Senate Passes Spending Bill Including Provisions on Home Health, Fraud, RAC Audits and Appeals
Tuesday, December 16, 2014
by: Visiting Nurse Associations of America

Section: Public Policy and Advocacy

The Consolidated and Further Continuing Appropriations Act 2015, otherwise known as the "cromnibus" spending bill passed the House on Thursday evening and then the Senate on Saturday night and is now waiting President Barack Obama's signature. The $1.1 trillion deal averted a government shutdown and funds most of the government through September 2015. The explanatory statement of the bill contains a number of provisions of interest available here.

There are four provisions of interest to VNAA members. VNAA is tracking these provisions closely and will update members as needed. Below are the items of particular significance:

Access to Home Health Care

The agreement requests that in the fiscal year 2016 budget request, CMS quantify and explain how the policy directing physicians to conduct face-to-face certifications for home health care has prevented fraud, increased access to health care, and impacted costs to the Medicare and Medicaid programs. The agreement requests that CMS include in the budget request how provider documentation for face-to-face encounters can be simplified. In addition, CMS should provide a public analysis related to rebasing Medicare home health agencies within 90 days of enactment of this act.


Fraud, Waste and Abuse


The agreement requests an update in the fiscal year 2016 budget request on CMS' process, across all operations, to ensure CMS maintains a focus on preventing improper payments and paying claims right the first time. The update shall include a proposal to measure prevention as opposed to typical ``pay and chase'' measures reported by CMS. Further, CMS is directed to increase its collaboration with the HHS OIG on the oversight of ACA- related contracts to ensure all contract recipients meet their performance obligations and are held accountable for any actions not in accordance to the contract. The agreement requests a report no later than 90 days after enactment of this act describing the current oversight measures in place for contracts awarded by CMS, including the recourse available in the event that an organization fails to meet its contractual obligations.

Recovery Audit Contractors (RACs)

Unintended consequences of RAC audits can reduce patient access to care and jeopardize the economic viability of critical health care providers. The Office of Medicare Hearings and Appeals (OMHA) have a backlog of nearly 750,000 appeals. The length of time to resolve an appeal, including OMHA's assignment of an Administrative Law Judge, can take over five years. CMS has an obligation to find a reasonable balance to eliminate true fraud and abuse while not slowing payment to the majority of honest providers that are negatively impacted by the RAC process. CMS is directed to educate providers on how to reduce errors, develop procedures to reduce the OMHA backlog; and establish a process that provides educational feedback from the OMHA to CMS and RAC contractors to reduce the identification of claims that are likely to be overturned once elevated to the OMHA.

The fiscal year 2016 budget request shall include a timeline, milestones, and measurable goals to address these concerns with the RACs to reduce the appeals backlog. The budget request for fiscal year 2016, and subsequent years, shall include an actuarial estimate on the amount of improper payments, actual and estimated recoveries by year with percentage of recovered payments.

CMS is directed to submit a report to the appropriate committees of the House and Senate, within 180 days of enactment, on the cross-agency working group reviewing the Medicare appeals process and its recommendations. The report should include the agency's strategy to analyze and improve the entire appeals process, as well as areas related to Medicare audit contractors' quality of medical reviews; proposed statutory challenges; timeline and strategy to eliminate the backlog; steps to address the high overturn rates at OMHA; and steps to improve stakeholder confidence that Medicare policies are interpreted consistently and transparently throughout the system.

Appeals Backlog


The agreement continues to be concerned over the substantial backlog in the number of cases pending before the administrative law judges at the Office of Medicare Hearings and Appeals (OMHA) and the two-year moratorium on assigning new cases. OMHA is directed to use the additional funds provided to address the current backlog and to increase its capacity to process the rising caseload. The agreement requests a report no later than 90 days after enactment of this act describing the plan to resolve the current and future backlog at OMHA.

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