Sustainability of Home Health… Can We Survive?

By: Melody Rabor-Dizon

 

People in the home health industry, like myself, in this time of uncertainty, are faced with constant changes in ruling, fee schedule proposals are fretting at the very thought of further cutting reimbursements, implementation existence of conditional payments, modification of the process of submissions claims, timeliness of submission and awaiting decision if home health visits will be an affirmed visit or a non-affirmed visit. In layman’s terms, approved or not approved.

In any given situation, there are always two ways to look at it. Either we let the gravity of the situation take us and get paralyzed by it or we rise above the situation and consider it as an opportunity to improve or to learn. I’m always one to take on the positive side. Positivity begets positivity. However, it may seem that the home health care industry may have been taken a lot of hits, challenges and spotlights lately, it still remains a fact that healthcare is geared towards home health because of cost containment, decreasing incidence of hospital infection, unnecessary hospitalization and/or unnecessary confinement to a nursing home. And for some of the readers who do not know or maybe in speculation as to why things are happening the way they do, I would like to be impartial and let the readers know where all of these is coming from. This is from Amy Baxter, from Axxes Technology Solutions, who was giving the seminar on Pre-Claim Review.

“The reason that we are in the position that we are in today is due to the fact that Centers for Medicare and Medicaid Services or CMS has found extensive evidence of fraud, that’s why pre-claim review is here now. CMS is using data to concentrate on Medicare fee-for-service outliers in the areas identified. Currently Medicare has identified 27 hotspots and many of the states have also an ongoing on what they called a moratoria wherein there’s a heavy utilization in the preclaim review model and there’s a heavy payment outlier history as well.

So all of those reasons together have raised red flags and that’s why the preclaim review model has been formulated. Medicare had stated that in 2013, there is a 17.3% improper payment data rate while in 2014 it showed that there has been a spike in their improper payment rate to 51.4% and has been projected to increase up to 59% in 2015. The goal of the pre-claim review is to assess means of reducing Medicare fee for service home health payment as well as reducing improper payments while maintaining or improving the beneficiary’s quality of care and experience. Pre-claim review is a process to request professional affirmation of coverage by submitting documentation and other information for review after the services have begun before the final claim is submitted. It ensures that applicable coverage payment and coding rules are met before the final claim is submitted.”

In other words: Traditionally , if I am given a referral before, as long as the patient meets criteria of homeboundability, patient has Medicare coverage, the patient is under the care of primary physician who is willing to oversee the patient while under home health and must have a face-to-face encounter with his physician within the last 90 days or within the 30 days of admission to Home health, then the patient is admittable to home health. Claims can be submitted considering orders had been signed, then agency gets a partial payment from Medicare.

Effective August 1st with the new CMS’ PRE CLAIM REVIEW:

With the new model, if I get a referral, all the face-to-face encounter must be in place (not new), documentation from physician’s medical record that supports patient’s homeboundability status must match what is on the face-to-face encounter (new), Medicare eligibility must be checked (not new), send in the home health order with their respective disciplines and frequencies needed (new), submission of pre-claim documentation via web, fax, mail (new). Even at this stage, everything is still “conditional” – not approved visits yet. But because there are policies we have in place for admitting patients and not just discharging them because of insurance reasons, in this case non-confirmed visits, we have code of ethics and we are nurses to begin with, we will take care of that wound, we will send physical and occupational therapist before even knowing the agency will be paid. Medicare says, we are given 10 business days to know if visits will be affirmed or not affirmed.

So, the question is, what happens if the agency already sent out all supplies, all necessary disciplines, everything the patient needs and the agency finds out the visits were not affirmed? Who pays for that? Uhmmmmm. The agency will have to absorb all of the cost. Then the bigger question arise, how can home health agencies survive in this kind of environment? How can agencies sustain?

The Illinois HomeCare & Hospice Council (IHHC) to whom the Association of Certified Home Health Agencies in Illinois (ACHHAI) have developed close alliance with, and on many occasions had sought assistance on how to address issues on home health on the state and federal level have released these on cue central issues how this will impact home health agencies and why implementing such mandate is really not addressing the real problem.

“This is the core problem of the CMS’ pre claim that was addressed by the IHHC who support efforts to root out fraud and abuse but also believes that pre-claim review will create a burden for all providers instead of targeting high-risk providers.”

1. It does not properly address the core problem of documentation that leads to the finding of “improper payments”;

2. It is overly broad in its application rather than targeted to high risk providers; and

3. It is inefficient, requiring extensive resources from Medicare and home health agencies.

CMS readily recognizes that the vast majority of so-called “improper payments” are based on documentation errors or omissions. At a recent hearing before the House Energy and Commerce Committee, CMS Director of Program Integrity Agrawal testified that the high incidence of “improper payments” is not due to fraud or abuse. Instead, it is due to paperwork errors. Neither Medicare nor home health agencies want this result.

There are better ways to address this matter than the use of an indiscriminate pre-claim review process that does little, if anything, to correct the underlying cause of “improper payments.” Most importantly, CMS should be addressing the root cause(s) of non-compliant documentation prior to the use of any expanded claim review process.

IHHC recommend the following alternative corrective action approach.

1. CMS and home health services stakeholders determine the nature and cause of the documentation errors and omissions. It should be assumed that home health agencies want to comply with all documentation requirements. The causes of non-compliance may include inadequate or confusing guidance, unnecessary complexities in the requirements, the absence of flexibility in the standards, inconsistent application of requirements by Medicare contractors, and provider negligence.

2. CMS institutes a Documentation Improvement Initiative that includes appropriate revisions to documentation policy requirements, education of providers and Medicare contractors, and compliance testing to determine the effectiveness of the initiative.

3. If CMS determines after the conclusion of the initiative that some form of pre-claim review may be helpful in achieving compliance, CMS should issue a proposal through APA public notice and comment procedures.

4. Any pre-claim review process should be targeted to high risk providers only. For example, county specific moratoria areas have been considered by CMS to present high risk. Alternatives would include new providers (one year or less of operations) and providers with a high error rate demonstrated by an agency-specific medical review audit.

It should take CMS no more than 12 months to take on each of these recommended steps. That would delay a pre-claim review process only until 8/1/17 if it is determined to be at all useful. It should be noted that there is no indication that CMS and its contractors have the capacity to competently handle a 50-fold increase in claims reviews that the project currently requires. At a minimum, the 12 month delay will provide CMS the time needed to implement any pre-claim review process without creating a high risk to patient care access, HHA operations, and MAC workload.

Opportunities in the horizon I can see:

Home health agencies will be more responsible with documentation, more responsible with billing, more responsible with timeliness of submission of notes, adherence to the new rules and regulations, be more of an advocate to the patient, lobby healthcare, prove to the rest that the good agencies are good agencies through and through. Mindful, that others are very mindful about federal dollars. Continue doing what they are doing of providing excellent care to their patients. Continue doing good and never tire doing good. It still doesn’t get old with me, when my Alzheimer’s patients recognize me instead of their family members. It warms my heart.

Updated Start Date for Illinois Home Health Pre-Claim Review

As the Pre-Claim Review Demonstration for Home Health Services goes into effect in Illinois, we are instructing Home Health Agencies (HHAs) in Illinois not to submit pre-claim review requests for episodes of care that began prior to August 3, 2016.

In order to allow time to resolve an administrative procedural requirement related to the Paperwork Reduction Act, implementation of the Pre-Claim Review Demonstration for Home Health Services in Illinois began on August 3, 2016. The revised start date does not impact demonstration requirements or processes, and the demonstration will be operationalized as planned for episodes of care starting on or after August 3, 2016. CMS’ Medicare Administrative

Contractors will work directly with any HHAs that submitted requests for episodes of care that began prior to August 3, 2016 and allow them to either have the requests withdrawn or processed as test requests.