CMS Releases New Consumer-Friendly Resources for the No Surprises Act

[On June 14], the Centers for Medicare & Medicaid Services (CMS) made available new consumer-friendly web pages for people with easy-to-read information regarding the consumer protections in the No Surprises Act.

The No Surprises Act protects people covered under group and individual health plans from receiving surprise medical bills when they receive most emergency services, non-emergency services from out-of-network providers at in-network facilities, and services from out-of-network air ambulance service providers. It also establishes an independent dispute resolution process for payment disputes between plans and providers, and provides new dispute resolution opportunities for uninsured and self-pay individuals when they receive a medical bill that is substantially greater than the good faith estimate they get from the provider.

Unexpected medical bills are a significant source of stress, frustration, and confusion for people in the United States. The No Surprises Act gives them new rights to prevent, navigate, and find resolutions to many of these “surprise” bills. 

To help consumers understand their rights, consumer-friendly web pages are now available for people with easy-to-read information and actionable guidance. The webpages’ design and content were informed by human-centered design research and user testing with patients, caregivers, patient advocates, and others.   

The webpage aims to be inclusive and accessible by: 

• Meeting Web Content Accessibility Guidelines (WCAG 2.1 AA)
• Providing all information in both English and Spanish
• Using plain language and clean design
• Centering the human experience with diverse and colorful illustrations
• Building the site to be responsive to different devices, including mobile phones and tablets
• Offering clear and multiple pathways for people to learn about their rights

When people visit the consumer website, they’ll be guided through: 

• Understanding their rights under the No Surprises Act, including out-of-network billing protections and good faith estimates for future care
• Identifying actions they can take to exercise their rights and find a resolution if they receive an unexpected medical bill, using a Q&A tool that asks about their situation
• Submitting a complaint if they think their provider, facility, or insurance company didn’t follow the rules of the No Surprises Act through an optimized process and redesigned form
• Disputing a bill if they are uninsured or didn’t use insurance and they were charged more than their good faith estimate
• Finding guides that will help them navigate medical billing questions, as well as learning how to connect with the No Surprises Help Desk

Resources:

• No Surprises Act Consumer Webpage: https://www.cms.gov/medical-bill-rights as well as en Español: https://www.cms.gov/derechos-facturas-medicas
• New Protections for Consumers: https://www.cms.gov/medical-bill-rights/know-your-rights
• Payment Dispute Webpage: https://www.cms.gov/medical-bill-rights/help/dispute-a-bill
• Submit a Complaint: https://www.cms.gov/medical-bill-rights/help/submit-a-complaint
• Find an Action Plan: https://www.cms.gov/medical-bill-rights/help/plan
• Resources for providers can still be found at:  https://www.cms.gov/nosurprises  

Study Offers New Insights into the Rapid Spread of Fraudulent Medicare Home Healthcare Filling

News-Medical | Reviewed by Danielle Ellis, B.Sc.
 
Findings from an innovative study conducted by a team of researchers at Dartmouth's Geisel School of Medicine and published in the journal Social Science & Medicine, are providing new insights into how the rapid spread (or diffusion) of fraudulent Medicare home healthcare billing has occurred across the U.S. in recent years.
 
To understand the significant growth of Medicare fraud during the 2000s in just a few regions of the country, the research team examined the network structure of home health agencies (HHAs) and identified a set of characteristics shared by regions where fraud was most likely to occur.
 
Among their key findings, they determined that these characteristics included: the sharing of patients across multiple (and often many) agencies; high rates of expenditures across hospital referral regions (HRRs) and rapid increases in rates over time, substantial growth in the number of HHAs, and whether a region would attract a Department of Justice (DOJ) anti-fraud office. They also found evidence of a peer effect in agency billings, which suggests a sharing of fraudulent practices locally between agencies.
 
There are currently more than 11,000 HHAs in the U.S. providing care to Medicare beneficiaries-;HHAs primarily perform skilled nursing and other medical (therapeutic) services in a patient's home.
 
Some common examples of documented fraudulent behavior have included: agency owners billing for unnecessary or nonexistent services; kickbacks to physicians, patient recruiters, and staffing groups to refer patients to their agency; or sharing of patient IDs across networks of HHAs owned by organized criminal organizations.

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When An Alzheimer’s Patient Begins Hospice Care

By Barbara Karnes

First, I’m going to switch from the word Alzheimer's to the word dementia. Alzheimer's is a specific disease associated with dementia. Dementia as defined by the Oxford Language Dictionary is a “condition characterized by progressive or persistent loss of intellectual functioning, especially with impairment of memory and abstract thinking and often with personality change, resulting from organic disease of the brain.”

The CDC states that dementia is “not a specific disease but is rather a general term for the impaired ability to remember, think or make decisions that interferes with doing everyday activities. Alzheimer’s disease is the most common type of dementia.”

With dementia defined, let's now talk about dementia and a hospice referral. Hospice provides care and services for people in the last six months of their life. A doctor must specify, in his/her best opinion, that this person has less than  six months of life. Every 90 days of that six month period the physician must recertify that reasoning.

If the person’s disease is continuing to progress toward a death within six months, the doctor can recertify a patient for an additional sixty days at the end of the original six months. There are all sorts of fancy words to outline this Medicare protocol but simply put, if the patient isn’t dying fast enough, at some point they have to come off of hospice services.

The basic areas that say a person has entered the dying process are: gradual decrease in eating, gradual increase in sleeping, and gradual withdrawal from social interactions. This generally occurs over a period of months when disease is involved and years with old age and no disease present.

This is how most people progress toward death BUT not with dementia. A person with dementia can be withdrawn and non communicative for years. A person with dementia can sleep all the time for years. It isn’t until a person can’t eat enough calories for maintenance (choking, holding food in their mouth, not swallowing) that we in the medical arena can say a person has entered the dying process. If we don’t eat we can’t live. Now the person is ready for hospice care…

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Strengthening Quality and Your Marketing Edge: Disease Management Certification for Home Health Agencies 

Introduction:  In the evolving landscape of healthcare, home health agencies face increasing demands to provide high-quality care to patients with chronic diseases and complex medical needs. Seeking disease management certification can serve as a catalyst for home health agencies to improve the quality of their services while gaining a competitive marketing edge. 

CHAP offers certification in six disease processes-Heart failure, COPD, Diabetes, Dementia, Stroke Recovery, and Wound Care.  Certification can be achieved in four steps. 

1. Read and understand the standards:  each disease state has standards and guidance written by industry experts with input from physicians with a specialty in each disease state.   
2. Adapt or build your Program:  the agency will purchase the specific disease program standards and begin to adapt an existing program or build a new program from the ground up.  The standards provide the agency with a framework from which to adapt/build your program.  There are CHAP– verified Disease Management Certification Program packages available to assist you with building your program to meet the standards.  MAC-Legacy currently has Heart Failure and COPD packages available.  These packages include tools to assist with education of staff in the disease state, best practice assessment and interventions, patient education, self-management strategies, and policies and procedures unique to the chosen disease state. 
3. Submit readiness and complete the survey process:  Once the program is built and structured and staff is trained, and in place, the agency will submit readiness for the survey process.  This process is done virtually, and policies and documents will be uploaded for review by a Disease Program Surveyor.  Once the review is complete, the agency will receive a report with findings, and successful agencies will move on to the interview process.  After all interviews are complete and all standards are met, the agency will receive a one-year certification.  If deficiencies with the initial review/interview are found, corrections and resubmissions are allowed. Each agency location is required to go through this process to achieve certification. 
4. Market your disease-certified program:  once the agency has achieved certification, it will receive a marketing it that includes: 
5. A seal of certification that can be included in marketing the program 
6. Press release and media templates to use to alert your community of your achievement 
7. Approved and suggested verbiage to be used to describe your program 
8. Marketing plan templates, including referral partnership plan and sales messaging templates 

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