modifications for COVID-19

NAHC is once again showing great leadership and support of home health and hospice agencies by requesting that HHS & CMS institute policies and regulatory modifications that serve to reduce COVID-19 exposure risks to patients and caregivers, while increasing provider availability for patient care. Let’s take a look at the requests for modifications for COVID-19 that are still outstanding as of April 24, 2020.

Please note this information is up to date at the time of publishing. We will continue to update as additional information is received. Be sure to visit our blog post, “COVID-19: Home Health & Hospice Agency Updates” for the most recent information on CMS and HHS changes that may affect your agency. You can also visit our COVID-19 Resources page for additional information, updates, and best practices.

Home Health Legislative Requests

Request: Allow telephonic encounters as an alternative to face-to-face requirements.

Currently, providers can conduct face-to-face encounters by telehealth, but not by telephone. Many patients do not have access to this type of technology, so they must leave their homes for their face-to-face visits.

Request: Allow beneficiaries to qualify for home health based on the need for venipunctures.

The need for venipunctures is specifically excluded as a home health qualification reason. Physicians are asking agencies to perform the procedure for those who are unable to leave their homes.

Home Health Regulatory Requests

Request: Restore RAP payments to 60% of payment for initial 30-day periods and 50% for subsequent 30-day periods.

PDGM decreased RAP payments to 20% for 30-day periods. By increasing the RAP payment, agencies would have additional cash flow needed to maintain operations.

Request: Roll back the 4.36% behavioral adjustment included in PDGM.

CMS implemented the behavioral adjustment in PDGM under the assumption that agencies would actively look to avoid LUPAs by performing unnecessary and unskilled visits. Payment was cut to consider the overpayment agencies would receive in episodes of care where they’ve provided unnecessary visits. Suspending the adjustment would give agencies additional cash flow needed to maintain operations while the makeup of their patient population has vastly changed, and costs have increased.

Request: Allow agencies to be reimbursed when the primary diagnosis is a contact/exposure code.

Currently, symptom codes like Z03.818 and Z20.828 are unacceptable primary diagnosis codes for home health. Therefore, agencies can’t be paid for care provided to PUI for COVID-19.

Request: Waive or suspend the requirements that agencies have signed and dated physician certifications and care orders prior to billing.

Because physicians aren’t available to sign orders in an emergency, verbal orders should suffice.

Request: Allow physician-ordered telehealth and remote monitoring visits to count as Medicare home health visits.

While CMS approved the use of telehealth visits in home health care, it has unfortunately ruled against these visits counting toward the total number of visits performed by an agency for the purpose of reimbursement. While telehealth visits allow clinicians to provide quality care, home health agencies fear a revenue loss if telehealth visits replace in-home, reimbursable visits. Many patients are refusing scheduled visits in fear of exposure to COVID-19 through contact with a home healthcare employee. Too many missed visits will cause agencies to face LUPAs, resulting in lower reimbursement than initially anticipated.

Home Health Coverage Requests

Request: Provide flexibility in the definition of “intermittent skilled nursing” to allow a one-time skilled nursing visit for specified interventions, such as injections that would ordinarily be provided during a physician’s office visit.

The current CMS requirement is that a patient must have a medically predictable recurring need for skilled nursing. This prohibits a physician from ordering a one-time visit.

Request: Suspend the expansion of the Review Choice Demonstration (RCD).

CMS has suspended RCD. However, MACs are doing 100% post-payment review. NAHC has requested that be suspended as well, to reduce the burden and risk for agencies.

Request: Institute National Accelerated Appeals Settlements.

NAHC is requesting broad-scale settlements to reduce burdens on all stakeholders.

Request: Suspend Home Health Value-Based Purchasing.

Because of the change in case-mix and clinical practices for most agencies, it’s not currently feasible to learn about how financial incentives and penalties affect patient outcomes.

Conditions of Participation Requests

Request: Streamline home care aide competency evaluations to include only those required for direct patient care.

NAHC notes that several competencies could be waived to permit additional staff be trained as home care aides.

Request: Waive the 12-hour annual in-service training requirement for home health aides.

By doing so, home health aides can focus on patient care.

Request: Allow agencies to conduct an abbreviated comprehensive assessment, including only items needed for planning and payment.

Many items in the assessment are not required for payment or care planning. Shortening the assessment will allow clinicians to have more time for patient care. NAHC noted this has been approved in the past during other emergencies.

Request: Allow agencies to perform telephonic or telehealth OASIS recertification assessment visits for patients with continued skilled needs or those refusing visits due to fear of exposure.

Agencies can continue to monitor patients to assure there’s no decline in health.

Request: Waive the requirement that written information be given to a patient at admission, allowing for verbal communication instead.

Limiting the amount of written materials that must be provided frees clinicians to provide more direct patient care.

Request: Waive the “one service directly” requirement.

Due to potential staffing shortages, home health agencies may need to contract for all disciplines.

Request: Alleviate restrictions under the Clinical Laboratories Improvement Act that require agencies to have a designated lab and meet CLIA standards in order to conduct lab tests.

NAHC states that agencies will be well positioned to collect, transport, conduct, and report lab tests related to COVID-19.

Request: Delay OASIS-E.

Scheduled for 2021, there’s much work to be done by agencies, and they may not have the time to properly prepare.

Hospice Legislative Requests

Request: While hospice can use telehealth for face-to-face encounters, the request is to extend to telephone audio and record reviews as options.

This allows confirmation of eligibility while reducing risk to the patient and caregiver.

Request: Allow PAs to conduct the face-to-face encounter.

Allowing PAs to conduct the face-to-face encounter will alleviate some of the burden on physicians.

Request: Allow PAs and NPs to certify hospice eligibility.

By doing so, some of the burden will be relieved from physicians.

Hospice Regulatory Requests

Request: Include telehealth visits on claims for GIP and respite care when needed for consultations between hospice staff and patient’s facility.

This will limit the spread of the virus and maximize staff usage.

Request: Allow contracting for core services like nursing, medical social services, and counseling.

This will help address staffing shortages while meeting patient needs.

Request: Extend the timeline for completion of initial and comprehensive assessments.

While the ability to visit patients is limited, it’s more difficult for assessments to be completed within the usual timeframe.

Request: Allow for flexibilities related to GIP, CHC, and Inpatient Respite Care to address circumstances where the patient may not be admitted to a nursing home or requires more intensive care due to caregiver illness. Allow respite care to be provided in the home. Allow hospices to determine care needs. Waive the 5-day limit for respite care.

These flexibilities would address challenges with care transitions, the need for additional care when a family caregiver is sick, fewer inpatient and respite beds in facilities, and allows patients to meet eligibility requirements given special pandemic circumstances.

Request: Align the timeframe for review of the plan of care with the extended timeframe for the comprehensive assessment.

This allows hospices to review the plan of care along with completing the updates to the comprehensive assessments.

Request: Provide flexibility on the five-day timely filing requirement for NOE/NOTR.

This would allow staff to focus on direct patient care.

Request: Allow for verbal election of the Medicare Hospice Benefit when the patient can’t make their own decisions and the legal representative isn’t available to sign due to the pandemic.

By doing so, patients who need care can begin receiving services immediately.

In addition to agencies experiencing losses due to the COVID-19 pandemic, they’re also concerned with the rising costs of providing care during this unprecedented time. Most have seen increased costs for PPE and other infection control measures, as well as additional staffing costs as caregivers face infections or stay home in order to care for loved ones.

CMS has given in to several requests from NAHC thus far. However, we have yet to see whether the requests for modifications for COVID-19 will gain approval and provide additional relief to agencies in desperate need of financial support.

Click here to view all the requests to CMS from NAHC regarding regulatory considerations.

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