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This month, the Wisconsin State Supreme Court issued an opinion in the case of Papa v Wisconsin Department of Health Services. The case, brought by Professional Homecare Providers, Inc., sought to resolve an issue in which the Department of Health Services was recouping Medicaid payments made to private-duty nurses after auditing their records.
DHS recouped between $15,000 and $48,000 each from four separate private-duty nurses after audits found errors in notes and medical records. In other, DHS recouped costs for the way records were written, not because of fraudulent claims. Professional Homecare Providers, Inc. sued the state because of this documentation “perfection policy” created by DHS.
The State Supreme Court sided with the nurses, stating in the ruling, “There is no legal basis for the perfection policy.”
Writing the unanimous opinion, Justice Annette Ziegler said, “We conclude that…DHS may recoup Medicaid payments from service providers only in cases where DHS cannot verify one of the following: (1) the actual provision of covered services; (2) that the reimbursement claim is appropriate for the service provided; and (3) that the reimbursement claim is accurate for the service provided.”
While the case was brought by private-duty nurses, the ruling applies across the board to all Medicaid providers and clarifies the only justifications for DHS to recoup payments as stated by Justice Ziegler.
The following article was originally published this month by NBC-affiliate WTMJ4 in Milwaukee:
MILWAUKEE — As nursing homes have become hot spots for COVID-19 outbreaks, home health care may become a more popular avenue for those who are able to receive it, but the industry is currently facing a shortage of registered nurses in Wisconsin, according to a state agency.
"When it comes point to make a decision for our loved ones we're going to want to keep them in their homes," said Leah Perras, the executive director of Transitions at Home.
Perras is also a member of the Wisconsin Association for Home Health Care, or WiAHC. She says home health care was already growing in popularity and anticipates additional clients because of the COVID-19 pandemic.
"The pleasing factors of home health is that you have [fewer] people coming into your home," Perras said. "So, you have a decreased risk factor of getting that virus."
Making the transition could be tough based on the number of registered nurses in the field in Wisconsin.
Citing state and federal data, the WiAHC said 6 percent of Wisconsin RNs are working in home health care, compared to the national average of 13 percent.
We asked fellow WiAHC member Greg Von Arx why there's such a gap, and he said it's because of the way the state pays providers for Medicaid patients.
"The Medicaid rates for home care for seniors in Wisconsin haven't changed since we've been in business for 11 years and we've never had a rate increase in Wisconsin," Von Arx said.
The state reimburses providers for caring for Medicaid users based on a fixed rate. Because that rate hasn't changed, Von Arx said it's hurting their bottom line, making it more difficult to recruit, hire and retain nurses.
"The Medicare rates have continued to increase in the Medicaid rates just haven't, haven't kept up," he said. "So we've had to do one of two things. And that is either do more Medicare or turn away some Medicaid business."
"We need that money in order to hire retain recruit those you know great qualified nurses and other caregivers," Perras said.
Without it, the shortage of nurses could grow.
"It's hard to find nurses that want to be in the home health industry," Perras said. "So once you find a good one that you truly want to retain and have represented your company, you don't want to overwork them. You don't want to do anything to run them out the door."
Lawmakers proposed a plan to increase the Medicaid rate last September. The proposal never made it out of committee.
NAHC Report for July 30, 2020
Hospice PEPPER Available
The Hospice PEPPER, a data report that contains a single hospice’s claims data statistics (obtained from the UB-04 claims submitted to the Medicare Administrative Contractor (MAC)) for areas targeted by CMS as being at risk for improper Medicare payment, is now available.
Each Medicare certified hospice has access to a PEPPER (Program for Evaluating Payment Patterns Electronic Report), which contains statistics for these target areas, regardless of whether the hospice’s data are of concern. The report shows how a hospice’s data compares to national, MAC jurisdiction and state statistics for the three most recent years. Hospices must download their PEPPER via the PEPPER Portal.
Hospices can also access a User’s Guide and other PEPPER resources from the PEPPER Resources webpage.
NAHC is planning for a Hospice PEPPER webinar to be held in the near future.
Key CMS Updates for Hospice & Home Care in New Open Door Forum
The Centers for Medicare & Medicaid Services (CMS) held a Home Health, Hospice, & DME Open Door Forum (ODF) on July 29. This is the first ODF held since the current Public Health Emergency (PHE) began. A summary of this ODF is below.
NAHC Report for July 29, 2020
Home care and hospice workers are on the front line of the fight against the spread of the COVID-19 pandemic and they face more risks to their own health than almost anyone. These heroes deserve more than our thanks – they deserve our support and protection. As Congress crafts additional legislative responses to the pandemic, it is imperative that a set of core principles be considered for an equitable, effective, and efficient deployment of programs. Tell Congress to give our front line workers in the home the protection and compensation they deserve. Take action now!
The Wisconsin Department of Health Services (DHS) has released two new ForwardHealth Updates that explain Electronic Visit Verification (EVV) policy and training:
The EVV soft launch starts November 2, 2020, in Wisconsin. To prepare, provider agencies that do not have a Medicaid ID will need to obtain a unique provider agency ID. This includes provider agencies that plan to use an alternate EVV system and those who operate a self-employed business.
The provider agency ID is generated in real time and will display once you have finished submitting your information.
Review the email listed on the Mailing Address panel in the demographic maintenance tool in your secure ForwardHealth Portal account, and update the email address if necessary. DHS will use this provider agency email address for EVV communication with providers. DHS must have the correct email on file for the individual in your organization that is responsible for the administration of EVV.
Please complete the email verification by July 31, 2020, to ensure receipt of needed EVV information.
For information about and to register for EVV training, go to the EVV Training webpage. Training begins mid-August and is required to access the DHS-provided EVV system.
The Wisconsin Association for Home Health Care joined a coalition of medical societies in Wisconsin that created an open letter to the people of Wisconsin on the importance of wearing masks and social distancing to help curb further spread of COVID-19.
The Wisconsin Department of Health Services (DHS) invites you to attend a Medicaid Telehealth Expansion interactive webinar.
This webinar will seek your response to DHS’s proposed launch of Wisconsin Act 56: Telehealth Expansion, which will significantly expand Wisconsin Medicaid’s permanent telehealth policy. The presentation will include the following items:
1. General overview of telehealth expansion
2. General policy information
3. Wave 1 priority acute and primary service areas:
4. Proposed services included in telehealth
5. Proposed services excluded from telehealth
6. Input from attendees
Following the presentation, DHS will take questions from attendees via the DHS telehealth mailbox.
How to join
Thursday, July 30, 10:30 am – 12:00 pm
Click this URL to join; Password: 07302020
Join by phone: 646-558-8656; Webinar ID #933 1403 1869
Friday, July 31, 2:00-3:30 pm
Click this URL to join; Password: 07312020.
Join by phone: 646-558-8656; Webinar ID #999 9957 0817
Wisconsin Association for Home Health Care Announces
2019-2020 “Friend of Home Health Care” Recipients
Designation bestowed on select group of legislators
(Madison, WI) – Today, the Wisconsin Association for Home Health Care (WiAHC) announced its 2019-2020 “Friend of Home Health Care” recipients. The designation is meant to publicly identify Wisconsin State Legislators that supported the expanded utilization of home health care as an effective, affordable option for post-acute care.
The 2019-20 “Friend of Home Health Care” recipients include the following legislators:
Rep. Jimmy Anderson
Sen. Dale Kooyenga
Rep. Chris Sinicki
Rep. David Bowen
Rep. Scott Krug
Rep. Ken Skowronski
Rep. Rob Brooks
Sen. Chris Larson
Rep. John Spiros
Rep. Jonathan Brostoff
Rep. Amy Loudenbeck
Rep. Mark Spreitzer
Sen. Tim Carpenter
Rep. Nick Milroy
Rep. Lisa Subeck
Rep. Dave Considine
Rep. Jeff Mursau
Rep. Rob Summerfield
Rep. Barbara Dittrich
Rep. Beth Myers
Sen. Lena Taylor
Rep. Steve Doyle
Sen. Steve Nass
Sen. Patrick Testin
Rep. James Edming
Rep. Warren Petryk
Rep. Jeremy Thiesfeldt
Rep. Jodi Emerson
Rep. Sondy Pope
Rep. Ron Tusler
Rep. Mary Felzkowski
Rep. Melissa Sargent
Rep. Don Vruwink
Sen. Dan Feyen
Sen. Patty Schachtner
Rep. Chuck Wichger
Rep. Cody Horlacher
Rep. Katrina Shankland
“These legislators were critical to our legislative success and championed our most important priorities,” said Lisa Kirker, Chair of the WiAHC Board of Directors. “Home health care agencies across Wisconsin are grateful for the support and partnership of these individuals.”
WiAHC was very active during the 2019-2020 legislative session in educating legislators on the workforce issues facing home health care agencies and how increasing MA reimbursement rates can alleviate financial burden as well as attract new staff. WiAHC was successful in advocating for the introduction of Assembly Bill 447/Senate Bill 416, which aimed to increase MA reimbursement rates by 10% for home health visits. The bill received a public hearing in the Senate Health Committee, and WiAHC is hopeful there will be continued interest in the legislation next session. WiAHC also successfully advocated for legislation that allowed all MA reimbursable services to be conducted via telehealth.
WiAHC is a membership-based association that represents home health care agencies and their staff. WiAHC helps to support the common interests of its members to promote home health care as a quality, cost-effective health care option in our state. Home health care services are not the same as personal care services. Home health care services are medical, skilled nursing services as opposed to personal care services administered by non-health care professionals.
Do you know a colleague who would be a great fit for the Board? Submit a nomination today!
WiAHC is run by a volunteer Board of Directors. Board members are elected annually to staggered three-year terms. Board members develop and manage affairs of the Association and are supported by Committee Chairs and staff. Positions include Chair, Vice-Chair, Secretary/Treasurer, Regional and At-Large Representatives.
Positions serve a three-year term, starting January 2021. Those elected will also be invited to attend the final Board meeting of 2020.
To be eligible, a nominee's home health agency must be a current member of WiAHC.
How to Nominate
Nominating is easy, quick and simple! Submit a nomination using the form below.
The deadline to submit nominations is August 20, 2020.
In a 6-0 decision, the Wisconsin Supreme Court reinstated a 2016 circuit court order prohibiting the Wisconsin Department of Health Services (DHS) from recouping Medicaid payments made to Medicaid providers “if the provider’s records verify that the services were provided and the provider was paid an appropriate amount for such services, notwithstanding that an audit identified other errors or noncompliance with [DHS] policies or rules.”
The Supreme Court labeled DHS’ recoupment policy for such services provided a “perfection policy” and held that such a policy was not consistent with Wisconsin’s Medicaid recoupment statute or administrative rules.
The case, Papa vs. Wisconsin Department of Health Services, involved the extent of DHS’ authority to require repayment from providers for previously paid claims based on failure to follow all documentation and other technical requirements contained in a confusing series of administrative rules in the Forward Wisconsin Provider Handbook, technical bulletins and other sources. In 2016, a Waukesha County Court found that DHS’ position that compliance with all technical and documentation requirements by providers as a prerequisite for payment amounted to a “Perfection Rule” that exceeded its authority to recoup payments otherwise properly made. However, the Wisconsin Court of Appeals overturned that decision in July 2019.
In today’s 6-0 decision, the Supreme Court reversed the Court of Appeals and restored the county court’s 2016 order limiting DHS’ authority to recoup payments, concluding that “so long as DHS can verify that a covered service was actually provided, the claim was appropriate, and the claim was accurate, DHS cannot recoup payments based on a record imperfection. A record imperfection alone is not an independent basis for recouping payments.” The decision provides clarity and greater certainty for physicians, who could otherwise face demands for repayment of thousands of dollars months or years after the fact based entirely on unintentional documentation errors.
563 Carter Court, Suite BKimberly, WI 54136Phone: 920-560-5632 | Fax: 920-882-3655
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