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The Pulse: June 8, 2012


Unified Long Term Care Advisory Work Group and ICDS Updates

On May 31, the Unified Long Term Care System (ULTCS) Advisory Workgroup met to discuss Ohio’s initiatives regarding long term care. Updates from the meeting include:

Integrated Care Delivery System Proposal
The state is continuing their work on the Integrated Care Delivery System (ICDS) Proposal to the Center for Medicare and Medicaid Services (CMS) to manage care for dually Medicaid and Medicare individuals in Ohio. On May 25, applications were due from health plans to be considered as ICDSs in each of the seven ICDS regions. The state still intends on choosing two plans per regions, with the exception of three plans in the northeast region. Ohio Medicaid has begun reviewing the ten applications submitted, and according to the state’s proposed timeline should finalize a three-way contract between Ohio, CMS, and the chosen ICDS plans by July 2.

The state has begun negotiating their proposal, submitted on April 2, with CMS. So far in their negotiations, the state has learned that parts of the proposal may need altered. For example, CMS cannot support the implementation schedule as proposed, so the state is looking at alternatives such as beginning implementation in April and continuing quarterly. For all intent and purposes the state appears confident that its dual project will unfold for the most part as it is laid out in the proposals.  MCA’s is providing a number of initiatives to help providers prepare for these changes.  Initially the “preparedness survey” was broadly distributed and over 46 Ohio providers completed this survey.  Our annual meeting will feature the Corridor Group and a program focusing on leadership and change.  And MCA has contracted with Health Dimensions Group to provide a series of programs to prepare providers for the changes that come with an integrated health system.  We will continue to keep you informed as the proposal and contract with CMS is finalized.

Case Management of ODJFS-Administered Waivers
Ohio Medicaid plans to rebid case management contracts for Ohio Department of Jobs & Family Services-administered home- and community-based services waivers. Ohio Medicaid plans to release a Request for Proposals later this summer or early fall, and finalize case management contracts to be in place early 2013. As more information is released, we will keep you informed.

Medicaid Eligibility Simplification Excludes NFs and HCBS
The Office of Health Transformation (OHT) has released for public comment a draft request to "waive" existing barriers to eligibility simplification, part of an initiative to streamline and simplify outdated eligibility processes for health and human services. The eligibility simplification initiative does not include institutional care, home- and community-based services, or children.

However, interested parties have until July 6 to submit comments, which OHT will consider for incorporation into a final Medicaid 1115 Demonstration Waiver request to the federal government in July 2012. For more information on Ohio's plans to modernize eligibility determination systems, to view the draft waiver request and related documents, and for more information about how to provide comments on the draft request, click here.

For more information on the ULTCS Advisory Workgroup, of which Midwest Care Alliance is a member, please click here. We will continue to keep you informed of updates and policy work, and if you have any questions please contact Jeff Lycan at (614) 545-9016 or or Katie Rogers at (614) 545-9032 or

Governor to Sign Mid-Biennial Review Budget Next Week

Governor Kasich is expected to sign House Bill 487 (Amstutz) next week—the Mid-Biennial Review (MBR) budget that the legislature has been working on for much of the spring. It is anticipated that the governor will veto language that directs $30 million budgeted dollars to nursing facilities for an additional quality bonus payment based on quality measures implemented late last year in Senate Bill 264 (Jones). Of the provisions included in the MBR, are new laws regarding criminal background checks for home health employees will be critical to Midwest Care Alliance home care members. The bill will revise the laws governing criminal records checks of home health providers and employees, to make them consistent across the different Ohio agencies that oversee home health.

The bill, once signed into law, will allow the Ohio agencies to create rules that could require criminal records check both before employment of a new employee, and possibly periodically over the duration of employment. Midwest Care Alliance will work with these Ohio agencies in crafting the rules so that they are not burdensome to member providers. To see the provisions of the bill, visit and search “criminal records check.”

We will continue to keep you informed of updates and policy work, and if you have any questions please contact Jeff Lycan at (614) 545-9016 or or Katie Rogers at (614) 545-9032 or

Chronic Pain Committee Suspended

On Friday June 1st, the State Medical Board notified participants working on the chronic pain rules that the Medical Board was suspending its review of the rules (Chapter 4731-21, Ohio Administrative Code).  In lieu of the committee’s work the participants were informed of the Governor’s Reforming Prescribing Practices Committee. The Reforming Prescribing Practices Committee is discussing what and/or whether timeframe, dosing levels, or other clinical considerations should be required within the context of chronic pain treatment. 

These discussions may lead to the introduction of legislation and the State Medical Board felt it was appropriate to suspend its current review of the Chronic Pain Rules in an effort to respect the time and efforts of the Panel members as the details of potential legislation are determined.  There were suggestions made at the last Reforming Prescribing Practices Committee meeting on Wednesday May 30th to include the individuals working on the Chronic Pain Rules.  MCA’s Jeff Lycan is a member of the Governor’s Reforming Prescribing Practices Committee as well he has been participating on the Chronic Pain Rules discussions.  MCA will be making some recommendations regarding additional participation on the Governor’s committee.  MCA continues to monitor the focus of these discussions and protect the exemptions currently in place around malignant and the terminally ill.  From a timing perspective these discussions and movement towards further action is expected to move along quickly. 

The committee is in process of forming two key subcommittees that will meet BEFORE the next full committee meeting: Trigger Clinical Subcommittee and Metrics Subcommittee.

    The Trigger Clinical Subcommittee will be chaired by Dr. Ted Wymsylo.  In order to elicit clinical participation, we will be holding this meeting on Saturday, June 23rd, 9:00 am to 2:00 pm.  This working session will be used to offer ideas, work through challenges and controversy and arrive at consensus on a concrete recommendation for the full committee’s June 28th meeting. 
    The Metrics Subcommittee to be chaired by Christine Morrison.  Again, to include a broader clinical perspective, this meeting will be held in the late afternoon, specifically, Tuesday, June 19th, 4:00 – 6:00 pm.  This first meeting of the group will focus on metrics resources available.  It is anticipated that this subcommittee will need to meet a few more times following the work of the Trigger Clinical Subcommittee and subsequent discussion at the June 28th full committee meeting.

Medicaid to Support Training to Build Provider Workforce

The Ohio Department of Job and Family Services (ODJFS) stated Monday it is launching efforts to train more than 1,000 people to help develop and retain health care providers who served Medicaid recipients. The department said it secured federal funding of $2 million for FY12 and more than $8 million for FY13 for the Ohio Medicaid Technical Assistance and Policy Program Healthcare Access Initiative. The initiative will provide training through partnerships with 15 departments or programs at six of the state's colleges and universities, as well as clinics, community-based practices, hospitals and other entities.

"These projects will provide unique and diverse training opportunities," Medicaid Director John McCarthy said in a statement. "After they graduate, participants will go on to work at clinics in neighborhoods that need doctors and other health care professionals. Participants can help people there with both their
short-term and long-term health needs, and help them learn more about what it takes to maintain a healthy lifestyle."

ODJFS said the following university programs will receive funding:

University of Akron, College of Nursing
Case Western Reserve University
     School of Dental Medicine
     Departments of Family Medicine/MetroHealth System, Pediatrics and Psychiatry
Kent State University, College of Nursing
The Ohio State University
     Colleges of Dentistry and Nursing
     Moms2Be Program
     Interdisciplinary Behavioral Health Education Program
     Interdisciplinary Curriculum Development Program and
     Medicaid Practice Placement and Learning Experiences Partnership Program
University of Toledo, Department of Psychiatry
Wright State University
     Division of Child and Adolescent Psychiatry
     Community Psychiatry Collaborative (involving the departments of Psychiatry, Geriatrics,Community Health and Family Medicine).

Information on the program is available by clicking here.


Click here for a list of key legislation Midwest Care Alliance is monitoring and its status, as well as news from around the state that affects legislation, regulations, and policy.


Hospice Marketing Practices Receive Media Attention

USA Today reports that some hospice marketers are recommending that hospitals refer Medicare patients to hospice rather than readmitting them.  The article calls this an “exploitation” of the 2010 health care law because it would let hospitals avoid paying Medicare penalties if patients need to be readmitted to the hospital within 30 days.  

Rick Chesney is a hospice marketing specialist and, according to the article, Chesney notes that patients with severe heart disease and those with pneumonia “tend to decline quickly and often move in and out of hospitals.”  He also suggests, “It might be better” for hospitals to employ “people to talk to family members about hospice, instead of a doctor, who is more focused on not losing a patient.”

Chesney discussed his proposal at NHPCO’s recent Management Leadership Conference.  Stan Massey, chief marketing officer for Transcend Hospice Marketing, blogged about Chesney’s presentation (see link below).  He wrote, “Mr. Chesney pointed out that as Medicare readmission penalties increase over the next three years, new attention will be focused on ways to decrease hospital inpatient stays and readmissions, as well as post-discharge services.  Under new rules of healthcare reform, the ‘new buyers’ of hospice will increasingly include hospital administration, Accountable Care Organization (ACO) management, and Medicare Managed Care (MCO) management.  Mr. Chesney noted that this shift will mandate a decidedly different approach than marketing directly to physicians and other referrers.  Instead, hospices also will need to present their partnership advantages to C-level executives – and the conversation with them must be framed heavily in terms of financial benefit.”

Josh Perry, business and ethics professor at Indiana University, says that such proposals “warp” the idea of hospice.  Jon Radulovic, NHPCO spokesman, says that NHPCO members have worked with hospitals in the past, but the focus has been on reducing readmissions because patients get better care, not because of money.  According to the article, Carolyn Cassin, president of the National Hospice Work Group, expressed surprise at the idea of marketing hospice as a way to cut hospital costs, and said that the goal has been to assure that patients received the care they need.

CMS spokesman Brian Cook said that the penalties for excessive readmissions to hospitals were meant to “encourage hospitals to provide better care, not farm out patients elsewhere for care.”  The incentives are intended to “ensure that savings come from better care, not cutting care.”  Cassin added, “It’s about doing the right thing, not keeping costs down.”    

Healthcare Renewal also responded to the USA Today article.    
Click here to read the article in USA Today. (USA Today, 5/21)
Click here to access the Healthcare Renewal blog.  (Transcend Hospice Marketing Group, 4/11)
Click here to read the Hospice Marketing Group article. (Healthcare Renewal, 5/25)

Concerns about Palmetto GBA and the ADR Process

In recent weeks, NHPCO and representatives of the Hospice Coalition met by conference call with Palmetto GBA about the recent ADR medical review process.  The following is a summary of the meeting with Palmetto GBA and their responses to the questions and concerns about the process. 

From Palmetto GBA: 

Thank you for your willingness to discuss the Coalition and NHPCO’s concerns regarding Palmetto GBA’s recent review of medical records.  We are very thankful for our strong partnership and are appreciative of our open dialogue.

Provisional Payment:  As we discussed, the completion of medical reviews took longer than anticipated and caused some claims to age beyond customary processing time frames.  Therefore, Palmetto GBA released for provisional payment hospice claims for which Palmetto GBA had the medical records in house for more than 60 days. Claims that were provisionally released may be identified by a notation found in the Direct Data Entry (DDE) system. We have placed remarks stating “Provisional Release” on page seven (7) of the released claims.

Adjustment and Recovery of Overpayments:  Now that the claims have been provisionally paid, we will continue the record review process and will make a formal determination based on the records already submitted.  If our review determines the claim is payable, no further action will occur. If our review results in a denial or payment reduction, Palmetto GBA will perform an adjustment and recover any overpayments.  For any denial or reduction, the provider will receive a remittance advice informing them of the decision. Appeal rights will be available for these claims.  

Technical Denials:  If your members received technical denials during the review process where the documentation was clearly missed by the medical review staff, please contact the Medical Review voicemail box to relay your concerns.  The voicemail box is 803.763.7491.  We will return your call within two business days.

Accelerated Payment Option:  If your members ever experience financial hardship due to issues outside the provider’s control, they may be eligible for an accelerated payment. Accelerated payment criteria and request instructions are on the Palmetto website.

Monthly Billing for Hospice Claims:  As we relayed to you during our call, we discovered during the review process that some hospices have been billing in weekly or bi-weekly increments. CMS requires monthly billing for hospice claims.  We posted an article to our website and we contacted the top 50 providers to educate them. 
Click here to access the full article.

The Hospice Coalition is a group of individuals that primarily represent the 16 state hospice organizations that fall within the Palmetto MAC region.  The Coalition has been meeting with Palmetto GBA for more than 17 years.