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Launch of the CMS Beneficiary Notices Initiative (BNI) Mailbox Portal for Beneficiary Notices and Related Policy Questions
This message is to announce the launch of the new CMS Beneficiary Notices Initiative (BNI) mailbox portal for beneficiary notices and related policy questions. Please note this mailbox portal replaces the BNI mailbox, BNImailbox@cms.hhs.gov. The purpose of this new BNI mailbox portal is to provide a more efficient method for responding to provider, industry, and stakeholder questions.
The new BNI mailbox portal provides links to a variety of resources and links to other CMS mailboxes and e-mail addresses. CMS encourages you to review the available resources before submitting a question to ensure that we have not already provided information on the specific topic in question. Please also refer to the list of other CMS mailboxes and e-mail addresses to ensure that you direct your question to the most appropriate area of expertise.
Nursing Home Strategy Part 1 – Strengthening Oversight
The Centers for Medicare and Medicaid Services (CMS) posted the 5th episode of the CMS: Beyond the Policy podcast which focuses on the first of the CMS’s 5-pronged strategy on strengthening oversight in nursing homes. This podcast features CMS Administrator Seema Verma, Dr. Kate Goodrich, CMS Chief Medical Officer and Director of our Center for Clinical Standards and Quality and Matt Hittle, Senior Adviser for Administrator Seema Verma discussing CMS’s efforts regarding nursing home oversight.
The Department of Health and Human Services Office of Inspector General issued two new reports that address the identification, reporting and investigation of incidents of potential abuse and neglect of our nation's most vulnerable populations, including seniors and individuals with developmental disabilities. OIG issued an early alert in 2017 based on the preliminary findings of this work. Our resulting work, released in June 2019, identify thousands of Medicare claims that indicate abuse and neglect of beneficiaries, including beneficiaries in skilled nursing facilities. If you suspect someone is the victim of abuse or neglect, contact law enforcement immediately.
CMS Could Use Medicare Data To Identify Instances of Potential Abuse or Neglect
Incidents of Potential Abuse and Neglect at Skilled Nursing Facilities Were Not Always Reported and Investigated
On April 5, the new Q4FY18 Skilled Nursing Facility (SNF) PEPPER was released. Find information here: https://pepper.cbrpepper.org/About-PEPPER/Distribution-Schedule-Get-Your-PEPPER
The CMS contractor will also hold a web session to review the release.
NOTE: CMS updated this file In March 2019.
The April 2019 changes include revisions to the inspection process, enhancement of new staffing information, and implementation of new quality measures.
This includes a lifting of the ‘freeze’ on the health inspection ratings instituted in February 2018. CMS ‘froze’ the health inspection star ratings category after implementing a new survey process for Long-Term Care facilities. Because facilities receive surveys at different times, some facilities would have been surveyed under the old process and others under the new process. Without placing a ‘freeze’ on health inspection star ratings, the facilities would have been scored using two different evaluation processes making the outcomes misaligned and the data inaccurate. CMS ‘froze’ the health inspection star rating score until all nursing homes were surveyed at least once under the new survey process for Long Term Care facilities. Ending the freeze is critical for consumers. In April, they will be able to see the most up to date status of a facility’s compliance, which is a very strong reflection of a facility’s ability to improve and protect each resident’s health and safety.
Additionally, CMS is setting higher thresholds and evidence-based standards for nursing homes’ staffing levels. Nurse staffing has the greatest impact on the quality of care nursing homes deliver, which is why CMS analyzed the relationship between staffing levels and outcomes. CMS found that as staffing levels increase, quality increases and is therefore assigning an automatic one-star rating when a Nursing Home facility reports “no registered nurse is onsite.” Currently, facilities that report seven or more days in a quarter with no registered nurse onsite are automatically assigned a one-star staffing rating. In April 2019, the threshold for the number of days without an RN onsite in a quarter that triggers an automatic downgrade to one-star will be reduced from seven days to four days. CMS is also making changes to the quality component on Nursing Home Compare that would improve identifying differences in quality among nursing homes, raise expectations for quality, and incentivize continuous quality improvement.
To provide further value and remain consistent with CMS’s Meaningful Measures initiative the April 2019 Nursing Home Compare Update includes adding measures of long-stay hospitalizations and emergency room transfers, and removing duplicative and less meaningful measures. CMS is also establishing separate quality ratings for short-stay and long-stay residents and revising the rating thresholds to better identify the differences in quality among nursing homes making it easier for consumers to find the right information needed to make decisions.
CMS Improperly Paid Millions of Dollars for Skilled Nursing Facility Services When the Medicare 3-Day Inpatient Hospital Stay Requirement Was Not Met (A-05-16-00043)
According to Federal law, to be eligible for coverage of posthospital extended care services, a Medicare beneficiary must be an inpatient in a hospital for not less than 3 consecutive calendar days (3-day rule) before being discharged from the hospital. CMS improperly paid 65 of the 99 skilled nursing facility (SNF) claims we sampled when the 3-day rule was not met. Improper payments associated with these 65 claims totaled $481,034. On the basis of our sample results, we estimated that CMS improperly paid $84 million for SNF services that did not meet the 3-day rule during 2013 through 2015.
We attribute the improper payments to the absence of a coordinated notification mechanism among the hospitals, beneficiaries, and SNFs to ensure compliance with the 3-day rule. We noted that hospitals did not always provide correct inpatient stay information to SNFs, and SNFs knowingly or unknowingly reported erroneous hospital stay information on their Medicare claims to meet the 3-day rule. We determined that the SNFs used a combination of inpatient and non-inpatient hospital days to determine whether the 3-day rule was met. In addition, because CMS allowed SNF claims to bypass the Common Working File (CWF) qualifying stay edit during our audit period, these SNF claims were not matched with the associated hospital claims that reported inpatient stays of less than 3 days.
CMS Guidance to State Survey Agencies on Verifying Correction of Deficiencies Needs To Be Improved To Help Ensure the Health and Safety of Nursing Home Residents (A-09-18-02000)
State survey agencies (State agencies) must verify that nursing homes corrected identified deficiencies, such as the failure to provide necessary care and services, before certifying whether the nursing homes are in substantial compliance with Federal participation requirements for Medicare and Medicaid.
CMS has issued two transmittals updating Chapter 30, "Financial Liability Protections," of the Medicare Claims Processing Manual.
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