Wednesday, July 27, 2016

CMS Clearly Knows What It Is Doing. Do You?

Nine states are now subject to Value Based Payment modeling; five states are subject to the pre-claim submission demonstration; CMS spent $450m on building tools and staff to chase fraud, waste and abuse (key in on “waste”); aggressive CMS/MAC audits are the policy du-jour; DOJ prosecutes 300 in a nationwide health care abuse round up; round two of the OCR HIPAA audits are now underway. It would be difficult to see these actions as unrelated or random. Even more difficult not to see the writing on the wall.

Clearly, CMS believes that there are too many home care service businesses. Too many that are under-capitalized; too many that are not profitable; too many that are serving too small a patient base; too many that are operationally, weakly managed; too many that can’t make the necessary leap to technology advances and yes, too many that submit unjustifiable or inconsistent claims, purposeful or not.

It can’t be lost on the home care industry that CMS is accumulating empirical evidence that quality of care can and does improve and at a lower cost when the industry is forced to a value based payments model and STAR ratings. I would blame the capacity to be able to now demonstrate care improvements on the industry…how did the industry end up in that circumstance? Results are showing that there existed and there is room for improvement. It seemingly needed to be externally driven.

So what is the CMS strategy? Reduce the number of home care services so that fewer are serving a bigger census and doing a better job of it. The question quickly becomes strategic for industry players. Become a new era player, survive and grow or get audited or bureaucratized into bankruptcy.
The consensus forecast is that the ~ 12,000 home care agencies will end up being around ~6,000.

The four operational axioms I would focus upon to survive in this new era are:

1.       Don’t submit to CMS/MAC what you can’t defend
2.       Know your OASIS outcome analytics – deeply
3.       Be sure care plans are done actively and not at some later point in the day or week.
4.       Anticipate the re-certification hurdles

Seeing the benefits of these four axioms is not conjecture it is based on experience. If you would like to discuss that experience, please do let me know. I’d be happy to do so.