Section 1 Short title
This Act may be cited as the “Home Health Documentation and Program Improvement Act of 2017”.
Home Health Documentation and Program Improvement Act of 2017
A BILL
To amend title XVIII of the Social Security Act to make changes to documentation of eligibility for Medicare home health services, and for other purposes.
Sec. 2 Information to satisfy documentation of Medicare eligibility for home health services
Part A— Section 1814(a) of the Social Security Act (42 U.S.C. 1395f(a)) is amended by inserting before “For purposes of paragraph (2)(C),” the following new sentence: “For purposes of documentation for physician certification and recertification made under paragraph (2) on or after January 1, 2018, and made with respect to home health services furnished by a home health agency, in addition to using documentation in the medical record of the physician who so certifies or the medical record of the acute or post-acute care facility (in the case that home health services were furnished to an individual who was directly admitted to the home health agency from such a facility), the Secretary shall use documentation in the medical record of the home health agency as supporting material, as appropriate to the case involved.”.
Part B— Section 1835(a) of the Social Security Act (42 U.S.C. 1395n(a)) is amended by inserting before “For purposes of paragraph (2)(A),” the following new sentence: “For purposes of documentation for physician certification and recertification made under paragraph (2) on or after January 1, 2018, and made with respect to home health services furnished by a home health agency, in addition to using documentation in the medical record of the physician who so certifies or the medical record of the acute or post-acute care facility (in the case that home health services were furnished to an individual who was directly admitted to the home health agency from such a facility), the Secretary shall use documentation in the medical record of the home health agency as supporting material, as appropriate to the case involved.”.
Sec. 3 Voluntary settlement of home health claims
Settlement process for home health claims—
In general— Not later than one year after the date of enactment of this Act, the Secretary of Health and Human Services shall establish a settlement process under which a home health agency entitled to an eligible administrative appeal has the option to enter into a settlement with the Secretary that is reached in a manner consistent with the succeeding paragraphs of this subsection.
Process and consideration of home health claims— A settlement under paragraph (1) with a home health agency that is with respect to an eligible administrative appeal may only be reached in accordance with the following process:
A settlement under such paragraph with the home health agency shall be with respect to all claims by such agency, subject to paragraph (4), that, as of the date of such settlement, are under an eligible administrative appeal.
For the duration of the settlement process with such agency, an eligible administrative appeal that is with respect to any such claim by such agency shall be suspended.
Under the settlement process, the Secretary shall determine an aggregate amount to be paid to the home health agency with respect to all claims by such agency that are under an eligible administrative appeal in the following manner:
The Secretary shall, for purposes of applying clause (ii) with respect to all settlements under paragraph (1), select a percentage. In selecting such percentage, the Secretary shall consider the percentage used under the Centers for Medicare & Medicaid Services hospital appeals settlement that began on October 31, 2014.
The Secretary shall, with respect to each denied claim for such agency that is under an eligible administrative appeal, calculate an amount (referred to in this subparagraph as an “individual claim amount”) by multiplying the net payable amount for such claim by the percentage selected under clause (i).
Such aggregate amount with respect to such agency shall be determined by calculating the total sum of all the individual claim amounts calculated under clause (ii) with respect to such agency.
Effect of process—
Effect of settlement—
Further appeal— As part of any settlement under paragraph (1) between a home health agency and the Secretary, such home health agency shall be required to forego the right to an administrative appeal under section 1869 of the Social Security Act (42 U.S.C. 1395ff) or section 1878 of such Act (42 U.S.C. 1395oo) (including any redetermination, reconsideration, hearing, or review) with respect to any claims for home health services that are subject to the settlement.
Judicial review— There shall be no administrative or judicial review under such section 1869 or otherwise of a settlement under paragraph (1) and the claims covered by the settlement.
Effect of no settlement— In the event that the process described in paragraph (2) does not, with respect to a home health agency, result in a settlement under paragraph (1) with such agency, any appeal under such section 1869 that is with respect to a claim by such agency that was suspended pursuant to paragraph (2)(B) shall resume under such section.
Coordination with law enforcement— The Secretary of Health and Human Services shall establish a process under which individuals in the Department of Health and Human Services responsible for executing a settlement under paragraph (1) may, in order to avoid the inadvertent settlement of cases that involve fraud or other criminal activity, coordinate with appropriate law enforcement agencies.
No entitlement to settlement process— Nothing in this section shall be construed as creating an entitlement to enter into a settlement process established pursuant to subsection (a).
Eligible administrative appeal defined— For purposes of this section, the term “eligible administrative appeal” means an appeal under section 1869 of the Social Security Act (42 U.S.C. 1395ff) (including any redetermination, reconsideration, hearing, or review)—
that is with respect to one or more claims that—
are for home health services that—
were furnished on or after January 1, 2011, and before January 1, 2015; and
were reasonable and necessary under section 1862(a)(1)(A) of such Act (42 U.S.C. 1395y(a)(1)(A)); and
were timely filed consistent with section 1814(a)(1) of such Act (42 U.S.C. 1395f(a)(1)) or sections 1835(a)(1) and 1842(b)(3) of such Act (42 U.S.C. 1395n(a)(1), 1395u(b)(3)); and
either—
was timely filed consistent with section 1869 of such Act (42 U.S.C. 1395ff) and is pending; or
for which the applicable time frame to file an appeal has not expired.
Conforming amendment— Section 1869 of the Social Security Act (42 U.S.C. 1395ff) is amended by adding at the end the following new subsection:
“(j) Application with respect to certain home health claims—For the application of the provisions of this section with respect to certain claims for home health services that were furnished on or after January 1, 2011, and before January 1, 2015, see section 3 of the Home Health Documentation and Program Improvement Act of 2017.”