How 2021 CMS Proposals will change the Medical Billing Systems

On June 28th, 2021, the Centers for Medicare & Medicaid Services (CMS) published its proposals through the annual Home Health Prospective Payment System. These new rules are going to affect the entire workflow management of medical billing systems. Therefore they are highly crucial to note for all stakeholders in the USA medical industry. The proposals are open for public comments till August 27th, 2021. Let’s see what they are!

1.Role of Occupational Therapists:

The change in the role of occupational therapists is one of the permanent modifications as per the CMS proposal.

  • The usual rule for Medicare coverage states that a doctor or a healthcare provider needs to certify that a patient requires occupational therapy.
  • The Medicare Part B insurance coverage is valid in these cases but only for outpatient services.
  • In the proposed rule for Home Health, the occupational therapist will conduct the preliminary assessment for the patients.
  • The therapist takes into account the abilities of the patient and tallies them with the desired outcomes. They assess the home conditions of the patient and conclude to see if the home health plan is suited for them.
  • This rule is valid for patients who have any of the following in their care plan: Physical therapy, Speech Therapy, or General Occupational Therapy.
  • However, the plan does not include skilled nursing services for patients.

2.On-site Survey for Patients:

The rule for initial on-site survey for patients was introduced with the onset of the pandemic. In its proposed rules, CMS wants to make it a permanent one.

  • A 14-day on-site survey for patients is the current mandate according to the latest rules.
  • The 14 day period will start 48 hours from the day the doctor prescribes the home health care plan for the patient.
  • This rule is valid for patients who need skilled nursing services as a part of their care plan at home.
  • The home health aide’s role is to determine if the care plan is working for the patient and how they are adapting to it.
  • The CMS had opened up the option of conducting these surveys via audio-video conference during the massive hike in Covid-19 cases in 2020.
  • In the newly proposed rule, the telehealth option remains. However, the CMS has particularly mentioned that it prefers on-site surveys, especially for in-patients.

3.Changes in Payment Rate:

Changes in payment rates will directly affect the medical billing systems. The teams should update themselves on the upcoming rates for home health to maximize the reimbursements.

  • For the year 2022, the CMS has proposed increasing home health payment rates by 1.8%.
  • The Medicare body expects that this change will increase the overall reimbursements for home health agencies by a mighty USD 330 Million.
  • However, they have also acknowledged the anticipated revenue decrease due to the rural add-on payment option.
  • The rural add-on payment plan released by Medicare in 2020 shifted the payment add-on focus from umbrella-based rural communities to targeted rural populations.
  • Earlier, the focus was broadly overall rural communities. With the rule of 2020, the CMS shifted the focus to only specific rural clusters which do not have much access to home health plans.
  • With these changes, the total reimbursement might decrease by around USD 20 Million, bringing down the rate by 0.1%.

4.Penalty for Quality Non-Maintenance:

The quality of stakeholders in Home Health care plans is one of the forerunners to determine their eligibility. The CMS has stressed the need for strict adherence to quality and has issued penalties for those who do not maintain it.

  • As per the latest CMS proposal, the penalty stands at an annual reduction of 2 percentage points.
  • The home health aides must submit their quarterly Home Health Quality Reporting Program (HH QRP).
  • Along with it, the Outcome and Assessment Information Set (OASIS) and Consumer Assessment of Healthcare Providers and Systems (CAHPS®) Home Health Survey need submission as well.
  • The only exemption to this rule was made back in the first half of 2020 during rising cases of Covid-19.
  • The exemption period has ended way back in June 2020. Therefore the home health aides must return to their usual quality maintenance programs to ensure healthy medical billing systems.

5.Value-based Payment Program Expansion:

The value-based payment program model has been in the system since 2016. CMS had introduced it as a new modification and has been evaluating the changes ever since. The current proposal is a reflection of the latest evaluation.

  • According to the proposed rule, the CMS wants to expand the value-based payment program nationwide.
  • Earlier, this model was used for home health agencies, certified by Medicare, in only nine states of the USA.
  • The third and latest evaluation of the changes shows that quality scores have improved by a reasonable 4.6% just in the period of 5 years.
  • It has also aided Medicare to reach an annual saving milestone of USD 141 Million.
  • These figures indicate the apparent success of the model. Therefore, Medicare wants to expand the model to other states as well.

How do these proposals affect the medical billing systems?

Medical billing systems, especially dealing with federal programs like Medicare and Medicaid, need frequent upgradation according to the latest rules.

  • Home Health Organizations having in-house teams need to keep track of the latest changes and implement them in the system.
  • Any redundant billing system can harm the cash flow of the organization. They might also bring the organizations under the radar of CMS for not following the latest guidelines.
  • Therefore, these agencies and organizations should conduct staff training programs so that the revenue cycle management is uninterrupted.
  • If you are struggling with an understaffed team, you can outsource the medical billing systems to the leading revenue cycle management companies.
  • They have competent professionals to deal with billing and coding issues. You can expect good accountability along with reasonable standards of medical billing systems.
  • They also offer staff training programs that you can keep an eye on. These programs will help your staff to stay in the loop regularly.
  • You can also take their help to benchmark your financial performance to stay ahead in the field.

We hope this blog gave you a good idea about the latest proposals of CMS regarding the home health payment plans. For more such news on healthcare management and technology, subscribe to our blog. For regular updates, follow us on Facebook, Instagram, Twitter, and LinkedIn. For any queries or suggestions, do not forget to leave a comment below.




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