CMS Has Received 12K Complaints of No Surprises Noncompliance; Won $1.7M in Restitution

Healthcare Dive | By Rebecca Pifer

The most common complaints against providers were for surprise billing, while the top complaints for health plans included incorrectly calculating qualifying payment amounts.

Dive Brief:

• Federal regulators received more than 12,000 complaints that insurers and providers weren’t complying with the No Surprises Act through the end of June, according to new data released by the CMS.
  
  
• Regulators also won more than $1.7 million in restitution for consumers and providers from closed complaints related to the law, which banned surprise medical billing, an agency spokesperson said.
  
  
• The most common complaints against providers were for surprise billing for both emergent and non-emergent care, while top complaints against health plans were for calculating qualifying payment amounts, or QPAs, incorrectly.
  
  

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From Facility to Home: How Healthcare Could Shift by 2025

McKinsey & Company | By Oleg Bestsennyy, Michelle Chmielewski, Anne Koffel, and Amit Shah

Up to $265 billion worth of care services for Medicare fee-for-service and Medicare Advantage beneficiaries could shift to the home by 2025.

When patients enter a healthcare facility, their primary aims are to become well again and to go home. While increasing disease burden and rising healthcare costs in the United States have already contributed to a boost in Care at Home services, the COVID-19 pandemic has created a catalyst to truly reimagine their future.¹

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Based on a survey of physicians who serve predominantly Medicare fee-for-service (FFS) and Medicare Advantage (MA) patients, we estimate that up to $265 billion worth of care services (representing up to 25 percent of the total cost of care) for Medicare FFS and MA beneficiaries could shift from traditional facilities to the home by 2025 without a reduction in quality or access.² That number represents a three- to fourfold increase in the cost of care being delivered at home today for this population, although how the shift will affect reimbursement rates is not yet clear. What’s more, Care at Home could create value for payers, healthcare facilities and physician groups, Care at Home providers, technology companies, and investors. It also could improve patients’ quality of care and experience.

That said, several factors could affect adoption of these services. We outline those factors below, along with actions that stakeholders can take to address them. We also discuss why Care at Home services are rising, how Care at Home could create value for stakeholders and lead to higher-quality care for patients, areas where care could shift from traditional facilities to the home, and strategies for successfully adopting Care at Home…

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How Home Health Providers Can Prepare For HHVBP In 2025

Home Health Care News | By Joyce Famakinwa 

The third year of the Home Health Value-Based Purchasing (HHVBP) Model expansion comes with changes. Some measures will be retired, and some new ones will be added. 
Home health providers looking to achieve HHVBP success will need to prepare for this updated version of the model. 

“You need to be thinking about how you’re doing in 2024, and then preparing for 2025 and making sure that you’re improving in the right areas,” Yancey McManus, senior director of solutions management at WellSky, said during a presentation at last month’s National Association for Home Care & Hospice (NAHC) Financial Management Conference.

Staying on top of utilization management, as well leaning on accurate data, will be key for providers looking to gain HHVBP wins.

“To prove our value and leverage insight, we really need to bank on data-informed decisions, especially as the machines are learning, and helping us understand what else is going on, because we know that our care doesn’t just happen during our visits,” Cindy Campbell, senior director of advisory services at WellSky, said during the presentation. 
Campbell also pointed out areas where providers are leaving money on the table, so to speak.

She noted that purchasing analytics and not using them optimally was one way providers leave money on the table. Investing in RPM but not implementing it, and not leveraging patient engagement tools and check-in calls, were other ways providers sometimes fall short.

Ultimately, there are three key areas providers who are looking to stay on top can set their sights on mastering — OASIS-E, claims and HHCAHPS.
Indeed, providers need a strong assessment technique for OASIS-E and accurate documentation capture.

HHCAHPS is one area that McManus believes doesn’t receive enough attention, but one that could have the power to help providers differentiate their organization.

“HHCAHPS together represent 30% of your TPS score, so while individually they may not seem that important, together it’s incredibly important,” she said. 

When it comes to claims, it’s important to be goal directed and aligned with the patient, Campbell noted. 

“Focus on OASIS competence, we know that’s really important in the assessment technique, and look at what’s going on under the claims data to see where we are having problems with hospitalization,” she said. 

Campbell also urged leaders to remember that throughout their efforts to improve, things may get worse before they get better.

“When we lead value-based purchasing differently, our staff will respond differently,” she said. “There might be some pushback. Behaviors may get a little worse, when suddenly we’re controlling utilization better, right before they ever get better, but they will.”…

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Half of Falls Occur During Home Care Providers’ Off-Hours, Industry Survey Finds

McKnight’s Home Care | By Adam Healy
 
Falls frequently occur when home care providers are off-duty. Fortunately, patients’ risk of falling can be reduced through communication and trust with care workers, according to Sensi.AI, a home care technology firm.
 
Sensi.AI examined data collected by its audio-based artificial intelligence technology. It found that nearly 50% of falls that home care patients experience occur at night and on weekends, which are typically hours that home care providers are not present in the home. 
Nighttime poses other risks to home care patients. Symptoms of cognitive decline are 30% more pronounced at night, and seniors are more likely to experience mood changes at night, according to Sensi.AI. These, in addition to falls, can have negative effects on older adults’ well-being.
 
However, these risks can be mitigated by providers forming strong bonds with patients. Roughly 40% of falls can be avoided when there is a strong match between client and caregiver. This match is characterized by appreciation, compliments and praise. Moreover, medication errors are about 48% less likely to occur when communication and trust exist between home care workers and their clients.
 
In contrast, older adults are 61% more likely to fall when displaying care resistance, compared with those reporting positive care experiences.
 
“How are we going to know if something happens to our aging parents with no caregivers to be there watching over them 24/7?” Romi Gubes, the co-founder and chief executive officer of Sensi.AI, asked in a statement. “We need a better way to ensure our loved ones can safely age in place.”
 
More than half of falls at home happen in patients’ bedrooms or bathrooms, and Sensi.AI highlighted the need for targeted safety measures in these areas. Home modifications like ramps and grab bars are common tools to promote seniors’ safety while aging in place.