August 12, 2016

Looking Back, Moving Forward: The Weekend Edition for Saturday, August 13, 2016

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Welcome to the weekend, and thanks for checking in.

We’re bringing you the news from this past week as well as providing you with a look at the week ahead.

Looking back, here are two big story we have been monitoring this week…

CMS Updates Nursing Home Five-Star Quality Ratings

The Centers for Medicare & Medicaid Services (CMS) updated the popular Nursing Home Compare Five-Star Quality Ratings to incorporate new measures, noting that new quality measures are being included in the overall calculation for nursing home star ratings.

In making the announcement this week, CMS said the new measures look at successful discharges, emergency visits, and re-hospitalizations, and complement other nursing home measures previously announced in April. 

“When residents and their families are faced with important decisions about care, they need an easy, transparent way to figure out which facility is the best fit for them or their loved ones,” said CMS Deputy Administrator and Chief Medical Officer Patrick Conway, M.D., MSc, in the news release posted on the CMS site. “With this update, star ratings will provide an even more accurate reflection of the services that nursing homes provide.” 

CMS said that its Nursing Home Compare is the agency’s public information website that provides information on how well Medicare and Medicaid certified nursing homes provide care to their residents.

CMS explained that nursing homes receive four different star ratings on the Nursing Home Compare website (each ranging from 1 to 5 stars): one for each of the components – health inspections, staffing, and quality measures – and one for an overall rating, which is calculated by combining each of the three component star ratings. With the new quality measures added to the calculations, the quality measures star rating for each nursing home, as well as the overall rating, will likely change.

Judge Approves Settlement, Certifies Nationwide Class Action Suit Challenging Medicare’s Appeal Process

The Centers for Medicare Advocacy, Inc. (CMA) reported this past week that a federal judge in Connecticut had approved a settlement in a nationwide class action lawsuit that will ensure that Medicare beneficiaries receive speedy hearings and decisions from administrative law judges (ALJs) on their appeals of coverage denials, according the CMA news release posted on its website. Exley v. Burwell, No. 14-cv-01230 (D. Conn., Aug. 1, 2016).  

A week after approving the Exley settlement, the same judge, Judge Jeffrey Meyer, in a related case challenging the 98 percent denial rate at the two levels of appeal below the ALJ level, denied the government’s motion to dismiss and granted the plaintiff’s motion for certification of a nationwide class.  Sherman v. Burwell, No. 15-cv-1468 (D. Conn., Aug. 8, 2016), according to CMA.  

In addition, according to the CMA news release, Judge Meyer certified a nationwide class of Medicare beneficiaries of home health care services who received an adverse initial decision dated on or after January 1, 2012 and who received or will receive adverse decisions at the Redetermination and Reconsideration levels of appeal. 

 “The immediate effect of the decision is that the government must respond to the written discovery requests that plaintiff had submitted prior to the motion to dismiss,” said CMA. 

This story was first reported by Nancy Beckley of Nancy Beckley and Associates. In her June 12, 2015 story for RACmonitor, Beckley wrote that in Exley v. Burwell, the lead plaintiff attorney Ali Bers from the CMA said this would the perfect case for class certification. 

“While this class-action suit was filed on behalf of beneficiaries and seeks to address their timely appeal rights, it represents yet another glaring spotlight being shone on the broken Centers for Medicare & Medicaid Services (CMS) appeals process, which has ballooned since the permanent Recovery Auditor program (RAC) began complex medical reviews, with hospitals reporting additional documentation requests (ADRs) at the maximum allowable per ADR request cycle,” Beckley wrote.

The Center for Medicare Advocacy, Inc., is a national nonprofit, nonpartisan organization that provides education, advocacy, and legal assistance to help older people and people with disabilities obtain fair access to Medicare and necessary healthcare. The Center was founded in 1986 and is headquartered in Connecticut and Washington, D.C., with offices throughout the country.

Chuck Buck

Chuck Buck is the publisher of RACmonitor and is the program host and executive producer of Monitor Monday.

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