February 2010: In November 2009, the Centers for Medicare and Medicaid Services (CMS) announced changes to Medicare’s 2010 home health prospective payment system rates and modifications to the home health outlier policy. The rule became effective January 1, 2010.
In recent years, CMS has become more attuned to the growth in outlier payments, specifically very high outlier payments in certain areas of the country. An outlier payment is made for an episode that has a cost which exceeds a threshold amount. A Home Health Agency must bear a fixed dollar loss (FDL) before an episode becomes eligible for outlier payments. In 2009 CMS did not raise the FDL ratio due to the extremely high outlier payments in designated areas.
For CY 2010, CMS underwent an analysis of all providers who received outlier payments, focusing on total HH PPS payments, total outlier payments, number of episodes, number of outlier episodes, and location of provider. This analysis prompted CMS to propose an agency level outlier cap: in any given calendar year, an individual HHA will receive a maximum of 10 percent of its total HH PPS payments in outlier payments. In addition, CMS proposed to reduce the FDL ratio to .67 for CY 2010 (from .89 in CY 2009).
See the attachment to read the rule as published in the Federal Register on November 10, 2009.
For more information regarding the impact of this rule on Home Health Providers, please visit https://www.wachler.com/ or contact a Wachler & Associates attorney at 248-544-0888.