FutureFocus January 31, 2018 Preventable Hospitalizations for Home Health

Lisa Remington

In this week’s FutureFocus, is an important development to the future of home health. CMS is developing potentially preventable hospitalizations for the home health setting. This is an indicator of a future quality measure. In another move, CMS is continuing its moratoria on enrollment of new Medicare home health agencies in certain states. We provide the details. In an effort to detect fraud, the Department of Veterans Affairs (VA) and CMS are partnering to share data, data analytics and best practices.

Lisa Remington, President, Remington Health Strategy Group

CMS extended for another six months its moratoria on enrollment of new Medicare home health agencies in Florida, Illinois, Michigan and Texas, and on new Part B non-emergency ground ambulance suppliers in New Jersey and Pennsylvania.

 CMS extended for another six months its moratoria on enrollment of new Medicare home health agencies in Florida, Illinois, Michigan and Texas, and on new Part B non-emergency ground ambulance suppliers in New Jersey and Pennsylvania.

The extension also applies to new non-emergency ground ambulance suppliers and home health agencies in Medicaid and the Children's Health Insurance Program in those states. CMS implemented the moratoria on newly enrolling Medicare providers and suppliers after it identified patterns of fraud, waste or abuse among these particular provider types and geographic locations.

Background

Determination of the Need for Moratoria

In imposing these enrollment moratoria, CMS considered both qualitative and quantitative factors suggesting a high risk of fraud, waste, or abuse. CMS relied on law enforcement's longstanding experience with ongoing and emerging fraud trends and activities through civil, criminal, and administrative investigations and prosecutions.

CMS' determination of a high risk of fraud, waste, or abuse in these provider and supplier types within these geographic locations was then confirmed by CMS' data analysis, which relied on factors the agency identified as strong indicators of risk. (For a more detailed explanation of this determination process and of these authorities, see the July 31, 2013 notice (78 FR 46339) or February 4, 2014 moratoria document (79 FR 6475)).

Because fraud schemes are highly migratory and transitory in nature, many of CMS' program integrity authorities and anti-fraud activities are designed to allow the agency to adapt to emerging fraud in different locations. The laws and regulations governing CMS' moratoria authority give us flexibility to use any and all relevant criteria for future moratoria, and CMS may rely on additional or different criteria as the basis for future moratoria

See details here