by Michael McGowanIt was a true story. "The Perfect Storm,” a book by Sebastian Junger, made into a 2000 film by Wolfgang Petersen and starring George Clooney, chronicled the tragic story of the Andrea Gail, a fishing boat that encountered a rare confluence of three meteorological events, all hitting at once, destroying the ship and its entire crew.
Though these events occurred in New England, home health agencies in Florida are about to find out exactly what the Andrea Gail crew experienced during their final day on Earth. A perfect regulatory storm is approaching Florida from the north, from Security Boulevard in Baltimore, to be precise:
Florida is used to its storms, but nothing like this.
So, what does this mean to the HHA striving to meet compliance standards and hoping to still be in business next year?
Many agencies believe the F2F "form" is the actual F2F encounter note. This is a mistake. Contract auditor review teams require the actual F2F note or discharge summary note from the physician, the one that includes the date of the encounter by the NPP or Physician.
The note must include the date of the encounter and the documentation in it must be related to the primary reason home health services are necessary. There is no requirement the note contain a declaration of "homebound status," however, if the physician does incorporate such a statement, it can only help. In short, no note = no referral.
2 - Pre-Claim Reviews
Pre-Claim Review is no more and no less than the evaluation of compliance with long standing requirements established in regulatory statutes. There is nothing new about what is required other than the form to fill out and submit to Palmetto and the date it has to be submitted.
The early submission date moves your referral intake process and your OASIS processes to a status where they become the key factors to your success. Agencies starting a case before assuring compliance with these requirements are frequently being presented with pre-claim denials.
Even worse, in some Florida areas, ZPIC investigations have discovered "altered" physicians' documents being utilized in home health episodes to authorize care. Consequently, more and more physicians in these areas are growing extremely reluctant to share their notes with agencies, for fear that something nefarious may happen with the documents, resulting in their own ZPIC visits.
In our consulting practice, we teach a proprietary process through which QA staff in the office engage with the nurse in the home during the OASIS visit, producing a RAP-ready, compliant claim shortly after the clinician is done.
3 - OASIS
The implementation of OASIS C-2 and the changes in the grouper and case mix compilation make it much more difficult to obtain accurate acuity scores reflective of the patient's actual abilities and deficits. Many agencies make the mistake of submitting "light acuities" with heavy service utilization, a practice that always triggers ZPIC radar. The result is further problems in the form of probe edits, prepayment review, and occasionally millions of dollars in extrapolation.
Our consulting practice acknowledges that clinicians have an inherent understanding of what their patients need, yet they often struggle to translate those needs into OASIS data supportive of the care they want to provide. In light of that, we teach a unique, two-person, live QA process. This technique aligns the clinical expectations of the clinician, detailed in the plan of care, with the transmitted assessment data. The result across our client base is substantial increases in case-mix accompanied by near zero ADR risks.
4 - HHVBP
The inability to and effectively score OASIS assessments, meaning accurately and consistently across all clinical staff, virtually dooms an agency to failure under an HHVBP payment system as currently envisioned by CMS. If no room is left for improvement between start of care and discharge, it is impossible to demonstrate positive outcomes.
The difficulty lies primarily in the limitations inherent in the practice of sending a single clinician into the home without any accountability, until much later, of how an assessment is to be performed. Lack of consistency among assessing clinicians in the same agency creates a haphazard data pattern, which is all MAC, ZPIC and Pre-Claim reviewers have to go by to determine if an agency is compliant. What you submit to CMS, you own.
A growing number of HHAs in Florida and other states have begun to use the two-person OASIS system we teach. Generally, they find they can accurately complete four or more OASIS events per clinician per day. They routinely submit each day's RAPs and Plan of Care documents prior to the close of business that same day. In Illinois, they have PCR submission ready as well.
We have found this to be a practical, cost-effective business practice, possible for most agencies to achieve. It enhances compliance, increases case-mix revenue, and accelerates cash flow. To help with the impending perfect storm, we will be making this system known to Florida agencies through a number of means this month and next, including live sessions and webinars through HCAF and Curaport.
Upcoming Webinar Sponsored by Curaport
Thursday, April 6
Michael McGowan is the former OASIS coordinator for CMS Region IX. He is currently president and founder of OperaCare, a software system to streamline clinical process, improve compliance, and protect home health agencies against the appearance of fraud, waste and abuse. He can be reached at firstname.lastname@example.org
©2017 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. email@example.com