Tag Archives: CMS

What Makes A Five Star Hospital?

The Affordable Care Act includes many provisions aimed at improving the quality of care provided by different types of health care professionals and providers. Along these lines, the ACA expands the types of facilities and providers for which quality data will be publically available.  The Secretary of the United States Department of Health and Human Services was therefore directed to develop a Hospital Compare website (amongst other similar sites such as Physician Compare and Nursing Home Compare) that would allow Medicare enrollees to compare scientifically sound measures of physician quality and patient experience.

In accordance with these directives, on April 16, 2015 the Centers for Medicare and Medicaid Services (“CMS”) released the first ever Hospital Compare Star Ratings on its public information website.  The site is intended to make it easier for consumers to choose a hospital and understand the quality of care they deliver.  The data set from the website contains hospital-specific quality data for over 4,500 hospitals nationwide.  The ratings are based on the 11 publicly reported measures in the Hospital Consumer Assessment of Healthcare Providers and Systems (“HCAHPS”) survey, which assesses patient experiences.

The star ratings allow for an easy comparison using a five-star scale, with more stars indicating better quality care.  The quality data on Hospital Compare includes clinical process of care, patient outcomes and patient experience of care measures.  The national rankings are based on hospitals’ performance on the clinical process of care measures and a national survey of patients’ experience of care.  The hospitals’ ranks are combined into an overall, composite performance ranking, with process of care measures contributing 70% and patient experience of care measuring 30%.

However, just 251 out of 3,553 hospitals received the highest score in the rating system based on the experiences of patients who were admitted between July 2013 and June 2014.  Hospitals had an opportunity to preview the ratings in the fall and many have already expressed concern.  Hospitals question the methodology and whether the ratings reflect meaningful reflections of performance.  They also assert that the ratings are oversimplifying the hospital’s performance to a single score.

Notably, the patient experience star ratings are only based on the information on quality of care that is reported by patients.  The surveys are provided to a random sampling of patients within two days after discharge from a hospital and must be completed within 42 days.  Further, positive results may mean that the hospital is delivering good care.  However, these results are not taking into account other factors such as timely and efficient care and results or outcomes of care measures.  Moreover, the results places substantial reliance on patient review, which is just one measurement of hospital quality.  Lastly, if one does not review Hospital Compare extensively, information aside from the star ratings may easily be overlooked.  For example, the complete results for each HCAHPS measure can be found in the “Survey of Patients’ experiences” section.

On the other hand, supporters of Hospital Compare argue that while it’s not a perfect measurement system, it creates a healthy competition among hospitals.

For more information on Hospital Compare, other CMS initiatives or related issues, please feel free to contact Daniel Meier or any member of our health care practice group for a further discussion.

NYS Identifies $496 Million in Medicaid Home Health Erroneous Payments

On October 30, 2013, the New York State Office of the Medicaid Inspector General (“OMIG”) issued a press release that New York recovered $211 million from the federal government out of an identified $496 million in Medicaid erroneous payments related to home care recipients who are dually eligible for both Medicare and Medicaid funds.  On October 1, 2013, the New York State Department of Health’s Fiscal Group received the $211 million payment through the action of OMIG, which was the largest single monetary recovery in OMIG’s history.

These payments were recovered by New York State as part of a federal project, the Third-Party Liability Home Health Care Demonstration Project, which is reviewing home health care involving dual eligible recipients, and is being conducted in conjunction with the University of Massachusetts Medical School.  Continue reading

Circuit Court Upholds Immediate Jeopardy for Failure to Notify of Significant Change in Patient’s Condition

The U.S. 6th Circuit Court recently upheld a DHHS Departmental Appeals Board decision that found a skilled nursing facility’s (“SNF”) deficiencies were at an “immediate jeopardy” level relating to a failure to notify a physician or family member of a significant change in a patient’s condition. See, Claiborne-Hughes Health Center v. Sebelius, 6th Cir. No 09-3239, 6/25/10.

The Claiborne-Hughes Health Center is a SNF in Franklin, TN. The decision was based upon surveyors findings that the facility failed to comply with 42 C.F.R. §483.10(b)(11). Section 483.10(b)(11) requires a facility to immediately consult with a resident’s physician and notify the resident’s family members or legal representation when there is a significant change in a resident’s physical, mental, or psychosocial status.

The failure to comply with the applicable regulation related to Claiborne-Hughes’ policy on recording patient fluid-intake. Surveys completed in August and September of 2006 revealed that the facility was not sufficiently monitoring patient fluid intake in accordance with its own policies.

A copy of the decision can be found at – http://caselaw.findlaw.com/us-6th-circuit/1529702.html

CMS to Share Terminated Provider and Supplier Information with States

In order to implement requirements in the the Patient Protection and Affordable Care Act of 2010 (“PPACA” or the “Health Reform Bill”), CMS is starting to share information with the states about providers who are terminated from participation in Medicare.  CMS is going to start sharing the information via e-mail while it works on developing an electronic database.

Section 6401(b)(2) of the PPACA requires CMS to establish a process to make available to State Medicaid and CHIP agencies certain information on Medicare providers and suppliers that are terminated from participation in the Medicare program or CHIP. Additionally, Section 6501 of the PPACA requires state Medicaid programs to terminate any Medicaid provider that has been terminated from Medicare.

See this recent CMS Program Integrity memorandum from the CMS Center for Program Integrity.

Health Reform Includes Face to Face Practitioner Encounters for HHAs and DME

The Patient Protection and Affordable Care Act of 2010, H.R. 3590 (the “Health Reform Bill”) includes statutory provisions requiring face to face practitioner encounter requirements for home health certifications and prior to the provision of orders for durable medical equipment.

In the home health context, Title VI, Subtitle E, Section §6407(a) of the Health Reform Bill amends 42 U.S.C. §1395f(a)(2)(c). The amendment adds a condition to the existing conditions for payment.  The new condition provides that prior to making a certification that a patient meets the criteria for Medicare-covered home health services,  the physician “must document that the physician himself or herself has had a face-to-face encounter with the [patient] within a reasonable timeframe as determined by the Secretary’’. At some point in the near future, CMS will likely publish regulations defining “reasonable timeframe”.

In the durable medical equipment context, Title VI, Subtitle E, Section §6407(b) of the Health Reform Bill amends 42 U.S.C. §1395m(a)(11)(B). The amendment adds a condition to the existing conditions for payment.  The new condition provides that prior to providing an order for durable medical equipment under the Medicare program, “a physician, a physician assistant, a nurse practitioner, or a clinical nurse specialist [must have] had a face-to-face encounter with the [patient] during the 6-month period preceding such written order, or other reasonable timeframe as determined by the Secretary.’’ To the extent that CMS wants to redefine the timeframe, it will likely publish regulations in the future.

Additionally, Title VI, Subtitle E, Section §6407(d) of the Health Reform Bill provides that the encounter requirements shall apply to similar home health certifications or orders for durable medical equipment in the Medicaid program.