In a June 14 Open Door Forum, CMS representatives answered questions about the new Home Health documentation rule they will soon begin to test in five states. The "Pre-Claim Review" rule, as it is now called by the department that manages payments to Medicare home health providers, is being couched as an opportunity for those providers to "better manage their cash flow."
"Now, you will know in advance whether your documentation is correct and your claim will be paid when submitted," the CMS spokesperson read from a prepared script.
Here is how CMS anticipates the new system will help providers when it begins in Illinois on August 1, Florida on October 1, Texas on December 1, and Michigan and Massachusetts on January 1, 2017. (All dates are designated as "no earlier than.") Most of the following information was delivered in a brief summary and clarified during the Q&A section of the June 14 conference call.
There were questions that were not answered during the call, or were answered in a way that did not satisfy the questioner.
Q: If an HHA receives a disapproval that says the need for skilled services is not verified, won't they be motivated to discontinue services before their unpayable visits mount up to unacceptable losses?
A: "We expect that Home Health Agencies are oriented toward patient care and would not abandon a patient simply because they are not going to be paid for the services provided."
Q: Does the plan of care have to be signed before the pre-claim review documents can be submitted?
A: Normal requirements apply. (We interpret this to mean the plan of care has to be signed before the final claim is submitted but the CMS spokespeople would not confirm that this is how your MACs will interpret it.)
Q: Looking at recent MAC and ZPIC historical evidence, we know that quick hiring and training of new staff leads to problems. Training is often superficial, knowledge of home health regulations on the part of the trainees is inadequate, new auditors with insufficient understanding of Medicare Home Health regulations often improperly deny payments and demand ADRs. In the past, this problem has resulted in 80% to 90% overturn of denials by the ALJ, when that department was available. How are we to be assured that this history will not be repeated when MACs rapidly staff up and superficially train newcomers once again to meet this massive increase in documents arriving as soon as six weeks from now?
A: "We met with the MACs and told them to be ready."
Q: You know who the bad actors are. We reluctantly accept that you were unable to figure out a way to target the criminals and leave the rest of us alone, but is there a way for a high-performing agency to be excused from the pre-approval requirement, for example if they receive no disapprovals for a year?
A: "This is a three-year trial. All HHAs in these five states will be on the program for the full three years regardless of their performance."
Editor's comment: While it is a relief that it has been clarified that in-home patient care services will not have to be delayed until pre-approval is received, indicating less fear of putting patients in danger than once thought, this regulation continues to disappoint on two levels. CMS has found extra money in the budget to defray the added costs the regulation imposes on MACs but refuses to acknowledge that HHA costs will rise as well. The hope that "cash flow will be more predictable" is little condolence. This reinforces the long-suspected CMS attitude that MACs are the police, the "good guys," while all home health agencies, not just the tiny percentage of fraudulent players, will cheat if not constantly watched.
Secondly, to the extent this regulation is a punishment, as it has been described by the Partnership for Quality Home Healthcare (last week's issue, Partnership Expresses Disappointment with Medicare Home Health “Pre-Claim Review” Demonstration), it will be a most ineffective one. It imposes equal burdens on criminals and legitimate providers. What is worse, as Bill Dombi has been making clear during his round of visits to state association meetings this spring, the bad guys will find a way around it. The rule ensures that documentation indicates homebound status and medical necessity, but it does not guarantee that there is an actual patient behind the documentation, a living human being receiving home health services.
As CMS continues to push the total number of HHAs from 12,000 to 6,000, we can only hope that the criminals will be the ones eliminated. Current efforts do not seem to be leading in that direction.
©2016 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. firstname.lastname@example.org