Tag Archives: Pre-claim reviews

Conditions of Participation, Home health agencies, Uncategorized

What PCR reprieves, CoPs delay could mean

Future-gazing: A delay or not?
Either way,  there’s work to do!

It seemed almost too good to be true, like some April Fool’s Day prank offering false hope to home health agencies braced for a new onslaught of federal regulations.

Just one day before home health agencies in Florida expected to join Illinois agencies in a long-fought Pre-Claim Review (PCR) demonstration by the Centers for Medicaid and Medicare Services, two announcements by CMS changed the game. At least for now.

 After months of deadlock, a temporary reprieve from massive new regulatory changes – not just in Florida but nationwide – suddenly shifted from highly unlikely to plausible.

 CMS announced Friday that it would grant Florida a second reprieve from the PCR demonstration scheduled to begin April 1, suspend for at least 30 days the PCR program in Illinois which has been underway since August, and possibly give home health agencies an additional six months to prepare for new Conditions of Participation in the Medicare program.

   “These two developments made for an interesting Friday in home health,” said J’non Griffin, owner and president of Home Health Solutions LLC. “The PCR delay in Florida really was an 11th hour save. The clock was ticking, and agency personnel were attending last-minute PCR training workshops every day last week in cities all across Florida to get the information and training they needed to be ready for the PCR launch.”

 But brand new CMS administrator Seema Verma, who was just confirmed to her position at the Department of Health and Human Services on March 13, was also seeking information last week. She asked to meet directly with home health care providers and advocates from both Florida and Illinois, where the nation’s first PCR demonstration began last summer. The new CMS administrator said she wanted to hear their concerns about the impact of increasing regulatory demands on home health.

   Following that meeting, CMS on Friday announced plans for a 60-day public comment period to seek information that will be evaluated in determining whether to delay the implementation of new CoPs, standards which are widely expected to be difficult, time-consuming and costly for agencies to put into place. Under the current timeframe, agencies are required to meet new CoPs by July 13. The six-month delay, if approved, will give agencies until January, 2018, to make the necessary changes.

Soon after that announcement, word came from CMS that the PCR demonstration in Florida would no longer begin on April 1 as scheduled — and that the ongoing PCR demonstration in Illinois would be suspended for at least 30 days. CMS offered no further timetable for PCRs to resume, but promised a 30-day notice will be provided before that happens.

Relief, hope — and politics

Home health professionals across the country greeted Friday’s news with a mixture of relief and cautious hope for a changing climate in Washington D.C. regarding federal regulations on home care.

New Health and Human Services Secretary Tom Price has been described as knowledgeable about and supportive of many home health issues by William Dombi, Vice President of Law for the National Association of Home Care. At the 2017 Illinois Home Care and Hospice Conference last month, Dombi painted Price as a potential ally for home health, telling attendees that Price was considering supporting a CoPs delay.

But less than 100 days into a new administration, the Department of Health and Human Services headed by Price is still coming together, with many of its senior positions still unfilled.
And, as battles continue between lawmakers over the government’s specific role in health care, many of our nation’s health care policies have yet to be determined, much less put into place.

“It’s definitely a good sign for top officials in D.C. to actively seek input from home health and listen to our concerns, but there are still a great many unknowns right now,” J’non said. “No one really knows exactly how all this is going to play out.”

The future of PCRs and CoPs

What will the delays in Florida and Illinois mean for PCR demonstrations?

Industry experts believe it is likely that CMS will make changes to the PCR model before continuing with the demonstration first launched in Illinois last August. The demonstration in that state proved to be so chaotic, confusing and largely unsuccessful in its initial months that CMS was forced to pull the plug on expansions planned for Florida the following October and into Texas, Michigan and Massachusetts by the beginning of the year.

With the issues that plagued Illinois corrected, what might the revised demonstration look like?

“It really isn’t possible to say for certain at this point,” J’non said. “It seems more important to note that the PCR demonstration will go forward. This is a delay, and not a repeal. Agencies in all states still need to add PCR readiness to their ongoing training efforts.”

Under the current model, agencies in states where the PCR demonstration operates have the choice to participate or not. However, those who do not submit the proper paperwork for review prior to filing actual claims will automatically lose 25 percent of any Medicare reimbursement on claims not previewed.There has been no word at this time that the 25 percent reduction for non-participation will change.

While dramatic, last-minute PCR suspensions in Florida and Illinois grabbed most of the attention on Friday, the CMS announcement regarding a possible delay in the implementation of new Conditions of Participation could have a more immediate impact on most of the nation’s 30,000 home health providers.

The implementation of most new CoPs would be delayed until January 13, 2018, under the proposed rule.

Agencies would have extra time to meet some of the Quality Assurance and Performance Improvement (QAPI) standards required. Phase-in requirements would give agencies until July 13, 2018, to implement performance improvement projects, allowing six months after the January 2018 start date to collect the data they will be required to use in their data-driven performance improvement projects beginning in July 2018.

Administrators would be affected 
   Additionally, the proposed rule would grandfather all administrators employed by agencies prior to January 2018, so that they do not have to meet the new personnel requirements identified in the revised CoPs. 

  Of particular interest to agency administrators is what new personnel requirements will mean for future employment, and their ability to move from a grandfathered position at their current agency to an administrator position at a different agency.

Under the new CoPs, administrators who do not meet the requirements would lose their grandfathered exemption when they leave one agency to take a position at another agency, J’non said.
The clock is ticking

One of the primary arguments for delay of a start date for new CoPs has been concern about the lack of interpretive guidelines, which Surveyors will use to evaluate whether agencies have met the standards.

Agencies have expressed concerns they are not certain exactly what Surveyors will be looking for, particularly in the areas of data-driven performance improvement projects.
CMS agreed, in its announcement on Friday, that there is merit to that argument, and that is one of the reasons the delay is being considered.

“With so many other major clinical and operational changes to implement in such a short period of time before July 13, which is the start date effective under current law, there has been growing concern in the industry about the lack of time in which to put all of it into place,” J’non said.

   New Conditions of Participation were approved in January, giving agencies only six months to make the required changes. It was the first time in almost three decades that CMS addressed the standards set out for home health agencies under CoPs.

“With such a limited amount of time, agencies really need to be making the necessary changes now, without waiting on interpretive guidelines,” J’non said. “Guidelines are more for the benefit of Surveyors. Agencies must meet the standards as they are set out in the CoPs.

“It’s important to remember that the delay is only under consideration at this point, and the July 13 start date could remain in effect,” she said. Many agencies will not have the resources to make necessary changes on their own, especially under the current time frame, and will need to outsource much or all of the work, J’non said.

Even if the delay is approved, and extra time is granted, many of the new requirements will be so labor-intensive that agencies will still need to rely on outsourcing, she said.

Delays aren’t repeals

  J’non offered this advice to agencies wondering what these delays may mean and how they will affect preparation timelines:
“It’s important to note that, as with PCRs, a possible delay is not the same thing as a repeal,” J’non cautioned. “Agencies need to proceed as if the July 13 start date will remain in effect. If they wait, and the start date is not delayed at the close of the 60-day comment period, it will be too close to July to be able to implement the required changes by the deadline.”

EDITOR’S NOTE: This article first appeared in The Absolute Agency, a free monthly e-newsletter published by Home Health Solutions as a best-practices guide for agency administrators.
To subscribe, click here.

Home health agencies, Home Health News, Pre-claim reviews

What’s next for home health? Experts at conference admit they’re baffled

In a week of intense debate in the nation’s capital over efforts to repeal and replace Obamacare, the future of myriad home health regulations remains as uncertain as other health care issues. 

But one thing IS certain, according to Home Health Care Solutions owner J’non Griffin, who joined other home health experts at the 2017 Illinois Home Care and Hospice Conference & Exhibition near Chicago this week. Whether lawmakers change, repeal or leave in place existing Medicare requirements, agencies must continue to streamline their processes and focus on quality improvements to remain profitable in the increasingly challenging home health  field. 

Agencies in Florida hoping for a reprieve from an April 1 rollout of pre-claim reviews by the Centers for Medicare and Medicaid Services are likely to be disappointed, according to keynote speaker William Dombi, who serves as The National Home Care Association’s Vice-President  for Law. 

The eyes of the nation remain fixed on the D.C. debate over replacing the Affordable Health Care Act with an as-yet-unnamed plan which has been alternately dubbed Trumpcare,  Ryancare and Obamacare Lite. How the proposed replacement would impact home health has not yet been determined.

Meanwhile, the clock ticks inexorably toward the April 1 deadline in Florida, leaving little time or attention for NACH’s efforts to derail PCRs.

“The Washington perspective is that we are all crazy at this time. No one knows at all,” Dombi told hundreds of home health professionals attending the Illinois conference. “My concern is that day after day, hope of something in Florida diminishes.” 

NAHC has prioritized stopping the PCR process in additional states, including Florida, and curtailing the process in Illinois, which became the first state to undergo a PCR demonstration in August, 2016. Dombi said NACH is petitioning CMS to allow agencies which have had consistently high affirmation rates to opt out of the PCR process without being penalized financially. 

But NAHC’s efforts to get lawmakers to support the repeal of PCRs have been largely overshadowed by the bigger repeal efforts on Capitol Hill, and the political fallout. Republican lawmakers unveiled the replacement health care act promised by the Trump administration this week to major discord in Washington D.C., with condemnation from Democrats, the American Medical Association, the American Hospital Association, and even some Republicans. 

What will happen next is anyone’s guess, Dombi told conference attendees. He describes the situation as “very chaotic.” 

As federal lawmakers grapple with complex issues such as the extent of individual rights to health care, whether responsibility for health care is a federal or state priority and whether the role of the government in health care should be as partner or provider,  Dombi sees some areas of hope on the horizon for home health. 

The new administration’s Secretary of  Health and Human Services, Tom Price, has a sound grasp of many home health concerns and a history of support for many of them, Dombi said. 

Price has indicated some support for delaying new Conditions of Participation for Medicare which are scheduled to become effective July 13, Dombi said.  The new CoPs will require many operational changes for home health agencies, and there is some concern within the industry that there is not enough time for agencies to fully implement all the changes.

With no interpretive guidelines released four months away from the implementation,  NAHC believes surveyors aren’t ready for new CoPs and has been lobbying for a delay. Word in D.C. is that Price is “seriously considering” NAHC’s position, according  to Dombi.

However, it is important to note that no delays of PCRs or CoPs have been approved at this time. Industry experts at the Illinois conference strongly encouraged agencies to proceed as if new Conditions of Participation, Pre-Claim Reviews and Value Based Purchasing initiatives (in which agencies are rewarded or penalized depending on how well they make improvements) are inevitable. 

No one knows if or when or where CMS will expand Value-Based Initiatives beyond the nine states in the current trial, whether PCRs will proceed to other states after the Florida rollout, or exactly what will happen next in home health, but agencies must be prepared anyway, PPS Plus educator Jennifer Warfield told her conference audience.

“Even if the actual term Value Based Purchasing goes away, the future of your agency is always going to be tied to its improvement processes,” she said. 

Joyce Ryan Boin with Strategic Health Care  Solutions encouraged agencies to redirect their focus toward education and ongoing strategy for measurable improvement. 

“We’re not in Kanas any more,” she said. 

 EDITOR’S NOTE:  Check out HHS Owner J’non Griffin’s four-part webinar series on the new Conditions of Participation, providing an overview and highlighting compliance strategies for agencies to develop a QAPI program. The series begins March 15 at 10:30 a.m. CT, and will continue March 29, April 11 and April 25. 
For details or to register, click here.

 

 

 

Documentation, Home Health News, Pre-claim reviews

CMS suspends pre-claim review rollout in Florida

pcr-rollout-delayed
“Whew!”
That’s the word of the day for home health agencies in Florida, where there is industry-wide relief in the wake of a last-minute decision by the Centers for Medicare and Medicaid Services to suspend a pre-claim reviews rollout.
The rollout was set to begin Oct. 1,  but home health industry advocates and state lawmakers have lobbied hard to postpone the program, saying agencies are not prepared to meet the extra burden of preparing and submitting pre-claims.
Opponents pointed to a disastrous six weeks of initial efforts in Illinois, the first state to be included in the pre-claim demonstration, where very few pre-claims were approved on first submission.
The Home Care Association of Florida  was among the industry advocacy groups cautioning that patients needing home care were at risk as agencies scrambled to meet the pre-claims review burden. HCAF officials expressed relief Monday over the decision by CMS to grant agencies additional time.
No new timeline has been provided for the PCR demonstration in Florida or in other states which were previously scheduled to become part of the PCR demonstration over the next few months. Texas, Michigan and Massachusetts were on track to become part of the demonstration by Jan. 1.
CMS has indicated it will provide a 30-day notice before resuming the demonstration.  The demonstration already underway in Illinois is not included in the suspension, and will continue.
   In making the announcement, CMS acknowledged that problems experienced during the initial rollout in Illinois showed additional education will be needed before the demonstration can proceed.

Illinois non-affirmations

In Illinois, the demonstration that rolled out Aug. 1 has been marked by widespread non-affirmations, with an estimated 80 percent of first submissions failing to meet approval.
A large number of non-affirmations were based on the failure of agencies in Illinois to establish homebound status of the patient and medical necessity for home health services.
The National Association of Home Care and Hospice has fought the PCR demonstration, citing numerous problems with electronic submissions. NAHC’s Vice President for Law Bill Dombi called it “a complete mess.”

Use the reprieve to get prepared

“This delay gives home health agencies some much-needed time to better prepare for the pre-claims review demonstration,” says J’non Griffin, owner and president of Home Health Solutions LLC.
“But it is important to note that the process has only been postponed, and not canceled, so agencies will still need to prepare.”

Not sure where to start?

Home Health Solutions has a great DIY Kit to get your agency started, and it’s priced at just $25. Give us a call at 888-418-6970.
Many agencies are also considering outsourcing the preparation and submission of PCRs. Home Health Solutions is working with agencies who need PCR assistance, and will be glad to speak to you about how we can help your agency.

 

Documentation, Home Health News, Pre-claim reviews

How home health agencies can meet the pre-claim reviews burden

preclaims-reviews-2
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.

What’s ahead?

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

map-4

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.