Do you know the two primary risk areas?
Here’s a look at what’s being rejected —
and four things agencies need to do
This article first appeared in the September issue of SOLUTIONS, a monthly e-newsletter from Home Health Solutions LLC. If you’d like to receive our free newsletter, click here to subscribe.
Six weeks into the first Medicare pre-claim review demonstration in Illinois, the rest of the home health field is watching, hawk-like, to assess the damage and determine industry-wide risk.
Uneasy curiosity hinges on three questions:
What’s being denied? How bad is it? How can agencies insulate themselves?
“As a whole, it’s not going well,” reports J’non Griffin, owner and president of Home Health Solutions LLC.
“One agency has reported getting no non-affirmations — and they say they are uploading 80 to 100 different pages to justify the care for each claim.
“The last figure I saw, though, was about an 80 percent non-affirmation rate overall on the first submission.”
J’non’s assessment is backed up by the National Association of Home Care and Hospice. Bill Dombi, NAHC’s Vice President for Law, has called the pre-claim demonstration in Illinois “a complete mess.”
Agencies have reported individual claims taking up to an hour each to submit.
Some say they are unable to stop and save partially uploaded submissions once the uploading process has begun.
Several agencies say they have repeatedly been told their submissions are illegible. Many say their documents were lost during transmission.
The number of disappearing documents prompted CMS at one point to advise agencies to rely on fax submissions rather than electronic.
Currently, NAHC is lobbying Congress to suspend the next rollouts planned in Florida, Texas, Michigan and Massachusetts between now and the first of the year. Florida legislators are taking the lead in the opposition, since Florida is next in line with an Oct. 1 rollout.
But the clock is ticking, and despite overwhelmingly negative reports from home health agencies in Illinois, attempts by lawmakers there to suspend the process, and current efforts of Florida lawmakers to delay the next round, it seems likely for now that the pre-claim demonstration will move forward.
How can agencies prepare?
“To successfully meet the new burden of pre-claim reviews, home health agencies need to get much faster, with fewer documentation errors and oversights, expedited turnarounds, and a thorough understanding of exactly what is expected of them,” J’non says.
(For more information about how agencies can successfully handle PCRs, be sure to check out the detailed recommendations in J’non’s “4-Point Roadmap for PCR Success,“ below. )
Is your agency ready?
Industry experts agree that agencies will almost certainly be forced to hire additional full-time employees to meet the burden of pre-claim reviews. Generally, they estimate that for every 100 to 350 patients an agency serves, an additional one-and-a-half FTEs (one RN and one clerical) could be required.
For many agencies, however, a faster and more cost-effective solution may be to outsource the preparation and submission of pre-claim reviews. Home Health Solutions is now working with agencies needing assistance with PCRs.
“Agencies are discovering, as the requirements placed upon them increase, that it often makes more sense financially to outsource coding, billing and many other services so that they can focus on patient care,” J’non says.
Going it alone?
For agencies choosing to navigate the PCR process on their own, J’non recommends purchasing a helpful tool from Home Health Solutions. Think of the PCR Do-It-Yourself Kit as a $25 compass to point your agency in the right direction to steer through all the necessary paperwork. A checklist and staff tutorial are included.
To order, call HHS at 888-418-6970.
Roadmap for PCR success
J’non also offers the detailed 4-Point Roadmap below to help agencies successfully prepare for the pre-claim review process:
Step 1: EXPEDITE WORK FLOW
Agencies must streamline their operations, with faster turnaround times for coding, for developing a Plan of Care and getting the physician to sign off on it, and for collecting all documents needed to submit the pre-claim review.
Efficient teamwork will be an essential part of streamlining operations, J’non says.
She recommends agencies:
- Identify key staffers and their responsibilities, and make certain there is no confusion about who is responsible for each step in the process of completing documents and collecting necessary forms to submit and re-submit claims.
- Develop a back-up system to avoid delays in the event a key staffer becomes unavailable.
- Determine who will be responsible for follow-up, and how often.
- Make certain the person submitting pre-claims has immediate access to all required documentation and billing information.
- Review the process with the full staff, stressing the need for timeliness and accuracy. Put policies and procedures in writing for easy access to avoid confusion or delays.
Step 2. TARGET TWO AREAS MOST LIKELY TO BE REJECTED
Agencies in Illinois are reporting that a high proportion of pre-claim reviews are being rejected on the basis that the patient is not homebound or the care is not shown to be medically necessary.
J’non recommends agencies look closely at their supporting documentation to make certain they have correctly established both patient eligibility and medical necessity.
A few reminders about documenting homebound status:
- To be considered homebound, the patient must be unable, due to illness or injury, to leave home without special equipment or assistance from another person. Be sure to document WHY the illness or injury requires special equipment or assistance.
- Document the impact on the patient from any excursion outside the home, the reason for the trip, and the effort required to leave home.
- Make certain Face-to-Face documentation specifies why the patient is homebound. The physician’s note must specifically address the reason the patient needs home health services.
Step 3: CLEAN UP DOCUMENTATION
Review, review, review. Agencies can’t do too many in-house reviews and self-evaluations as they attempt to shore up compliance risks, limit oversights and reduce errors.
In particular, J’non recommends agencies focus on:
- Accurate completion of the OASIS, especially in preparation for C-2 revisions which take place Jan. 1. This data collection tool offers numerous areas where clinicians can become confused. The HHS team frequently sees agencies making mistakes as simple as entering dates in the wrong place on this form, erroneously establishing non-compliance.
- Proper documentation of Face-to-Face Encounters. Make sure the physician has documented the date of the F2F Encounter and provided the reason home care is necessary. A clinical note from the physician will be required, not just a form, and the content of the note must address the reason the patient needs home health care.The signature of a nurse-practicioner or other provider on the F2F will not suffice unless it is a co-signature with the physician. Even if the nurse-practitioner performed the F2F, the certifying physician’s signature and date will be necessary. Review all F2F dates to make certain there are no discrepancies. Mismatched dates are automatically denied.
- Collect all necessary information before submitting pre-claims
- Attach the assigned pre-claim number to all final claims and resubmissions.
- For re-certifications, be aware that the re-certification statement on the projected length of time the patient will need home care will need to be submitted separately from the Plan of Care.
- Also note that the projected length of care will shorten each time the patient is re-certified unless there is a documented reason showing why that is not the case. In a recent workshop on pre-claims reviews, Palmetto representatives stated that the re-certification statement is expected reflect a shorter duration for each episode of home health care for which the patient is re-certified. The first re-certification projection, for example, might be six months, but the next re-certification projection would be only four months. Be sure to include supporting documentation showing the need for any change in the projected length of stay.
Step 4: INVEST IN TRAINING
Agencies will need to shore up training in many areas in order to reduce compliance risks and achieve success in today’s challenging home health market, J’non says. In particular, she recommend OASIS training and F2F review to prepare agencies to better handle pre-claims reviews.
HHS offers online training for both in its online store, with 8 CEUs offered for the OASIS course.
Click here to shop the online store now.