CMS Finalizes ‘Fast-Track’ for Patient Appeals of MA Plan Home Health Denials
McKnight’s Home care | By Adam Healy
The Centers for Medicare & Medicaid Services finalized a rule Thursday that aims to expedite the process by which beneficiaries could appeal home health claims denied by Medicare Advantage plans.
Traditional Medicare utilizes a Quality Improvement Organization (QIO) to review fast-tracked appeals, whereas MA plans do not. Rather, the MA plan itself is responsible for reviewing appeals for denied services. In its new rule, CMS will require QIOs to also review MA appeals, which should make fast-track appeals more accessible to MA enrollees.
“CMS is revising regulations to require the QIO, instead of the Medicare Advantage plan, to review untimely fast-track appeals of a Medicare Advantage plan’s decision to terminate services in a skilled nursing facility, comprehensive outpatient rehabilitation facility or by a home health agency,” CMS stated.
The rule would also “fully eliminate the provision requiring forfeiture of an enrollee’s right to appeal a termination of services from these providers when they leave the facility,” it said. These changes will more closely align MA regulations with traditional Medicare, expanding MA enrollees’ ability to take advantage of the fast-track appeals process, according to CMS.
The final rule will also update standards set for Supplemental Benefits for the Chronically Ill (SSBCI). New regulations hold that MA plans must be able to demonstrate that these benefits “meet the legal threshold of having a reasonable expectation of improving the health or overall function of chronically ill enrollees,” CMS said. To prove that the benefits meet all requirements, MA plans must compile databases of research to back up their claims that SSBCI can meet beneficiaries’ heath needs.
Finally, CMS’ rule updated MA marketing policies to protect customers from misleading advertising. Plans must now include disclaimers in all marketing materials that mention SSCBI to ensure enrollees are aware of the benefits they can access, encourage greater utilization of these benefits and “ensure MA plans are better stewards of the rebate dollars directed towards these benefits,” CMS said in the rule. |
It’s Past Time for An Upgrade To The Medicare Hospice Benefit
Health Affairs Forefront | By Cara Wallace
When most people think about hospice care, they imagine someone such as the late Rosalynn Carter, who enrolled onto hospice and died within a few days. Jimmy Carter’s long hospice stay, now more than a year, has shown a different model for hospice—one that supports its mission to help people live well, with dignity and quality of life, for whatever time remains.
However, current policy restrictions to enroll and remain on hospice make it difficult for many hospice recipients to receive hospice care for “whatever time remains,” as 17.2 percent of Medicare hospice patients are discharged alive.
To enroll on hospice, a person must meet eligibility criteria based on their specific disease, with a physician statement of a six-months or less prognosis. The person must also elect hospice care by being willing to forgo any curative treatment related to their terminal diagnosis.
To remain on hospice care, a person must show demonstrable decline toward death, as a physician must recertify the patient for ongoing care every 90 days during the first six months, then every 60 days thereafter.
These restrictions are closely tied to the two most common reasons for a live discharge from hospice: decertification—when a patient is removed from hospice care due to a stabilized condition; or revocation—when a patient chooses to leave hospice care to seek curative care. Both are challenging and disruptive and are the result of inflexibility in current policy.
Live Discharge Is Disruptive For Patients, Families, And Hospices
First, let’s consider decertification, or rather when a patient does not experience enough decline in their condition for a physician to recertify them for ongoing care. Medicare refers to these patients as “no longer terminally ill,” although in most cases the patients’ diagnoses that qualified them for hospice in the first place remain the same. Because of this, we refer to this type of live discharge as decertification, although others refer to it as disenrollment, or more flippantly as “not dying fast enough” or “failure to die on time.”…
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Change Healthcare Attack Sheds Light on Industry's Weak Points
Axios | By Tina Reed
The expansive impact of the Change Healthcare cyberattack was a wake-up call for a health care system that's now racing to safeguard itself against another industry-rattling hack.
Why it matters: There's recently been increased focused on defending individual health care organizations against bad actors as the vulnerable sector increasingly finds itself under attack.
- But the Change Healthcare hack that disrupted payments to providers for weeks revealed the industry's heavy reliance on just a few technology companies to keep day-to-day operations running.
- That essentially creates what The Atlantic's Juliette Kayyem recently described as a "single point of failure" — and experts warn Change Healthcare likely isn't the only one.
What they're saying: "Change is the canary in the coal mine," said Nate Lesser, chief information security officer at Children's National Hospital.
- "We need to find out where the others are or we're just going to collapse."
Between the lines: Experts who spoke with Axios say there are a number of companies that offer critical infrastructure to pockets of the health care industry, creating major vulnerabilities in the event of an attack.
- Companies often create that kind of market share through mergers of smaller companies that later get acquired by bigger companies.
- "There are some of these pieces of software that have just been consolidated over and over and over, and it turns out like 50,000 pharmacies, usually within hospitals, use the same piece of software," said Kyle Hanslovan, CEO of cybersecurity firm Huntress.
- The way some of those products have been stitched together along the way, potentially pairing old and new technologies, could also introduce weaknesses that are difficult to completely engineer away, he said.
The Change Healthcare hack also showed how contracting practices within the industry even exposed health care providers who didn't have direct relationships with the company and initially didn't expect to be affected.
- That was the case for Children's National, which discovered that some insurers it worked with have exclusive relationships with Change Healthcare and wouldn't allow for claims to be submitted through any other vendor.
- These sort of opaque agreements can make it hard for providers to know exactly where their data is being shared, said Shawntea Gordon, a member of the Medical Group Management Association's government affairs council.
- "It made it very difficult for people to just say 'OK, let me bounce everything through somewhere else,'" Gordon said.
Some experts said the federal government quickly needs to do a sector wide accounting to understand where health care's biggest systemic cyber risks are and address them — before hackers beat them to it.
- The Change Healthcare attack "caught us all by surprise and shouldn't have," Lesser said.
- He pointed to actions the government took in the aftermath of the 2007-08 financial crisis to designate some banks as "systemically important," making them subject to tougher oversight and standards because their failure would jeopardize the entire banking system.
- If nothing else, the industry needs to take its own inventory to understand where catastrophic failure would be most damaging so health systems and smaller providers can better evaluate their risks and create appropriate backup plans, Hanslovan said…
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Incorporating Bereavement into the Continuum of Care
Medpage | By Charles Bankhead
A new sense of urgency has emerged for healthcare organizations to develop "sustainable and accessible bereavement care" and to cultivate a "bereavement-conscious" workforce to position bereavement as an "inherent element of the duty of care," authors of a recent opinion piece asserted.
Inadequate investment in bereavement care has led to a paucity of integrated services at organizational, national, and global levels. Failure to recognize bereavement as a vital component of continuity of care can leave bereaved families without access to psychosocial support, putting them at risk of illness that exacerbates the substantial public health toll of interpersonal loss.
"We need an investment in the healthcare system and in the community to build up support and grief-literate, compassionate communities," Lichtenthal told MedPage Today. "We need workplaces, schools, all institutions where people are, to be more informed and feel better about supporting grievers."
The public health toll associated with grief has been well documented, she said. Recent events have accelerated the urgency for sustainable and accessible bereavement care -- COVID-19, suicides, drug overdoses, homicides, armed conflicts, and terrorism.
Despite being integral to high-quality, family-centered healthcare, bereavement support often is poorly resourced, even described as the "poor cousin of palliative care." In an ideal setting, bereavement care begins with pre-death grief education, continues through the dying process and end of life, and transitions into community-based support and psychosocial services, as needed.
Recent reports on death, palliative care, and pain relief have highlighted the need for better bereavement care delivery infrastructure, the authors noted in their introduction. Acknowledging that "bereavement has been overlooked," the Lancet Commission on the Value of Death called for reorganizing priorities to address social determinants of death, dying, and grief. Imbalances in health and social care fostered by westernized medicine have "medicalized death and dying processes," resulting in disenfranchisement of family and community involvement throughout illness and end of life, the authors continued…
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