The Centers for Medicare & Medicaid Services (CMS) recently announced a 10 percent per-home health agency (HHA) outlier cap on agency outlier payments to address excessive, suspicious outlier payments that are occurring in a few discrete areas of the country. Targeting an overall percentage of outlier payments at approximately 2.5 percent would allow CMS to create a smaller outlier pool and return the remaining 2.5 percent to the HH Prospective Payment System (PPS) rates. Their analysis revealed that a 10 percent per-agency cap in outlier payments would mitigate potential inappropriate outlier billing vulnerabilities while minimizing the access to care risk for high needs patients.

CMS received many comments in favor of the proposed rule and its efforts to curb fraud and abuse, with many expecting the policy to be effective. However, some agencies do have concerns the reduction will greatly affect access to care for patients with more intensive care management needs. The example cited most often was daily or multiple daily insulin injections for diabetic patients, a subgroup of patients requiring short-term management for skilled observation, assessment, teaching and training activities.

So how will agencies manage diabetic patients under this rule?

• Diabetes Self Management Training (DSMT)
  Empower your patients by teaching them how to self-administer medication rather than relying on multiple visits from an RN.
• Train a caregiver or family member
  Agencies frequently overlook the fact that many patients have access to family members or some type of support system to administer insulin.

CMS expects the 10 percent of total payment in outliers to compensate agencies for administering care to the subgroup of patients who are incapable of learning self-management and also have no willing and able caregiver or community support to compensate for multiple visits.

How is your agency managing patients with more intensive care management needs?