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

The Centers for Medicare and Medicaid Services (CMS) and the Department of Veterans Affairs (VA) January 23 announced a partnership to share data, data analytics tools, and best practices for identifying and preventing fraud, waste, and abuse. 

This newest partnership enhances ongoing efforts between the country’s two largest public-private health-care payment organizations to help the nation’s veterans by leveraging the gains made by CMS, according to the VA. 

Consider the recent growth in VA-funded, private sector care, which has occurred since Congress created the Veterans Choice Program (VCP) in August 2014. Under the program, veterans can gain VA eligibility for care outside the VA system furnished by providers in the community when direct VA care appointments are delayed or access to VA care is problematic due distance from home. Over 1.6 million “unique veterans” have received care closer to home through the program, according to the VA. Also, the program has a national network of 433,000 providers.

"VA plans to capitalize on the advancements in analytics CMS has made by concentrating on its use of advanced technology, statistics and data analytics to improve fraud detection and prevention efforts."

“The VA-HHS alliance represents the latest example of VA’s commitment to find partners to assist with identifying new and innovative ways to seek out fraud, waste, and abuse and ensure every tax dollar given to VA supports veterans,” said VA Secretary Dr. David J. Shulkin. “This effort marks another step toward achieving President Trump’s 10-point plan to reform the VA by collaborating with our federal partners to improve VA’s ability to investigate fraud and wrongdoing in VA programs.”

VA to Capitalize on CMS’ Program Integrity Successes

As for CMS, it continues to focus on reducing and eliminating fraud, waste, and abuse in Medicare, and in 2010, it established the Center for Program Integrity to help with this work. CMS estimates that its Program Integrity activities saved Medicare operations $17 billion in fiscal 2015. Other Department of Health and Human Services combined efforts--including law enforcement--contributed to greater program savings. By using CMS’ successes in its Program Integrity protocols, VA will be able to close existing gaps in its own claims payment process.

VA plans to capitalize on the advancements in analytics CMS has made by concentrating on its use of advanced technology, statistics and data analytics to improve fraud detection and prevention efforts. Additionally, in November 2017, VA invited industry experts to provide information on the latest commercial sector tools and techniques to enhance VA’s fraud detection capabilities. In April, VA will invite these industry experts to demonstrate their capabilities for detecting and preventing fraud, waste, and abuse and recovering improper payments.

“We have a special obligation to keep America’s promise to those who have served our country and ensure that veterans receive high-quality and accessible health care,” said CMS Administrator Seema Verma. “CMS is sharing lessons learned and expertise to support VA to identify waste and fraud and eliminate these abuses of the public trust.”

The VCP was created as part of the Veterans Access, Choice and Accountability Act of 2014. Currently, the VA is working to transform the VCP to improve the experience for veterans, community providers, and VA staff. Under the VCP, according to the agency, community providers interested in participating must:

  • Establish a contract with one of the contractors, Health Net Federal, or TriWest Healthcare Alliance;
  • Accept Medicare rates;
  • Meet Medicare Conditions of Participation and Conditions for Coverage, or other criteria as established by the VA;
  • Be in compliance with all applicable federal and state regulatory requirements;
  • Have “same or similar credentials” as VA staff;
  • Submit a copy of the medical records to the contractor for medical care and services provided to veterans for inclusion in the VA electronic record.

Legislation is pending in Congress to reform the VCP, streamlining the eligibility and reimbursement processes and securing its funding.