October 5, 2016

Breaking News From HCAF


CLICK HERE to take action NOW!

Today, CMS released a small amount claims data from the ongoing Pre-Claim Review (PCR) Demonstration in Illinois.

Some items of note in the Illinois data:

  • As of week 8, 66% of PCR requests have received a provisional affirmation or partially affirmed decision.
  • As of week 8, the non-affirmation rate is 34%.
  • Click here to read all of the data and more PCR resources on HCAF’s website
Additionally, CMS indicates the top reasons for non-affirmation:
HCAF is working with our national partners and state associations to request more data through the Freedom of Information Act (FOIA). A FOIA request will help us gain far more data that providers, lawmakers and CMS need in order to truly know if the PCR Demonstration project is actually effective. PCR is absolutely not realistic in its current untargeted scope and more data will help us paint a better picture of the program’s future viability.

PCR began in Illinois on August 3, 2016. After our advocacy efforts, CMS earlier announced that they will not move forward with initiating the demonstration in Florida in October, but still continued with the program in Illinois.

We are sharing this data with Florida providers because this will help you prepare. PCR is delayed in our state but it’s not going away for good! CMS plans to release education on how to submit pre-claim review requests, documentation requirements, and common reasons for non-affirmation until they are ready to re-launch the program. CMS will undoubtedly move forward with PCR in Florida and will provide at least 30 days’ notice on their website prior to the beginning date. CMS has said that Florida will be the first state to start when they re-launch the program. 30 days is not enough time to prepare so please use this data coming out of Illinois to start re-organizing your agencies to ensure high affirmation rates when Pre-Claim Review does in fact come to our state.

We continue to advocate against Pre-Claim Review and we need your help to delay this program even longer and have a chance to permanently get rid of PCR. There is now legislation in the U.S. House of Representatives that would impose a 1 year delay. We need Florida lawmakers to sign-on as co-sponsors. Visit our Legislative Action Center to help us end PCR once and for all by writing to your lawmakers today! CLICK HERE to take action NOW!

**All content and images are credited and attributed to the Home Care Association of Florida.
August 25, 2016

The Flexibility Conundrum


CMS FAQ Update Reminds Providers: ICD-10 Flexibilities End October 1.
In a recent FAQ update, the Centers for Medicare and Medicaid Services (CMS) reminds providers: Flexibilities regarding the specificity of ICD-10-CM codes on Medicare physician/practitioner claims will come to an end on October 1. Last summer, CMS announced that for 12 months after the October 1, 2015, ICD-10 implementation, Medicare review contractors would not deny physician or other practitioner claims billed under the Part B physician fee schedule through either automated or complex medical record review based solely on the specificity of the ICD-10-CM diagnosis code, as long as the physician/practitioner used a valid code from the right family of codes.

The update also indicated that providers should already be coding to the highest level of specificity. Even with the ICD-10-CM flexibilities, a valid ICD-10-CM code has been required on all claims for dates of service on or after October 1, 2015. In addition, while unspecified ICD-10-CM codes should be avoided whenever documentation supports a more detailed code, unspecified codes are allowed because they have acceptable, even necessary, uses.

Although the “flexibility” period only applied to physicians, hopefully there will be a trickle down effect with documentation. We can only hope.

July 21, 2016

Our Men and Women in Blue

It is rare these days to turn on the TV or open our computers and not see deplorable violence against law enforcement. It seems to be a cancer that is spreading at a rapid pace throughout our nation. Always a dangerous career, but the threat level has certainly increased in recent events. The courage it must take those who wear the badge and knowingly go every day into the depths of perilous situations in order to bring peace to the masses must be daunting. But day after day, those officers proudly accept their duty to do so. The majority of citizens respect them and continuous acts of kindness have been displayed on their behalf.


As a community and a nation we have always overcome negative with positive. Our history has proven that time and again. We have survived a civil war, the civil rights movement and 9/11, to name a few. We are a fiercely strong country and good will prevail.

Police officers are a different breed. They do not risk their lives with each shift because of financial gain or notoriety. It is a profound sense of wanting to protect and make this world a better place that causes
them to put on the uniform and willingly go toward danger instead of run away from it.

God bless them for it.

“Darkness cannot drive out darkness; only light can do that. Hate cannot drive out hate; only love can do that.” Dr Martin Luther King.

July 1, 2016


us flag

As Independence Day soon approaches it gives us an opportunity to slow down and pause from our regular routine. Many of us will spend the weekend celebrating with family and friends, sharing food and exchanging stories and hopefully catching glimpses of fireworks as they light up our sky. We hope this break from your mainstream, hectic life offers a time to reflect and embrace the glory that is our country. With recent events and political uncertainty regarding the upcoming election, our country has been divided, divisive, and downtrodden. The 4th of July is the perfect reminder that despite all our differences as a people, we are a strong, remarkably resilient nation. We stand tall in the face of adversity and we have proven that we can come together in unity. We are extremely blessed to be Americans and that right does not come without great cost. As we recognize our independence, let it not be without recognizing the hard road it took to get there. We are proud. Proud of the past and what it took to gain our independence and proud of our future and the endless possibilities for our country. Celebrate with a new resolve and infinite hopefulness. This is the greatest country on earth. God bless each of you and God bless America!

June 23, 2016

Alert: Improper Arrangements and Conduct Involving Home Health Agencies and Physicians


June 22, 2016

Recent investigations and Office of Inspector General (OIG) studies have found that home
health services are vulnerable to fraud, waste, and abuse. The Federal government is stepping
up its enforcement efforts in this area. In the past year, the Federal government has obtained
criminal convictions and reached civil settlements with several home health agencies (HHAs),
individual physicians, and heads of home-visiting physician companies that defrauded Medicare
by, among other conduct, making (or accepting) payments for patient referrals, falsely certifying
patients as homebound, and billing for medically unnecessary services or for services that were
not rendered.
The government alleged that HHAs violated the Federal anti-kickback statute1 by paying
physicians, either directly or indirectly, in return for their referrals of Medicare beneficiaries to
the HHAs for home health services. The government also alleged that the physicians violated
the Federal anti-kickback statute by soliciting or receiving payments, either directly or
indirectly, from the HHAs in return for referring Medicare beneficiaries to the HHAs. In some
instances, these payments were disguised as compensation arrangements for services provided,
such as payments purportedly for serving as the medical director of an HHA.

HHAs and physicians that wish to enter into compensation arrangements for services provided
must ensure that those arrangements and the payments under them are fair market value and
commercially reasonable in the absence of Federal health care program referrals. Although
many compensation arrangements are legitimate, a compensation arrangement may violate the
Federal anti-kickback statute if even one purpose of the arrangement is to compensate a
physician for his or her past or future referrals of Federal health care program business.
Payments made (or received) to induce (or in return for) referrals, or for arranging for referrals,
potentially raise a number of concerns, including corruption of medical judgment, patient
steering, overutilization, increased costs to Federal health care programs, and unfair
1. 42 U.S.C. § 1320a-7b(b).
In addition to the alleged Federal anti-kickback statute violations, the government alleged that HHAs, physicians, and heads of home-visiting physician companies violated other Federal laws, including the health care fraud statute(2) and the statute prohibiting false statements relating to health care matters.(3) For example, the government alleged that HHAs billed Medicare for medically unnecessary nursing services provided to patients who were not confined to the home, and that the home-visiting physician companies upcoded patient visits (i.e., billed at a level higher than warranted) and billed for care plan oversight services that were not actually rendered. The government also alleged that the physicians falsely certified patients as confined to the home when they were not actually homebound. In OIG’s experience, the physicians participating in these schemes typically were not the Medicare beneficiaries’ primary care physicians, who often were unaware that their patients were receiving home health services. These types of fraudulent activities result in substantial additional costs to Federal health care programs.

HHAs must ensure that Medicare beneficiaries who receive home health services are confined to the home and require these services. (4) OIG encourages HHAs and physicians to carefully evaluate the terms of any compensation arrangements they may have with each other, and to ensure that the home health services provided to Medicare beneficiaries are both reasonable and necessary.

Those individuals and entities that commit fraud involving Federal health care programs are subject to possible criminal, civil, and administrative sanctions. For more information on HHAs, see http://oig.hhs.gov/reports-and-publications/portfolio/home-health/.

If you have information about HHAs, physicians, or others engaging in any of the activities described above, contact the OIG Hotline at https://forms.oig.hhs.gov/hotlineoperations/ or by telephone at 1-800-447-8477 (1-800-HHS-TIPS).

2. 18 U.S.C. § 1347.
3. 18 U.S.C. § 1035.
4. A more complete description of the conditions that must be satisfied before Medicare will pay
for home health services may be found in the Medicare Benefit Policy Manual, Chapter 7,
Section 30, available at: https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/bp102c07.pdf, which sets forth the Centers for Medicare & Medicaid Services’ policy regarding the implementation of sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Social Security Act (42 U.S.C. §§ 1395f(a)(2)(C) and 1395n(a)(2)(A)).