The New York Times (free registration) reports that Congress is putting the long term care insurance industry “under scrutiny.” The House Committee on Energy and Commerce is investigating long term care insurers Conseco and the Penn Treaty American Corporation.
It seems that certain long term care insurers are making policyholders jump through hoops to have their claims paid. Congressman John Dingell of Michigan told the paper that “We have two companies that seem to be engaging in questionable practices, and we have every reason to think we will turn up other companies engaged in questionable practices. Now that we’re aware this is occurring, we’re going to shine a light on it that won’t be extinguished.”
With people living longer and baby boomers entering long term care, whatever issues Conesco and Penn Treaty American Corporation have with paying claims likely will get worse. The investigation is coming at the right time.
The Texas Department of Aging and Disability Services (DADS) issued a letter dated May 25 to home and community-based services (HCS) and Texas Home Living providers (TxHmL) clarifying issues about National Provider Identifiers (NPI) that apply only to them.
By June 1, 2007, DADS must have NPI numbers for all HCS and TxHmL providers, which means these providers must apply for and obtain NPI numbers. Beginning July 1, claims that contain no NPI numbers will not be processed.
Additionally, DADS has determined that special NPI training for providers is no longer necessary. If you have questions, visit the NPI page. You may download the provider letter here.
The Bush administration seeks to cut Medicare reimbursements to hospitals, home health agencies, and skilled nursing facilities in an effort to save as much as $100 billion to fund health care proposals. (Kaiser Network)
Last week, the House Ways and Means Health Subcommittee, chaired by Democrat Pete Stark, held a hearing to consider a proposal from the Bush administration “to freeze Medicare reimbursements for home health agencies and skilled nursing facilities.”
A health care lobbyist said a freeze on reimbursements would leave home health agencies “absolutely annihilated” and would not generate the kind of savings expected.
The Texas Register published a notice about the Texas Health and Human Services Commission’s intent to submit the state’s application for renewal of the NorthSTAR Program §1915(b) waiver to the Texas State Plan for Medical Assistance under Title XIX of the Social Security Act.
The current waiver expires on September 30, 2007.
If you have questions or would like a copy of the waiver renewal, contact Carmen Capetillo by phone at (512) 491-1128 or facsimile at (512) 491-1953 or e-mail at carmen.capetillo@hhsc.state.tx.us. Write to Ms. Capetillo at the following address:
Carmen Capetillo
Health and Human Services Commission
P.O. Box 85200, H-620
Austin, Texas 78708-5200
The Texas Department of Aging and Disability Services (DADS) informed DADS Long Term Care Services and Supports Providers of the “importance and usefulness” of the Remittance and Status (R&S) Report Information in a letter dated May 18. To avoid incorrect and inaccurate billing, providers must make sure information is accurate.
DADS reminded providers that a new fiscal year is approaching, so they need to review R&S reports carefully. For more information, download the letter here.
In a May 22 letter, DADS informed all contracted providers that individuals receiving Foster Care Medicaid and Adoption Subsidy Medicaid were closed out in the System Application, Verification, Eligibility, Referral, and Reporting system and transitioned to the Texas Integrated Eligibility Redesign System (TIERS), effective February 1, 2007.
Some providers may have received notices, in error, that individuals are not eligible for Medicaid because of the change. If you received such a notice, you’ll need to verify the information by using the Medicaid Eligibility Service Authorization Verification Report or by checking the person’s current Medicaid card.
For information, download the letter here.
In a letter dated May 14, the Texas Department of Aging and Disability Services (DADS) notified assisted living providers, provider organizations, and surveyors about a conference called, “Clarifying the Myths in Assisted Living Facilities.” The conference will be held on July 19, 24, and 31.
Topics to be presented include aging in place, emergency preparedness, and medication management. For locations and times, you may download the letter here.
DADS reminded nursing facilities (in a May 15 letter) about the need to notify Medicaid clients of increases in their monthly applied income amounts — which resulted from a cost of living adjustment to Social Security benefits in January — pursuant to federal regulations and the state administrative code. You may download the letter here for more information.
The Texas Health and Human Services Commission (HHSC) proposed a series of rule changes that would align Medicaid rules with the requirement to acquire prior authorization for non-emergency ambulance transport. The rule changes would include terminology updates.
A public hearing will be held on May 24, 2007, from 9:00 a.m. to 10:00 a.m. in the HHSC Lone Star Conference Room, 11209 Metric Boulevard, Austin, Texas 78758. Send written comments to Garry Walsh, Senior Policy Analyst, Medicaid/CHIP Division, Texas Health and Human Services Commission, P.O. Box 85200, Austin, TX 78708-5200, Mail Code H-390 91X. You may fax Mr. Walsh at (512) 506-7808 or e-mail at Garry.Walsh@hhsc.state.tx.us. For more information, see the relevant section of the May 4 Texas Register.
HHSC has proposed to add new language to the rules that would establish the methodology that it will use to reimburse certain physicians under Medicaid. For more information, see the relevant section of the May 4 Texas Register.
In another update, HHSC has proposed to repeal certain reimbursement rate language and replace it with new language that will correspond with language approved by the Centers for Medicare and Medicaid Services concerning School Health and Related Services. For more information and to find out where to send written comments, see the relevant section of the May 11 Texas Register.
Long Island Care at Home vs. Coke, a federal case concerning home health worker compensation, got its second hearing before the U.S. Supreme Court on April 16, 2007. Before the justices: the validity of a longstanding Department of Labor regulation regarding “companionship services” provided by third parties (read: home health agencies) “to the care of the elderly or infirm.” Coke’s attorneys argued that Congress understood the terms “domestic service employment,” as used in the companionship exemption, to refer only to a personal employment relationship rather than a third-party relationship that involves an agency-employer.
The Second Circuit in this case agreed, overturning the Department of Labor (DOL) regulation that exempted such home care workers from both minimum wage and overtime requirements. Left to stand, at least in the Second Circuit, third-party employers of home health care providers will be liable for backpay and unpaid overtime — and at least need to start paying home health care attendants minimum wage. The detailed briefs of the defendant-home health agency and the plaintiff-aide can be viewed online at the Court’s website , and the United States’ brief filed in support of the home health agency can be viewed at the Department of Justice’s website.
After the first court ruling in 2004, the DOL issued a memorandum explaining that the Second Circuit was wrong and that the exemption should be upheld. Despite the Supreme Court’s vacating the Circuit’s earlier decision and remanding the case for reconsideration in light of the DOL memorandum, the Second Circuit, again, struck down the regulation. Essentially, citing administrative deficiencies, the Second Circuit found the DOL exceeded its legislative authority in construing the “companionship exemption” to cover third party home health agencies. The case is before the Supreme Court, again, upon the urging of Long Island Care at Home.
The effect of the Court’s ruling on ever-rising health care costs was not lost on either party. The home health agency argued that health care costs of the elderly and infirm would only rise if the regulation remains invalidated. Ms. Cook’s attorneys countered that a lack of fair wages – not compliance with the wage and hour laws – are the greatest threat to the availability of quality companionship services.
Our best bet, after analyzing the administrative questions involved, is that the Second Circuit decision will be overturned and the DOL companionship regulation upheld. We await the Court’s ruling.
DADS issued Information Letter 07-50 on May 10, 2007, requiring all Home and Community-Based (HCS) and Texas Home Living (TxHmL) Providers educate employees, contractors, and agents about federal and state fraud and false claims laws, and the whistleblower protections available under those laws. The mandate comes from the employee educational requirements under Section 6032 of the Federal Deficit Reduction Act (DRA) of 2005. Specifically, effective January 1, 2007, all providers who receive or make annual Medicaid payments of $5 million or more must:
• Establish written policies for all employees, contractors and agents that provide “detailed information” about the False Claims Act, administrative remedies for false claims and statements, any state laws pertaining to civil or criminal penalties for false claims, and whistleblower protections under such laws.
• Include as part of their written policies, detailed provisions regarding the provider’s policies and procedures for detecting and preventing fraud, waste, and abuse.
• Revise any existing employee handbook to include information on the above laws and employee protections, as well as policies and procedures for detecting and preventing fraud, waste, and abuse.
For purposes of compliance, DADS will incorporate the requirements of Section 6032 into new HCS and TxHmL provider contracts. Providers with existing contracts must comply in accordance with those contracts, which require compliance with all federal and state laws, regulations, and rules. In addition, DADS will implement monitoring plans and activities to ensure compliance with Section 6032 of the DRA. On an annual basis, DADS will have the provider submit to the State Office a signed affidavit with a list of employees that were trained on these policies and procedures during the previous federal fiscal year. Additionally, DADS Regulatory Services will verify employee training at the time of their regular onsite reviews of those providers that received $5M or more in Medicaid payments from DADS during the most recent federal fiscal year.
Affidavits must be submitted to:
Texas Department of Aging and Disability Services
Community Services Contracts Unit (MC W-517)
P.O. Box 149030
Austin, TX 78714-9030
Contact your legal counsel or consultant to revise personnel policies to ensure timely compliance. And, as always, do not hesitate to call if you have any questions.
Mary Ousley, past chair of the American Health Care Association, which represents long term care providers, testified before a congressional committee last week about the long term care profession’s experience with the Omnibus Budget Reconciliation Act of 1987 (OBRA ‘87).
OBRA ‘87 is considered landmark legislation because it established many nursing home oversight rules in place today. Ousley said that in order to improve nursing facilities, providers, regulators, and consumers must cooperate in the process.
“What we have is a system that defines ‘success’ and quality in a regulatory context that is often measured by the level of fines levied and the violations tallied – not by the quality of care, or quality of life,” Ousley said. “The statute envisioned a resident-centered, outcome-oriented, consistent system of oversight. Unfortunately the system we have today bears little resemblance to that vision.”
In response to the growing concern over long term care quality, lawmakers introduced a bill called the Long Term Care Quality and Modernization Act of 2006. Ousley believes this measure will help improve quality of care and encourage cooperation.
Source: American Health Care Association