Accessing Most Medicaid & CHIP Benefits Will Not Affect Immigration Status

On Thursday, September 8, 2022, the U.S. Department of Homeland Security (DHS) issued a final rule applicable to noncitizens who receive or wish to apply for benefits provided by the U.S. Department of Health and Human Services (HHS) and States that support low-income families and adults. The rule, which details how DHS will interpret the…

FY2023 Hospice Medicare and Medicaid Base Rates at a Glance

–Hospice Medicare FY2023 Pricer Now Available Beginning October 1, 2022, hospice base payment rates will increase by 3.8 percent, as published in the final FY2023 Hospice Payment Rule. As is customary, the Medicaid program waits until Medicare rates are finalized to issue guidance on the applicable corresponding hospice payment rates. The Centers for Medicare &…

The Better Care Better Job Act Deserves Your Support

GO HERE to support the Better Care Better Jobs Act with just a few clicks of your mouse Home care advocates have been meeting with members of Congress this week to ask for their support for the Better Care Better Jobs Act and it is important that home care professionals who did not make the…

HHS Expands HCBS for Elderly, People with Disabilities

More than 40 states and territories will now participate in Medicaid’s Money Follows the Person demonstration program, which has provided billions to help seniors and people with disabilities safely transition from institutional care to their homes and communities On August 23, 2022, the U.S. Department of Health and Human Services (HHS), through the Centers for…

CMS Open Door Forum to Discuss New HCBS Quality Standards

The next CMS Long-Term Services and Supports Open Door Forum from the Centers for Medicare & Medicaid Services (CMS) will take place on Tuesday, August 9, 2022, from 1:00 PM to 2:00 PM Eastern Time (ET). The topic will be the first-ever home- and community-Based Services (HCBS) quality measure set to promote consistent quality measurement within and across state Medicaid HCBS programs.

Learn more about that CMS announcement in this Hospice & Palliative Care Report article.

Please dial-in at least 15 minutes before call start time.

Conference Leaders: Jodie Sumeracki, CMCS and Jill Darling, CMS Office of Communications

**This Agenda is Subject to Change**

  1. Opening Remarks

Chair – Jodie Sumeracki (CMCS)

Moderator – Jill Darling (OC)

  1. Announcements & Updates

III. Open Q&A

Open Door Participation Instructions:

To participate by phone, dial: 1-888-455-1397 & Reference Passcode: 5109694

CMS Open Door Forum to Discuss New HCBS Quality Standards

The next CMS Long-Term Services and Supports Open Door Forum from the Centers for Medicare & Medicaid Services (CMS) will take place on Tuesday, August 9, 2022, from 1:00 PM to 2:00 PM Eastern Time (ET). The topic will be the first-ever home- and community-Based Services (HCBS) quality measure set to promote consistent quality measurement within and across state Medicaid HCBS programs.

Learn more about that CMS announcement in this Private Duty Source article.

Please dial-in at least 15 minutes before call start time.

Conference Leaders: Jodie Sumeracki, CMCS and Jill Darling, CMS Office of Communications

**This Agenda is Subject to Change**

  1. Opening Remarks

Chair – Jodie Sumeracki (CMCS)

Moderator – Jill Darling (OC)

  1. Announcements & Updates

III. Open Q&A

Open Door Participation Instructions:

To participate by phone, dial: 1-888-455-1397 & Reference Passcode: 5109694

CMS Releases Quality Measure Set to Improve Home & Community-Based Care

On July 21, the Centers for Medicare & Medicaid Services (CMS) announced it will release its first-ever home- and community-Based Services (HCBS) quality measure set to promote consistent quality measurement within and across state Medicaid HCBS programs. The measure set is intended to provide insight into the quality of HCBS programs and enable states to measure and improve health outcomes for people relying on long-term services and support (LTSS) in Medicaid.

The release of this voluntary measure set is also a critical step to promoting health equity among the millions of older adults and people with disabilities who need LTSS because of disabling conditions and chronic illnesses.

Nationally, over 7 million people receive HCBS under Medicaid, and Medicaid-funded HCBS accounts for $125 billion annually in state and federal spending. Implementation of the HCBS quality measure set will create opportunities for CMS and states to promote more consistent use, within and across states, of nationally standardized quality measures in HCBS programs to promote health equity and reduce disparities in health outcomes among this population.

The HCBS quality measure set is included in a State Medicaid Director Letter (SMDL) that also describes the purpose of the measure set, the measure selection criteria, and considerations for implementation. CMS strongly encourages states to use this information to assess and improve quality and outcomes in their HCBS programs. CMS expects to update the measure set in the future, including adding newly developed measures that address measure gaps, as the field of HCBS measure development advances.

CMS hopes the HCBS quality measure set will promote consistent use of nationally standardized quality measures in HCBS programs within and across states.

“CMS is using every lever available to protect and expand coverage for all people eligible for Medicaid. We are working to expand their access to care across settings — including in the setting of their choice,” CMS Administrator Chiquita Brooks-LaSure said in a press release.

“Today’s announcement provides states with tools to better understand and compare health outcomes across groups receiving home- and community-based services. The use of consistent quality measures across the country is another step toward reducing health disparities and ensuring that people with disabilities, and older adults enrolled in Medicaid, have access to and receive high-quality services in the community.”

Read the (SMDL) on the HCBS quality measure set HERE.

CMS Project Targets Providers for Deactivation

NAHC has recently become aware of a project the Centers for Medicare & Medicaid Services (CMS) has initiated that could have an especially negative impact on home health agencies that are not serving Medicare beneficiaries but are required to be Medicare-certified to meet state or non-Medicare payer requirements.  The project is titled “Organization Deactivation Project…

What About Private Duty/Homecare Services and Fraud?

Written by Elizabeth E. Hogue, Esq. and presented here with the authors permission. There seems to be a myth among providers of private duty or homecare services that the federal anti-kickback statute applies to Medicare certified providers only. On the contrary, the anti-kickback statute applies to providers who receive funds from any state or federal healthcare program;…

What About Private Duty/Homecare Services and Fraud?

Written by Elizabeth E. Hogue, Esq. and presented here with the authors permission.

There seems to be a myth among providers of private duty or homecare services that the federal anti-kickback statute applies to Medicare certified providers only. On the contrary, the anti-kickback statute applies to providers who receive funds from any state or federal healthcare program; including the Medicaid Program, VA, TRICARE, etc. Private duty providers: This means many of you!

Four companies in Pennsylvania, for example, contracted with the Medicaid Program to provide services to qualified recipients, including personal assistance services (PAS), coordination of services and non-medical transportation, among others. Between January, 2011, and April, 2017, the companies received more than $87M in payments from the Medicaid Program. PAS payments accounted for more than $80M of this amount.  Sixteen defendants in this case admitted to participation in a wide-ranging conspiracy to defraud the Medicaid Program to obtain millions of dollars in illegal payments through submission of claims for services that were never provided or for which there was insufficient or fabricated documentation to support claims submitted.

The defendants engaged in a number of fraudulent activities, including fabrication of time sheets to reflect the provision of care that was never provided to recipients. Participants in the conspiracy also paid kickbacks to recipients in exchange for their participation in fraudulent activities, including to the son-in-law of an owner. Claims were also submitted for services allegedly provided by “ghost” employees of the companies. Some of the defendants also admitted that they submitted claims for so-called “unused” hours, i.e., excess hours of care that recipients had not needed.

Finally, defendants admitted during the course of audits of the companies that they directed the fabrication of various documents for submission to state authorities in an effort to conceal fraudulent conduct. Fabricated documents included time sheets required by the PAS program, criminal history checks, child abuse clearance forms and required consumer affidavits.

Defendants were required to pay approximately $54 million in restitution.

Fraud and abuse enforcers have repeatedly urged and, in some cases required, private duty providers to develop internal compliance programs. How do compliance programs help providers avoid enforcement action?

First, as a practical matter, when providers establish and maintain Compliance Programs, they discourage regulators from pursuing allegations of fraud and abuse violations. Technically speaking, the Federal Sentencing Guidelines make it clear that establishment and implementation of Compliance Programs is considered to be a mitigating factor. That is, if accusations of criminal conduct are made, the consequences may be substantially less severe as a result of a properly implemented Compliance Plans.

Providers with Compliance Plans are more likely to avoid fraud and abuse. This is because Plans routinely establish an obligation on the part of employees to prevent fraud and abuse. Compliance Plans also make it clear that employees have an obligation to bring any potential fraud and abuse issues to the attention of their employers first.

Compliance Plans may also help to prevent qui tam, or so-called “whistleblower” lawsuits by private individuals who believe that they have identified instances of fraud and abuse. There are significant incentives to bring these legal actions since “whistleblowers” receive a share of monies recovered as a result of their efforts. Some whistleblowers have received millions of dollars.

Finally, the Deficit Reduction Act (DRA) requires providers who receive more than $5 million from Medicaid Programs per year to implement policies and procedures, provide education to employees, and put information in their employee handbooks about fraud and abuse compliance. These requirements can be met through implementation of a Fraud and Abuse Compliance Program.

In view of the above, providers of private duty services should implement and maintain effective compliance plans.

©2022 Elizabeth E. Hogue, Esq. All rights reserved.

No portion of this material may be reproduced in any form without the advance written permission of the author.