Home and Community
Based Services
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The Centers for Medicare & Medicaid Services (CMS), Medicaid agencies, providers, and advocates have worked collaboratively for many years to develop community-based services and supports to ensure vulnerable individuals are served in the least restrictive and most desirable and integrated setting. The number of Medicaid beneficiaries receiving care in community settings has grown in recent years, primarily through increased enrollment in home and community-based service (HCBS) waiver programs, approval of demonstration initiatives, and implementation of new innovative Medicaid state plan amendment options.

As HCBS services grow into an even larger share of Medicaid-funded programs, so do state responsibilities to ensure services are necessary and appropriate, have quality oversight, were actually provided, and that Medicaid claims were properly submitted and adjudicated. In addition to HCBS waiver design and application, Myers and Stauffer is equipped to assist states with cost-effectiveness calculations, person-centered planning, reimbursement system design, stakeholder engagement, and provider training.

The Program for the All-Inclusive Care of the Elderly (PACE) is quite unique in its design and goals. Unlike HCBS programs, the PACE program is limited to individuals age 55 or older, who are certified to need nursing facility care, yet are able to live safely in the community. PACE represents a fully integrated model of care in which Medicare and Medicaid resources are pooled to allow for greater service flexibility, coordination, and continuity of care. 42 CFR §460.182 requires that PACE rates be budget neutral; account for the frailty of participants; be set at a fixed amount; and can be renegotiated on an annual basis. To assist states in preparing PACE rates, we provide support as they contemplate the CMS-developed critical elements that should be considered as part of the rate development process and an associated set of questions that should be addressed in writing and submitted by states as part of their PACE rate setting packages (i.e., PACE Medicaid Capitation Rate-Setting Guide published December 2015).

Our key competencies in the PACE arena include performance of market analysis, reviewing program applications and financials, development of provider procurement tools, and conducting feasibility studies for program expansions. We are also experienced with reviewing PACE programs for compliance with federal requirements.

We provide the following services:

Rate Setting and Reimbursement

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Kris Knerr, CPA, CGFM
member
kknerr@mslc.com

317.815.2947

Our team works from the premise that rate setting must be accurate, transparent, and predictable, while simultaneously demonstrating that payments are sufficient to support the delivery of high quality, cost-effective services and promote good health outcomes. As a public accounting firm, we have intimate knowledge of required principles that must be followed in the setting of rates and auditing of payment systems, and we are able to effectively apply that knowledge to Medicaid policy and program objectives in a manner that is highly efficient and that makes the best use of limited public funds.

  • Cost report design.
  • Web-based submission and communication system design (Web-Based Portal) for cost report and documentation.
  • Cost reporting tools development for state specific criteria.
  • Cost report collection, database management, and analytics.
  • Cost report monitoring.
  • Cost settlement calculations and notice of program reimbursement.
  • 1915c design, CMS negotiations, quality measure incorporation.
  • Rate setting studies.
  • Rate setting consulting.
  • Level of care analysis.
  • PACE market feasibility studies.
  • Pace cost analysis reviewing expenditures or encounter data.
  • Program design and consulting.
  • Quality incentive program/value-based purchasing/pay-for-performance program
    development and oversight.
  • Acuity component calculations.
  • Acuity based rate setting.
  • Acuity based rate consulting.
  • Value based payment (VBP).
  • VBP rate setting.
  • Network adequacy analysis.
  • Program financing consulting.
  • Fiscal impact modeling.
  • State Plan Amendment and administrative code consulting.

Waivers

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Jerry Dubberly, PharmD
Principal
jdubberly@mslc.com

404.524.9519

Our expertise in delivery system and payment transformation, strategic planning, financial analysis, rate setting, and project management enables us to help our clients evaluate their needs and identify the appropriate federal authorities necessary to achieve their objectives for programs, including HCBS initiatives. We have worked closely with states and CMS to gain approval for the design and implementation of a variety of state initiatives. Myers and Stauffer’s services include, but are not limited to:

  • Strategic planning, stakeholder engagement, application development, and CMS negotiation support.
  • Designing, implementing, and evaluating 1115, 1915(b), and 1915(c) waivers.
  • Cost effectiveness calculations.
  • Waiver compliance and quality oversight reporting.

Benefit/Program Integrity

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Ryan Farrell, CFE
Principal
rfarrell@mslc.com

512.342.0800

Through our benefit/program integrity services, Myers and Stauffer reviews HCBS waiver programs, personal care services, and other home-based services to seniors and individuals with physical disabilities, intellectual disabilities, and other complex medical conditions. Provided to vulnerable citizens in private settings with minimal supervision, HCBS programs can be highly susceptible to fraud, waste, and abuse. Our approach uses computerized analyses to aid in the detection of improper provider billing practices including: services not rendered, services in excess of policy limits, duplicate services, and unreasonable service duration.

In addition to claims data analysis, Myers and Stauffer conducts reviews of provider service records focused on assessing the accuracy and completeness of the documentation for services billed to Medicaid with specific emphasis placed on the provider’s adherence to state Medicaid statutes, regulations, and policy. Our review of applicable documentation includes: assessments, plans of care, service plans, service authorization records, time sheets, and other service notes; electronic visit verification (EVV) records; attendant qualifications and criminal background checks; and any other applicable documents.

  • Claims analysis.
  • Post pay claims audits – clinical/financial.
  • Pre pay claims audits – clinical/financial.
  • Medicaid RAC services.
  • SURS/FADS/case tracking modules.
  • Provider compliance.
  • Payment system processing accuracy.
  • Fraud, waste, and abuse detection (FWAD) litigation support.

Legislation and Regulation

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Amy Perry, CPA
member
aperry@mslc.com

816.945.5342

We have supported our clients through significant periods of change since the inception of the Medicare and Medicaid programs. Our national experience in reimbursement system design for HCBS is comprehensive from inception of concept all the way through implementation and on-going maintenance. Our services include:

  • Regulation and policy development support.
  • Federal medical authorities consulting.
  • State plan amendment.
  • 1915(c)/(b), 1115, and 1132 waivers.
  • Administrative code consulting.
  • Public hearing and workgroup participation.
  • Expert testimony.
  • Analysis of programmatic and fiscal impact of proposed or passed legislation.

Audit and Attest

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Bob Hicks, CPA
member
bhicks@mslc.com

816.945.5321

For our HCBS engagements, we follow a variety of approaches designed to meet our state agency clients’ objectives. The approach focuses on areas such as using a cost report, to also gathering published data from the Bureau of Labor Statistics. Our HCBS services include:

  • Cost report collection.
  • Web-based data exchanges for cost reports, supporting documentation, and related information.
  • Cost report database management, analytics, and reporting systems.
  • Audit and attest work programs and standardized work papers.
  • Attest protocols compliant with state and federal definitions.
  • Risk assessments to target audit work.
  • Training programs for clients, providers, and other stakeholders.
  • Claims management and audit systems.

Managed Care Oversight and Compliance

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Mike Johnson, CPA, CFE
Member
mjohnson@mslc.com
404.524.0775

The extensive services offered by our highly skilled managed care team are generally focused on the health plans but can impact all provider types, including home and community based providers. Our services include:

  • Network adequacy and member access compliance.
  • Claims payment and denial assessments, accuracy, and timeliness.
  • Grievance and appeals analysis.
  • Prior authorization reviews.
  • Program effectiveness audits.
  • Health plan contract compliance.
  • Other provider specific issue review and resolution activities.