In The News

CMS Home Health Cuts Could Be More Significant Than Originally Estimated, New Analysis Reveals

Home Health Care News | By Robert Holly

If finalized as is, the home health proposed payment rule for next year could lead to larger cuts than originally estimated.
 
That’s according to an analysis from Homecare Homebase (HCHB), which pulled data from its vast customer base, representing nearly 50% of all Medicare-certified home health visits.

Released on June 30, the FY 2024 home health proposed payment rule from the U.S. Centers for Medicare & Medicaid Services (CMS) includes a 3% market-basket update that’s partly offset by a roughly 0.3% downward productivity adjustment. The agency’s plan also includes a 0.2% increase that reflects the effects of a proposed update to the fixed-dollar loss ratio used in determining outlier payments.
 
Added up, those figures produce a 2.9% increase in home health payments for 2024. That positive number, however, is offset by a whopping 5.1% cut from CMS, which believes it has to permanently adjust payments under the Patient-Driven Groupings Model (PDGM) to maintain budget neutrality, as mandated by the Bipartisan Budget Act of 2018.
 
The way the math currently works out, CMS estimates that its proposed payment rule would represent an aggregate cut of 2.2% next year, or about $375 million less compared to 2023 levels.
 
Broadly, CMS says it needs to make permanent adjustments to home health payment mechanics because providers adapted to PDGM in a way that’s different from how the agency assumed providers would behave under the model. Those behaviors are largely related to how agencies document and code for their patients’ functional-impairment levels, their number of clinical comorbidities and more.
 
“In the CY 2023 HH PPS final rule, using CY 2020 and 2021 claims, CMS finalized a methodology for analyzing the differences between assumed versus actual behavior changes on estimated aggregate expenditures and calculated levels of actual and estimated aggregate expenditures,” the agency wrote in a June 30 fact sheet. “Based on analyses of CYs 2020 and 2021 claims data, CMS determined a permanent adjustment was needed.”
 
But after doing its own numbers crunching, HCHB estimates that the 2024 cut could be even greater than 2.2%.
 
“In terms of HCHB’s methodology, as soon as the proposed rule is released, our regulatory and analytics teams immediately begin reviewing every detail of the rule and updating our ongoing models,” HCHB Chief Strategy Officer Scott Pattillo told Home Health Care News in an email. “Once the new model is complete and has been thoroughly tested, we take all the claims for 2023 (year-to-date) and run them through the proposed 2024 model. Then we compare the actual reimbursement in 2023 to the modeled reimbursement for 2024.”
 
After analyzing reimbursement by standard periods, Low Utilization Payment Adjustments (LUPAs), outlier payments, wage-index changes and other factors, HCHB estimates aggregate total home health payments next year could be trimmed by as much as 2.66%.
 
“This year’s results show that, if agencies saw the exact same patients and performed the exact same services, they would be paid 2.66% less for those patients in 2024 than in 2023,” Pattillo explained.
 
While a difference between the CMS and HCHB estimate may seem small, it ultimately could translate into several million dollars of home health payments.
 
Senior Director of Product Management Andy Guarnera and Product Manager Benjamin Hayes, both in the data analytics department of Homecare Homebase, helped spearhead the analysis.
 
Not equal for everyone
 
Pattillo was careful to point out that the proposed payment adjustment for next year wouldn’t be equal for everyone.
 
“Each of our customers has their own unique results,” he said. “While we cannot share the details by agency, we can share some ranges.”
 
Unique to this proposed rule, Pattillo noted, is that every state will see a cut, which hasn’t always been the case. Yet some states will be barely impacted at all, while others could receive an almost 6% cut.
 
“Agency results show a wide range from -6% for a few, to up to a 3.6% increase,” Pattillo said. “The biggest drivers of this variance are case mix and wage index.”
 
Generally, the greatest drivers of this year’s potential cut in terms of real impact are the reduction in standard payment and case mix, which is slightly offset by the increase in outlier revenue.
 
“Based on HCHB’s very large sample, we would expect this -2.66% to be representative of the aggregate impact to the whole industry,” Pattillo said.

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Salaried Exempt Employee Deductions from Salary

SESCO Management

To qualify for exemption, employees generally must be paid at least $684 per week on a salary basis. Being paid on a “salary basis” means an employee regularly receives a predetermined amount of compensation each pay period on a weekly, or less frequent, basis.

There are circumstances when deductions can be made from an exempt employee’s pay. Deductions can be made if the exempt employee is absent for a day or more for personal reasons (personal leave).

Also, deductions may be made for absences of a full day or more due to sickness or disability, if the deduction is made in accordance with a bona fide plan of providing compensation for loss of salary caused by sickness or disability (such as sick leave, PTO time, vacation, etc.). For example, if an exempt employee has accrued sick leave or PTO time and he is absent for 4 hours of the workday, he would be paid for the full day, but 4 hours would be deducted from his bank of sick leave. However, if the exempt employee has not yet qualified for sick leave or has exhausted his sick leave, there would be a deduction in his pay only if he is absent for a full day or longer.

An exempt employee’s salary may be reduced to offset amounts the employee receives for jury duty or military pay. Deductions are also allowed for penalties imposed for major violations of safety rules or for unpaid disciplinary suspensions of one or more full days for violation of the organization’s work rules.

Also, note that under the Family and Medical Leave Act (FMLA), an exempt employee’s pay may be reduced when unpaid FMLA leave is taken. This is the case even when less than a full day is taken as FMLA leave.

Inclement Weather

Poor weather conditions of the winter months can often raise pay-related questions for employers. Employees may not report to work because of hazardous conditions, or your business may close for the day. The issue is straightforward for non-exempt employees (i.e., employees paid on an hourly basis, subject to overtime pay). Non-exempt employees are paid for the actual time worked. Thus, if they do not report for work or the business is closed, they are not paid for the day. An employer may choose to allow these employees to use vacation or other paid time off to cover the lost wages.

The issue is a little more complex for salaried exempt employees. The question of pay is determined by whether or not the employer is open for business and whether the exempt employee works any part of the day. An employer that remains open for business during a weather emergency may lawfully deduct one full-day’s absence from the salary of an exempt employee who does not report for work for the day due to adverse weather conditions. In a recent opinion letter, the Department of Labor considers this an absence due to personal reasons; therefore, a deduction of a full-day’s pay will not violate the salary basis rule or otherwise affect the employee’s exempt status. It should be noted that deductions from salary for less than a full-day’s absence are not permitted for such reasons under the wage and hour regulations. The Wage and Hour Division has stated that an employer may, as an option, require an exempt employee who fails to report for work in this situation to take vacation or other paid leave to cover the full-day’s absence.

What about the pay of a salaried exempt employee if the business is closed? An employer may not make deductions “for absences occasioned by the employer or by the operating requirements of the business.” If the employer closes operations due to weather or other emergency for less than a full workweek, then the employer must pay an exempt employee “the full salary for any week in which the employee performs any work without regard to the number of days or hours worked,” because “deductions may not be made for time when work is not available.” Again, the Wage and Hour Division has ruled that an employer may direct exempt employees to take vacation or other paid leave in this situation, provided the employees receive in payment an amount equal to their guaranteed salary. However, if an exempt employee has no vacation or paid leave, the employee would still receive the full week’s salary in this situation (where the business is closed for less than a week).

Sickness vs. Personal Reasons for Absence

Deductions from a salaried exempt employee’s pay for sickness/disability or personal reasons may only be made as follows:

Employers With a Bona Fide Leave Plan:

  • Exempt-Sickness or Disability-Partial Day-Can be forced to use leave time. If leave is exhausted or has not become effective yet, no reduction in pay is allowed; however, the leave balance may be reduced to the negative.
  • Exempt-Sickness or Disability-Full Day-Can be forced to use leave time. If leave is exhausted or has not become effective yet a full day reduction in pay is allowed (an employer may pay leave time where the balance is zero thereby reducing the leave balance to the negative).
  • Exempt-Personal-Partial Day-Can be forced to use leave time. If leave is exhausted or has not become effective yet, no reduction in pay is allowed; however, the leave balance may be reduced to the negative.
  • Exempt-Personal-Full Day-Can be forced to use leave time. If leave is exhausted or has not become effective yet a full day reduction in pay is allowed (an employer may pay leave time where the balance is zero thereby reducing the leave balance to the negative).

Employers Without a Bona Fide Leave Plan:

  • Exempt-Sickness or Disability-Partial Day- No reduction in pay is allowed.
  • Exempt-Sickness or Disability-Full Day-No reduction in pay is allowed unless the full workweek is not worked.
  • Exempt-Personal-Partial Day-No reduction in pay is allowed.
  • Exempt-Personal-Full Day-Reduction in pay is allowed.

If you are not a retainer client of SESCO Management Consultants, contact them to learn about their services by calling 423-764-4127 or click here.

 

To Succeed with MA, Measure Performance Indicators, Guard Against Claim Denials, Experts Say

McKnight’s Home Care | By Adam Healy
 
As Medicare Advantage (MA) enrollment continues to grow, providers need strategies to best navigate this new payer landscape. Frontpoint Health CEO Brent Korte and Erin Masterson, associate principal of consulting at SimiTree, offered some of these during a session at the National Association for Home Care & Hospice’s (NAHC’s) recent Financial Management Conference in New Orleans. 
 
Currently, MA covers more than half of all Medicare beneficiaries, and the two experts estimate that the proportion will grow to over 70% by 2030. With this shift, the panelists said, providers have seen lower reimbursement rates, changing authorization requirements, a higher volume of claim denials, and an overall hard-to-navigate contracting and billing process with Medicare Advantage Organizations (MAOs).
 
MA plans generally have lower rates than Medicare fee-for-service, so the panelists agreed that agencies should look past revenue and instead modify their own cost structures. Finding ways to cut costs without cutting quality will allow providers to make more money without sacrificing the areas that make their agencies valuable to MAOs, they said. 
 
They also emphasized that providers should be measuring all of their performance indicators so that they can prove the quality of their services to MAOs. Focusing on measurements that MA plans value, such as being prompt in billing MAOs and not leaving services left unbilled, is the best plan of attack, they said.
 
“Know your numbers … because they think they know you better,” Korte said. Approach negotiations with an understanding of where your company succeeds, and “make them want you at the table.”
 
A higher rate of claim denials under MA means that providers should build processes to safeguard against them. Patients’ insurance should be reverified every month to limit any risk, they said, and staff members in charge of billing MAOs should be unwilling to accept denied claims. Masterson suggested incentivizing those employees who help to protect against low rates of denials. After all, $200 spent on incentive bonuses is a small cost compared to thousands lost when payers refuse claims.
 
“It’s worth a couple hundred bucks for the incentive if because of that we’re collecting a hundred thousand more, or two hundred thousand more,” she said.

 

Terminal Restlessness Is Part of the Way We Die

Terminal restlessness is a medical term for agitation as end of life approaches. It usually begins one to three weeks before death from disease or old age.

The restlessness shows itself by random body movements, hands picking the air or clothing, mumbling, talking but not making sense, by just not being settled and quiet. The person is now beyond expressing with words. There are few if any rational conversations.

This restlessness can be a lack of oxygen to the brain but more likely it is just part of the natural way we die.

We are all going to be afraid to some degree as we approach death. This is normal and natural. Also we know when we are dying. It is no secret. We live inside of our bodies--we know.

In the months before death from disease we don’t believe we can’t be fixed but there comes a point where we indeed know the time is near (one or three weeks before we actually die from disease is about that timetable). Can the restlessness being experienced be an expression of fear? Maybe?

Realizing in the core of our being that we are going to die we become frightened and that fear shows itself in agitation. “If I lay down and close my eyes I may die” so we don’t lay still, we move about.

Most of the time this restlessness, this agitation is not destructive. It is not severe.

Again this activity is normal and natural. It is a part of the dying process from disease or old age. Nothing bad or unusual is happening. The restlessness is just a part of the way we die.

This activity is actually one of the signs we look for that says the “labor of dying” has begun. It is that normal.

 

Introducing Hispanic Chaplaincy Program: Clinical Pastoral Education (CPE)

Reach the underserved hispanic community with the first of its kind Clinical Pastoral Education (CPE) for Latino chaplains that serve in hospices, home health and hospitals.

We are the only professional Chaplain organization in the USA to clinically train and certify Spanish-speaking healthcare Chaplains. We offer:

  • Online Clinical Pastoral Education (CPE) for existing and aspiring Chaplains
  • National Board Certification credentialing
  • Continuing Education in both English and Spanish

See Attached Flier

To Learn More Contact:

Chaplain Mark Allison, President, WSHO
[email protected]
801-870-0315
www.wshochaplaincy.org

 
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