NAHC/HHFMA Medicare Advantage Survey – 2024

The National Association for Home Care & Hospice (NAHC), in conjunction with the Home Care & Hospice Financial Managers Association (HHFMA), has developed a survey to assess the current state of home health within Medicare Advantage (MA) plans.

We are asking home health providers that contract with MA plans to complete this survey, estimated at about 10-15 minutes. Thank you in advance for your participation.

Take the survey at https://www.surveymonkey.com/r/SHDB2TH

CMS Finalizes Underwhelming Payment Adjustment For Medicare Advantage Plans

Home Health Care News | By Patrick Filbin
 
The Centers for Medicare & Medicaid Services (CMS) finalized a rule that will result in a 3.7% positive payment adjustment for Medicare Advantage (MA) plans in 2025.
 
According to an analysis done by the private investment banking company Stephens, rates are expected to remain virtually unchanged, with a slight decrease of 0.16%. This marks the second consecutive year of a cut to real “core” MA rates.
 
Although expected, the news worried some post-acute stakeholders who believe plans will pass cost concerns down onto providers.
 
“These inadequate rates paid by the MA plans destabilize the financial health of provider organizations more broadly,” LeadingAge President and CEO Katie Smith Sloan said in a statement shared with Home Health Care News. “Policymakers must act before we find few providers remaining to serve the more than 65 million Medicare beneficiaries, including the nearly 33 million who now receive their Medicare benefits via an MA plan.”
 
Under the new guidance, payments from the government to MA plans are expected to increase, on average, by 3.7% — or over $16 billion — from 2024 to 2025.
 
In previous years, CMS has bumped up the rate by 3.32% for 2024 and 8.5% in 2023.
“The finalized policies in the rate announcement will make improvements to keep Medicare Advantage payments up-to-date and accurate, lower prescription drug costs and ensure that people with Medicare have access to robust and affordable health care options,” CMS Administrator Chiquita Brooks-LaSure said in a statement.
 
The federal government is projected to pay between $500 and $600 billion to private health plans in 2025.
 
The final core 2025 rate update is well below expectations, Scott Fidel, an analyst with Stephens, wrote in the report.
 
As a result, Stephens projects the potential for slower enrollment growth for the MA industry in 2025 as MA plans look to adjust member premiums and benefits to preserve margins.
 
“Bottom line, we see the final core 2025 MA rate update of -0.16% as reflecting a ‘highly adverse’ outcome for the industry, inclusive of the additional industry headwind of higher utilization trends currently observed,” Stephens wrote in its report. “The final 2025 rates largely reflect a continuation of the negative CMS rate cycle — now denoted as ’Year 2’ — of a much more constrained annual MA reimbursement trend as compared to the significantly more favorable rate outcomes in 2022 and 2023.”
 
Generally, home health agencies have expressed dissatisfaction with payment rates and reimbursement policies set by managed care companies…

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What Home Health Providers Need To Know About The Medicare TPE Audit Process

Home Health Care News | By Joyce Famakinwa
 
There are decades-old home health providers that have not yet gone through the Medicare Targeted Probe and Educate (TPE) process. But all home health leaders should familiarize themselves with the review process and its potential outcomes, as well as its challenges.

That’s one key takeaway from a recent Home Health Care News webinar that was sponsored and presented by MatrixCare. 

Broadly, TPE is a medical review program that began for the home health and hospice settings in December 2017. The goal of the program is to weed out improper payments by zeroing-in on providers with high claims denial rates or unusual billing practices. 
The program was put on hold in March 2020, in accordance with the public health emergency. It was then reestablished in September 2021. 

TPE has three pillars. Target refers to errors or mistakes that are identified through data in comparison to providers or peers. 

Probe is the examination of 20 to 40 claims. The claim size is meant to be large enough to get a clear picture of the behavior without intending to be burdensome, Rachael Feeback, senior product manager at MatrixCare, noted during the presentation.

Education means helping providers reduce claim denials and appeals through one-on-one individualized education.

Some common claim errors include things like a missing signature of the certifying physician, documentation not meeting medical necessity and missing or incomplete certifications or recertification documents. 

When a provider becomes the subject of a TPE audit, they receive a letter explaining the process. Then a Medicare Administrative Contractor (MAC) reviews between 20 to 40 of their claims and supporting medical records. If the audit finds discrepancies, after education occurs, the provider has 45 days to fix these issues. After this, the process begins again.

“If you fail three rounds, you could be referred to the OIG or CMS, you could even be facing a UPIC or a SMRC audit,” Feeback said. “It’s really important that you have a good process here.”…

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CMS Readies Providers for Interoperability and Prior Authorization Rule

McKnight’s Home Care | By Adam Healy

The Centers for Medicare & Medicaid Services offered providers resources to help prepare for the newly finalized Interoperability and Prior Authorization final rule, which will go into effect in 2026. 

“In this rule, we explore ways that technology can improve and streamline the complex process of prior authorization,” Alexandra Mugge, deputy chief health informatics officer and director of CMS’ health informatics and interoperability group, said during a webinar last week. “By improving prior authorization processes for providers, we hope that they will be able to put that time back into taking care of their patients. So this would have a direct impact on the provider and saving time, but hopefully they can put that time into patient care, which will have a significant impact on the patient, as well.”

The rule is primarily focused on streamlining healthcare data sharing by using specialized application programming interfaces (APIs), tools that allow programs or applications to communicate with each other, Mugge explained. CMS’ rule will create multiple APIs for patients, providers and payers, which would “greatly improve data sharing and access to information” among these parties, she said.

Home care and hospice providers have generally not benefited from interoperable health data technology and, as a result, lack critical information about their patients. A specialized “Provider Access API” finalized in CMS’ rule would give all providers the ability to see their patients’ claims and encounter data, as well as their prior authorization information, another key focus of the rule.

“Automation and technological solutions are never enough to address a complex process like prior authorization,” Mugge said. “To truly look at prior authorization reform, we have also looked at … cultural changes that will help to support streamlining these processes in the future, in addition to the technology solutions.” 

These changes include reduced prior authorization decision timelines and a requirement that payers provide a specific reason for denials, according to the rule. Specifically, the rule requires certain payers — such as MA, Medicaid and Medicaid managed care plans — to make prior authorization decisions within 72 hours for expedited requests, and within one week for standard, non-urgent requests.

Meanwhile, some critics have called on CMS to reduce decision timelines even further. The Improving Seniors’ Timely Access to Care Act, which has been endorsed by LeadingAge, would require Medicare Advantage plans to make prior authorization decisions within 72 hours of a request.