Funding Than House Proposed
Inside Health Policy / By Maya Goldman
House Speaker Nancy Pelosi (D-CA) indicated at a Service Employees International Union rally Thursday (Sept. 23) that she’d like to see more funding for Medicaid home- and community-based services in the final reconciliation bill than the $190 billion pushed by a House committee, and Senate Majority Leader Chuck Schumer (D-NY) committed to increasing federal funding for HCBS to a level that will incentivize states to improve offerings.
President Joe Biden’s original Build Back Better agenda calls for a $400 billion investment in Medicaid home care, which advocates have said would be the largest-ever infusion of cash in HCBS.
The House Energy & Commerce Committee passed a provision last week that would invest $190 billion in HCBS. Advocates were glad to see HCBS included in the committee’s bill but said that level of funding won’t be enough to make Medicaid home care services widely available and to improve the quality of home care jobs.
“We don't think $190 billion will quite get [us] there. So we want to make sure the number’s as close to $400 billion as we can possibly get,” April Verrett, president of SEIU Local 2015 and chair of the union’s National Home Care Council, said prior to Thursday’s rally.
Schumer committed at the rally to making sure the reconciliation bill increases federal funding for home- and community-based services.
Schumer said he wants to expand the availability of HCBS to eliminate waitlists and improve labor standards for direct care workers.
“We want to increase federal funding for these services to a level that will encourage widespread universal uptake by the states,” Schumer said. “As Majority Leader, I am committed to making sure our reconciliation bill delivers these goals together."
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Targeted Probe and Educate (TPE) Process (from CGS)
The Centers for Medicare & Medicaid Services (CMS) is resuming the Targeted Probe & Educate (TPE) process, effective September 1, 2021. Based on data analysis of claims payment, CGS will identify areas with the greatest risk of inappropriate program payment. You may reference the Medical Review Activity Log for a list of review topics. Previous postpayment service-specific reviews will be phased out.
Key Points
- CGS selects providers for the TPE process based on the following:
- Analysis of billing data indicating aberrancies that may suggest questionable billing practices; or
- On targeted review and transitioned to the TPE process based on error rate results; or
- On service specific review error rate results.
- CGS will mail a notification to those who have been selected for TPE review. The letter will outline the reason for selection and will provide an overview of the TPE process and contact information.
- TPE consists of up to three rounds of review with up to 20-40 claims selected (prepayment or postpayment) with each round. Subsequent rounds will begin 45-56 days after individual provider education is completed. The review may be discontinued if appropriate improvement and an error rate below the target threshold is achieved during the review process.
- An Additional Documentation Request (ADR) is generated for each claim selected. CGS has 30 days (prepayment) or 60 days (postpayment) from the date documentation is received to review and make a payment decision.
NOTE: No response to ADRs counts as an error when calculating the error rate. CGS recommends using myCGS, our secure online web portal to submit documentation in response to medical review ADRs.
- For additional information, please reference the myCGS User Manual.
- If you are not already registered to use myCGS, enrollment instructions can be found under the Introduction tab.
- A review results letter will be mailed at the conclusion of each round. The letter will include the number of claims reviewed, the number of claims allowed in full, the number of claims denied in full or in part.
- Providers with a moderate to high error rate will be offered an individualized education session where each claim found in error will be discussed and any questions will be answered. CGS also offers education sessions via webinar, web-based presentation, or traditional teleconferences. Other methods may also be available. Questions and education requests may be sent to: [email protected].
- The TPE review process includes up to three rounds of a prepayment probe review with education. If the denial rate remains high after three rounds, CGS will refer the provider to CMS for additional action, which may include: additional rounds of TPE review, 100% prepayment review, extrapolation, referral to a Recovery Auditor, and/or referral for revocation. The review may be discontinued if appropriate improvement and an error rate of < 25% is achieved during the review process.
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USING YOUR BUDGET FOR CALCULATING LOST REVENUES FOR PRF REPORTING (From The Health Group)
Three methods are available to healthcare providers for determining lost revenues eligible to be applied as a qualified use of Provider Relief Funds. These are:
- Option 1: Actual 2020 and 2021 revenues compared against 2019 revenues,
- Option 2: Actual 2020 and 2021 revenues compared against 2020 budgeted revenues, or
- Option 3: Alternate lost revenue computation.
We have received numerous inquiries regarding the use of budgeted revenues in the determination of lost revenues. The following is provided by HRSA relating to the use of budgeted information:
“Lost revenues are calculated for each quarter during the period of availability, as a standalone calculation, with budgeted quarters serving as a baseline. For each calendar year of reporting, the applicable quarters where lost revenues are demonstrated are totaled to determine an annual lost revenues amount. The annual lost revenues for the years included in the period of availability are then added together. There is no offset.
Reporting Entities may use budgeted revenues if the budget(s) and associated documents covering the Period of Availability were established and approved prior to March 27, 2020.”
“When reporting use of Provider Relief Fund payments toward lost revenues attributable to coronavirus, Reporting Entities may use budgeted revenues if the budget(s) and associated documents covering calendar year 2020 were established and approved prior to March 27, 2020. To be considered an approved budget, the budget must have been ratified, certified, or adopted by the Reporting Entity’s financial executive, executive officer, or other responsible representative as of that date, and the Reporting Entity will be required to attest that the budget was established and approved prior to March 27, 2020. Documents related to the budget, including the approval, must be maintained in accordance with the Terms and Conditions.
https://www.hrsa.gov/sites/default/files/hrsa/provider-relief/prf-lost-revenues-guide.pdf specifically identifies the 2020 Budgeted Revenue as the basis for calculating budgeted revenues versus actual revenues for 2020 or 2021.
Many consultants are informing providers that they need a budget for 2021 for comparison to the actual revenues for the first two (2) quarters of 2021. Other consultants are recommending the use of budgeted revenues for 2020 to actual revenues for 2020; however, they recommend using actual revenues for the first two (2) quarters of 2020 to be compared against actual revenues for the first two (2) quarters of 2021.
It is no wonder why many providers are confused. HRSA has presented the following information which clearly indicates that a qualifying 2020 budget is not only used for comparison to actual 2020 revenues, but also that the first two (2) quarters of the 2020 budget are used for comparison against actual revenues for the first two (2) quarters of 2021. As evidenced by the HRSA presentation, the first two (2) quarters of the 2020 budget are repeated for comparison against the 2021 actual revenues to determine lost revenues.
All providers are responsible for their submission and, accordingly, must select the process for identifying lost revenues; however, we believe the following as presented by HRSA is clear regarding the use of a qualifying 2020 budget (approved before March 27, 2020) solely as the basis against which actual revenues will be compared for both 2020 and the first two (2) quarters of 2021. This approach makes sense as the 2020 budget would have been developed and accepted (before March 27, 2020) without considering any COVID-19 PHE impact, thus providing an appropriate comparison to actual revenues generated.
The entire HRSA presentation regarding “Period of Availability and Lost Revenues" is available here. The information presented in the above slide has not been altered by any of the subsequent information released by HRSA. |
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COVID Vaccine For Kids Ages 5 To 11 Is Safe And Effective, Pfizer Says
Matt Rourke/AP
The first results from the highly anticipated trial studying the effectiveness and safety of the Pfizer and BioNTech COVID-19 vaccine for children ages 5 to 11 showed promising results.
The pharmaceutical companies said early results of their trial indicate the vaccine is safe for children and establishes a strong antibody response against the virus.
Giving a two-dose regimen of 10 μg (micrograms) administered 21 days apart for children between 5 and 11 years old was well tolerated, according to Pfizer and BioNTech. Side effects were also generally comparable to those of people between the ages of 16 and 25 years old who received the vaccine.
This trial used a smaller vaccine dosage, 10 micrograms, rather than the 30 microgram dose used for people 12 and older. The dosage was selected as the preferred dose for safety and effectiveness in young children.
News of the results come as pediatric cases of COVID-19 are increasing amid a nationwide surge of infections.
"Since July, pediatric cases of COVID-19 have risen by about 240 percent in the U.S. — underscoring the public health need for vaccination. These trial results provide a strong foundation for seeking authorization of our vaccine for children 5 to 11 years old, and we plan to submit them to the FDA and other regulators with urgency," said Albert Bourla, the chairman and CEO for Pfizer.
"Over the past nine months, hundreds of millions of people ages 12 and older from around the world have received our COVID-19 vaccine. We are eager to extend the protection afforded by the vaccine to this younger population, subject to regulatory authorization, especially as we track the spread of the Delta variant and the substantial threat it poses to children," Bourla said in a statement.
Despite the strong results, it will be some time before the general public can see an official rollout of vaccines for children ages 5 to 11. Once analysis of the trial is completed, Pfizer and BioNTech will submit the results "in the near term" to the Food and Drug Administration for review and possible emergency use authorization.
A Vaccine For Children Is Not Likely To Be Approved Until The End Of Year
And even if the FDA grants that authorization, Dr. Francis Collins, director of the National Institutes of Health, recently told NPR that parents and caregivers will likely have to wait until the end of 2021 before a COVID-19 vaccine is fully approved for young children ages 5 to 11.
Trial results for children under 5 years of age could come later this year, the pharmaceutical companies said.
"Already in March 2021, we have started the study to evaluate the immunization of younger children. Our objective was to generate and submit the data for schoolkids to regulatory authorities around the world before the winter season begins," BioNTech CEO and co-founder Ugur Sahin said.
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