Posts containing links to new stuff from CMS. (Hopefully as soon as I hear about it.)
Well, in case you haven't heard, the new Home Health PPS rule was published by CMS this evening. I have not had a chance to read it, but thought I would post it so you could get a copy. I will post more after I have had a chance to look at it.
Attachments:
CMS-1541-FCdisplay.pdf
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I have been meaning to comment on the proposed ?resurvey fee? that was reported in Home health line a few weeks ago, but have been so busy, I got very delayed. Home health line recently reported a proposal from CMS to require hhas to pay a $1600 ?resurvey? fee if they require a revisit to demonstrate compliance after a survey. The proposal would even require a fee if the state agency only did a paper review at its offices.
Of course, CMS thinks this is a great idea, as it has the potential to generate millions of dollars in revenue for CMS, but there are a number of problems that it creates. First, once CMS starts charging a fee for federal resurveys, you can expect states to start doing it as well. Although you usually have a state and federal survey simultaneously, I can?t help but think that a state agency would start charging agencies a similar fee. I know in Indiana, the state has a hard time getting all of the sureys done, in part due to budgetary limitations, and a resurvey fee is one way to help fix this problem. Whether a state licensed and Medicare certified agency would need to pay two fees would be a separate question, but it is not beyond belief that you would get charged two resurvey fees. (Of course, this would seem like a windfall, since the state performs both surveys simultaneously.)
Worse than these issues, however, is the fact that such a fee further punishes agencies for a survey report that, even if it is obviously factually wrong, they have no ability to challenge. Charging this fee assumes the survey process is an objective one and that the findings are correct. Unfortunately this is not the case. A surveyor?s findings are the result of the surveyors interpretation of the evidence and judgment calls on the application of the regulations.
For example, many agencies have been cited by a surveyor for doing something one way, changed it to conform with what they surveyor demanded and then been cited again on their next survey for doing exactly what the last surveyor told them to do. Why should an agency have to pay a fee to be resurveyed in those circumstances? Another example is the mistaken surveyor. I have seen surveyors get their facts completely wrong and when later presented with clear evidence of their error, they still refuse to revise the finding. At this point, because the courts have decided that a survey report is not an order (even though it finds facts, determines liability and requires a response), you have no option but to submit a plan of correction and, if implemented, pay the fee.
In essence, you are being fined, but by calling it a resurvey fee, they are hoping to avoid providing you with any due process first. (It would be interesting to see if a court would view this ?fee? differently.) If you fail to pay the fee, you are then at risk for losing your Medicare billing privileges. This is just one more way to make a fundamentally unfair and subjective process even more unfair. The vast majority of agencies are cited for some violations every time they are surveyed. If you have to pay for a resurvey, you are looking at $1600 a year as an additional operating expense. (Combined with the potential revenue reductions courtesy of the revised PPS.) If an agency required more than one resurvey before they were found to be in compliance (which can happen), the agency could spend more than three thousand dollars on resurvey fees, not to mention on legal fees, consultant fees, etc.
If the government feels they are losing money due to resurveys, they should focus on the survey process, training surveyors and eliminating as much of the subjectivity as possible in an effort to reduce the need for resurveys. They could also look at ways to reduce the number of surveys. Indiana, for example, will not accept certain accreditations in lieu of an annual survey. (Yes, I know JCAHO costs money, but I have been told their survey process is not as onerous as CMS.) Agencies should not be punished for requiring a resurvey when they have not procedure to challenged erroneous findings in the survey.
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HHS has announced a new demonstration project to combat home health fraud. This demonstration project will begin in Los Angeles and Houston. HHS?s goal is to prevent fraudulent home health agencies from entering into the Medicare billing system. The project was announced as a response to a number of Medicare billing issues in the target cities.
Medicare has noticed that billings in these two areas have increased by as much as sixty percent and the number of providers has increased by 150%. This has apparently cased HHS to become concerned that there are unlawful agencies entering the market and billing Medicare. The announcement does not specifically state what type of fraud they are targeting, but it implies that certain home health agencies are preying upon the elderly.
It appears that the agencies are using the elderly patients Medicare numbers to bill for services that are not provided or to perform some other fraud and HHS believes this fraud is related to an increase in the number of ?illegal? home health agencies. As you can see from the project, they are especially concerned about ownership and strict compliance with Medicare requirements.
In order to combat this problem, the demonstration project will introduce a number of measures aimed at identifying illegal home health agencies and excluding them from the Medicare program. HHS?s first step is to have agencies in the Los Angeles and Houston areas resubmit their provider applications. The announcement does not make it clear if all agencies will have to reapply, but does state that agencies will receive a notice to reapply. Agencies who receive the notice but do not reapply within sixty days of receiving the notice will have their Medicare billing privileges suspended.
Providers who have failed or in the future fail to report a change of ownership or change of address will have their billing privileges revoked. Any provider whom HHS determines has an owner, partner, director, or managing employee with a felony conviction in the last ten years will have their billing privileges revoked. Any provider that no longer meets each and every one of the provider enrollment requirements will have their billing privileges revoked. Finally, any HHA that underwent a change of ownership in the last two years will be required to undergo a state survey.
While the project is initially slated in only two areas, I cannot help but focus on the phrase ?demonstration project?. Often, today?s demonstration projects are tomorrow?s regulatory practices. This practice would create a great deal of additional burden on any provider who received a notice. It will be interesting to see how they determine who has to reapply.
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I was reading another article on the new Home Health PPS and was struck by something a consultant said. The consultant was discussing the new therapy thresholds in the revised PPS system and mentioned that in his experience many agencies were not utilizing OT sufficiently. He suggested that agencies could justify higher numbers of therapy visits if they properly utilized OT.
While this may be a legitimate clinical point, the article made me a little uncomfortable. In the comments to the new PPS rule, CMS discusses that prior to the implementation of the original PPS rule, the statistical analysis they performed showed therapy visits ?clustered? at around 7. When they began analyzing data for the new PPS rule, the visits clustered around 10. Needless to day, CMS things agencies have been gaming the PPS system in order to increase their reimbursement.
Because CMS is suspicious as to the basis for the upswing in therapy visits, CMS has revised the therapy thresholds. In response, consultants are already offering strategies to ?better utilize? therapy visits, which will lead to an increase in the number of visits. This in turn would help an agency reach a higher therapy threshold and larger reimbursement. One article suggests that agencies are using 10 visits when ?they should be making 13-14? visits. While this may be true, I would be very cautious ?ramping up? therapy visits as the new PPS goes into effect.
Given that CMS has stated in the comments to the revised PPS that it believed agencies were gaming the system to increase reimbursement, I can?t help but think CMS will be very suspicious if it begins to see the number of therapy visits performed by agencies increase after the new PPS rule goes into effect. (They will be even more suspicious if your visits jump from the old ceiling to the new ceiling.) You can be certain they will examine the data from after the new PPS and they will notice a sudden increase in the use of therapy. It will be hard for the home health industry to argue that clinical practice determined a larger number of visits were always appropriate at the same time the new PPS rule went final.
In the same vein, it will be hard for agencies to say that they have been providing too few visits for years and just happened to discover this failing at the same time the therapy threshold jumped to 14. Again, I agree that in some cases this may be possible, but if the standard number of therapy visits jumps after PPS changes, OIG may very well take a long hard look at the industry.
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In this weeks issue of Home Health Line?, it is again being reported that the ?toy grouper? CMS posted to it website for use in ?estimating? the impact of the new PPS rule is flawed. Not only are the instructions unclear, but there are flaws in the supporting tables, which make the results incorrect.
A more interesting point from the article I read, and this is a sentiment CMS has expressed elsewhere, the grouper is only intended to give agencies an approximation of how the new rule will impact their reimbursement. In other words, you will have to wait until the rule is final and the new PPS system is in effect to determine how your bottom line is altered.
This strikes me as a bit unfair. The comment period for the PPS rule expires in July and, in my opinion, agencies will want to know how the new rule actually impacts their revenue before the comment period ends. They would also want to be able to more fully explore how the new PPS rule works so that they can offer more accurate suggestions on how the new HHRG, therapy threshold and other aspects of the rule should be altered to more accurately reimburse them.
Agencies that do not have accurate information may not realize, until its too late, how badly the new rule will alter their income or how CMS?s assumptions fail to consider key real world issues. Although generalizations about agency specific impacts are hard to make, it appears that reductions in reimbursement are likely to be the norm.
The same article discusses how software companies are creating their own tools to analyze the impact of this rule. Again, the discussion in the article makes it clear that the impact to each agency may be very agency specific. Factors such as your current average therapy range will determine whether or not you suffer a reduction under the rule.
The article mentioned that payment reductions also appear to result from the expansion to 153 case mix categories. The consultant who was interviewed seemed surprised by this result. Those of you who have seen my previous posts on the new PPS know that the PPS revisions appear to be, in my opinion, a concealed rate reduction. As such, you would expect the expansion of categories to reduce reimbursement.
It this ?hidden? reduction, that makes the lack of an accurate toy grouper so troubling. Unless your software company provides you with a tool to analyze your data, you may be surprised to find your reimbursement decline next year. Without information as to how the 153 categories and therapy threshold impact your reimbursement, you may find it difficult to provide clear comments to CMS about why their proposed revisions do not result in ?more accurate? reimbursement. (In other words, why the assumptions they made are incorrect.) When you do see how the new PPS results in reimbursement changes and how ?inaccurate? the new system is, it will be too late to comment. This is why it is unfair for the toy grouper to be inaccurate. Home health agencies may be denied the opportunity to provide relevant comments in the hopes of altering a massive regulation that will dramatically affect them. Seems counter to the concept of due process inherent in notice and comment rulemaking.
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So I was in Milwaukee recently a few new seminars for the Health Care Information Network and had a lengthy discussion of the proposed changes to the PPS system with Tom Williams. (You may know him as the head of Stony Hill management or as the developer of HCIN.) Tom was showing me a presentation he gave recently in Las Vegas in which he compared the home health PPS system and its history to that of the hospital inpatient PPS system.
Tom had an interesting theory regarding what these changes mean and where this is going long term. Tom believes we are seeing the hospital inpatient PPS ?playbook? being applied to the home health setting. For those of you who don?t know what that playbook is, let me explain.
When the inpatient PPS system came out, there was an allowance for what CMS considered a ?reasonable? profit margin. This margin was drastically reduced in phase two and then further reduced in phase three with the goal of ?flattening? reimbursement. In other words, fewer or smaller rate increases in the future. The belief was that the providers in an effort to keep making a profit would find ways to be more efficient (information technology, etc. in order to reduce costs and maintain some profit margin).
This means that agencies will need to find more ways to cut costs or cease operating. Of course, with home health agencies, there may be some gains in efficiency through the use of technology, etc., but a small or medium home health agency may not be able benefit from the economy of scale as much as a hospital.
Of course, the largest agencies do seem to turn a profit. These agencies serve larger areas, but they are able to turn a minor profit per patient into a larger overall profit, because of their size. This points to the potential for the Home Health PPS system to drive home health the way of hospital care ? an industry primarily composed of large multi-state ?super agencies?.
For the majority of home health agencies the reduction translates less into an incentive to be efficient (because they already have an incentive ? their margins are thin already) and more into a further reduction in already narrow profit margins. (I know, some of you would state that the margins were already so thin this is an elimination.) For the smaller agencies, this will be problematic. However, if home health reimbursement follows the trend from Hospital PPS that Tom showed in his speech in the coming years reimbursement rates will continue to remain flat (or near flat) which will eventually even hurt the larger agencies.
No matter what CMS says, operating costs always go up ? supplies become more expensive due to inflation, software licensing fees increase, rent increases, employees cost of living increases, health insurance rates increase etc. From year to year it costs agencies more to provide the same services, regardless of efficiencies. Eventually, you run out of areas to ?trim? and start seeing profit margins shrink. Even large agencies that can generate a profit due to the large number of patients they serve could see that per patient amount dwindle over time. If rates truly remain flat, agencies go out of business.
I can?t help but think, if CMS is looking long term to ?flatten? reimbursent, this could ultimately eliminate the concept of ?aging in place? (at least for Medicare beneficiaries) as there will be fewer and fewer Medicare providers available to care for them. To the extent CMS believes there are ?economies of scale? that can be leveraged as in a hospital setting, they don?t realize that many of these economies only apply to the largest agencies and even then, there is only so much ?efficiency? to be gained in any endeavor.
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There is a great deal of discussion right now about CMS?s proposed changes to the Home Health PPS. CMS has couched its discussion of these changes in terms of ?more accurate? payments to agencies. The more commentary I read about the changes, as consultants and billing experts wade through the details, the more I think CMS is using the phrase more accurate to mean lower amounts of reimbursement.
Depending upon which article you read and which client the consultants use, you see wild swings in Medicare revenue to providers under the proposed new rule. Given the ongoing struggles most agencies have to simply break even, CMS?s efforts to disguise a rate cut in terms of more accurate payments is very troubling.
Even looking at CMS?s numbers at the end of the proposed rule show wild swings amongst different categories of providers. Again, CMS touts the $140 Million in ?additional payments? it will make under the revised rule, but its statistics foreshadow a decline in reimbursement, especially for proprietary agencies.
CMS seems very concerned about the case mix averages going from 1.0 to 1.23 over the last eight years. CMS spends some time discussing how this increase is due in part to coding practices (meaning agencies gaming the system), as opposed to the actual changes in clinical need of home health patients. But then admits that only 8% of the increase is really a result of changes in coding practices. This leads one to conclude that the other 15% increase is due to changes in patients needs.
Of course, CMS appears intent on taking back the 8% in the form of a 2.75% reduction each year for three years beginning in 2008. This would offset the 2.9% increase that is proposed under the new rule. I have not seen a lot of discussion about this, but if the base payment rates is being reduced by 2.75% at the same time the market basket is being increased 2.9%, the 2.9% ?increase? is mostly offset by the takeback and the ?net? increase is a mere 0.15%.
When you combine the ?net increase? with the suggestion that the new PPS calculation system will reduce payments for many agencies, CMS is using the PPS system not to ?increase payment accuracy? as much as to effect a sweeping rate reduction without calling it a rate reduction. I imagine this reduction will further reduce the number of Medicare certified agencies as the proprietary providers realize that they will lose money trying to care for Medicare beneficiaries and move into the Private Duty realm instead.
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Yesterday, the Inspector General of the Department of Health and Human Services gave testimony to the house committee on ways and means. The testimony covered a wide range of topics related to the Office of Inspector General?s duties, but one portion of his testimony is of special interest to the home health community.
The Inspector General reiterated his offices ?long standing? concern with the accuracy of payments made to home health agencies. He stated that OIG continues to believe that CMS?s failure to adjust for ?substantial unallowable costs? claimed by HHAs in their cost reports has led to ?inflated base rates.?
He went on to outline steps OIG will be taking to evaluate payments made to HHAs. They plan to look at the accuracy of assessment form coding and appropriates and medical necessity of certain rehab services. Although he did not go into specifics, this testimony raised a red flag for me.
IF OIG feels that HHAs are receiving payments based upon an inflated base rates resulting from bad data, the result of OIGs efforts may be to correct this ?mistake.? Personally, I see how HHAs are struggling to get by on what CMS pays, but OIG seems to think you are getting paid too much. The effect of a ?correction? could be a reduction in the PPS base rate. Just one more place the government is looking at rate reductions. Practically, knowing that OIG is going to be reviewing the accuracy of coding on assessment forms and issues related to rehab services, providers should make efforts to ensure they are doing things correctly and accurately.For those hospice providers who read this blawg, the only mention of hospice was in connection with nursing homes. It should not surprise you that OIG testified that it is continuing to review the ?appropriateness of payments and care for hospice beneficiaries residing in nursing homes.? The potential for fraud and abuse in hospice-nursing home relationships is a long standing concern of OIGs.
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Last week I commented on the recovery audit contractor (RAC) experiment that CMS was performing in Florida, New York, and California. The post was spurred by an article I saw in a recent Home health line? Well, in this weeks, Home health line, the news regarding RACs is not good. In its final session this fall, Congress passed legislation that not only made the RAC process national, it applied the process to home health agencies.
Under this legislation, there must be recovery audit contractor audits in every state by January 1, 2010. In other words, you will soon see auditors coming to your agency who are paid on the basis of what they recover for Medicare. Many home health agencies feel that the survey process is premised on surveyors being trained to ?look for problems.? Well, the RAC process promises to be even worse, because the auditors are not just encouraged to look for overpayments, they are paid a percentage of any identified overpayment.
If the experience of providers in Florida, New York and California proves to be the norm, you will see more overpayment findings. This will likely lead to more appeals on behalf of agencies. You should be aware of how the appeals process works, because if you get a letter finding an overpayment based upon the efforts of an RAC, you will need to make some quick decisions.
In any administrative process, there are specific deadlines. Any request for a reconsideration/appeal must be filed within those deadlines, or the right to appeal is lost, forever. Adding to the problem is that the process for challenging overpayment determinations/recoupments is rather convoluted. There are a number of layers to the appeals process and you may have to deal with everything from a simple reconsideration up to hearing before an ALJ or even the need to file in federal court.
For these reasons, it is worthwhile to retain counsel to assist you. You will need to a lot of the work to swiftly identify records and documents that support your position regarding the alleged overpayment, but the process of filing the reconsideration request and moving the appeal through the various levels of the administrative process is something you should undertake yourself with a great deal of hesitation. As I said before, procedural mistakes are often fatal in administrative matters.
In addition, because later levels of appeal are only reviews, failing to include counsel at the beginning of the appeal process may limit your options later. If you retain counsel only as you are preparing to proceed to an ALJ, your attorney may identify additional issue or evidence that could have been helpful in the appeal. Unfortunately, but not raising these issues at the beginning, you most likely have waived them. Generally in the appeals process, at later stages you are prohibited from introducing new evidence and you are often prohibited form interjecting new issues later. (Because the later levels are not performing new hearings they are simply reviewing what the previous level did, they will not accept new evidence.)
These are things to keep in mind as we enter the brave new world of RACs. If you think an auditor is wrong, you should consider your options carefully and quickly.
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OIG issued its work plan for 2007. I have included any work plan issues related to home health in this post.
Reimbursement related matters OIG will be reviewing include, outlier payments, home health therapy, Medicaid reimbursement for home health services, and long distance physician?s claims.
OIG will also be evaluating the accuracy of the home health compare website.
Another one that jumped out at me was the evaluation of cyclical non-compliance. As part of CMS?s mandate to evaluate the quality of care provided by HHA?s, OIG will be looking at ?trends? in compliance. One of their areas of concern is whether agencies show a pattern of ?cyclical? non-compliance. In other words, do they see patterns of certain tags popping up, being fixed, and then resurfacing in a later survey. An important factor in this review will be how do they define a cycle ? once a year, once every two years, once every three years.
In conjunction with this review, OIG will be looking at the sanctions imposed on HHA?s to determine if they were appropriate. I would guess that this means they will be evaluating the penalties imposed upon HHA?s identified as cyclically non-compliant.
It will be interesting to see what OIG determines, but I can?t help but think that after the review, they will recommend stiffer penalties to agencies that demonstrate cyclical non-compliance. (Whatever they define that to mean.) How this affects providers will hinge upon how the determine a ?cycle? of non-compliance.
With my two cents out of the way, here is the excerpt.
Medicare Home Health
Home Health Outlier Payments
We will determine whether outlier payments to home health agencies (HHA) were in compliance with Medicare laws and regulations. Medicare makes outlier payments as a loss-sharing mechanism for costly cases in which the estimated cost exceeds a threshold amount for each case-mix group. We will evaluate the frequency of outliers and whether they cluster in certain home health resource groups (HHRG) or geographical areas. We also plan to determine whether the current outlier methodology is equitable to all HHAs.
(OAS; W-00-04-35107; various reviews; expected issue date: FY 2007; work in progress)
Enhanced Payments for Home Health Therapy
We will determine whether HHAs' therapy services met the Medicare regulations threshold for higher payments. We will analyze the number and duration of therapy visits provided per episode period.
(OAS; W-00-04-35108; various reviews; expected issue date: FY 2007; work in progress)
Cyclical Noncompliance in Medicare Home Health Agencies
We will examine trends and patterns in HHA survey and certification deficiencies. The Social Security Act requires that CMS survey the quality of care and services furnished by HHAs, as measured by indicators of medical, nursing, and rehabilitative care, every 36 months. We will also identify whether any HHAs show patterns of cyclical noncompliance with certification standards and whether CMS applies appropriate sanctions to noncompliant HHAs.
(OEI; 09-06-00040; expected issue date: FY 2007; work in progress)
Accuracy of Data on the Home Health Compare Web Site
We will determine to the extent to which the Home Health Compare Web site includes accurate and complete information on Medicare-certified home health agencies. The CMS maintained Web site provides beneficiaries and their families with information on all home health agencies certified by Medicare as of January 2003. We will also examine how CMS identifies and updates missing and incorrect information on the database.
(OEI; 00-00-00000; expected issue date: FY 2007; new start)
Accurately Coding Claims for Medicare Home Health Resource Groups
The review will determine the extent to which Medicare HHAs accurately code the HHRG in the Outcome and Assessment Information Set. We will also determine the extent to which providers improperly code HHRGs and the level of inappropriate payments made as a result of any miscoding.
(OEI; 00-00-0000; expected issue date: FY 2008; new start)
Home Health Rehabilitation Therapy Services
This review will determine the extent to which rehabilitation therapy services provided by HHAs were provided by appropriate staff and were medically necessary. We will determine the extent to which patients' plans of care identified the need for the amount and level of therapy they received. We will also determine the amount of reimbursement that providers received due to medically unnecessary HHA therapy.
Long Distance Physician Claims Associated with Home Health and Skilled Nursing Facility Services
We will determine if Medicare Part B long distance physician services are inappropriately billed for beneficiaries of home health and skilled nursing facility services. Previous inspections identified instances of physicians ordering or billing for services that would normally require face-to-face examination for beneficiaries who live a significant distance from the physician's office.
Medicare Medical Equipment and Supplies
Durable Medical Payments for Beneficiaries Receiving Home Health Services
We will review medical records for durable medical equipment (DME) items and supplies furnished to beneficiaries receiving HHA services to determine whether the items and supplies were reasonable and necessary for the beneficiaries' conditions.
Medicaid Payments for Medicare-Covered Home Health Services
Home health services constitute a significant portion of both Medicare and Medicaid expenditures. Medicare pays a prospective payment rate for each 60-day episode of home health coverage for a beneficiary. Most States pay for Medicaid home health services on a fee-for-service basis. This evaluation will determine the appropriateness of Medicaid payments for Medicare-covered home health services.
Identification of Potential Abusive Claims Volumes
We will analyze claims filed by providers participating in the Medicaid program to identify potentially abusive claims volume. We plan to analyze areas such as outpatient prescription drug claims, home health care services, DME supplies, and psychiatric services, to identify beneficiaries and/or providers' claims that need further review
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There has been more information on the HHABN this week. Home Health Line?s (?HHL?) September 18, 2006 issue has two stories related to HHABNs and NAHC has had two separate Q&A?s responding to member?s HHABN questions.
In all of this, the biggest piece of news is CMS stating that not only are ranges on HHABNs unacceptable, but that when issuing an HHABN relating to a patient whose POC contains ranges, that the agency must pick a frequency from the range that meets the patients needs.
This response from CMS seems to eliminate another option that has been put forward by NAHC and others ? stating a minimum number of visits on the HHABN. The theory was that as long as you met the minimum, no reduction occurred and, therefore, no HHABN was necessary. (I always assumed that CMS would eventually rule that option out.)
The discussion by the unnamed CMS staffer, as well as the examples given both require the use of a specific frequency so that when the number of visits reduces, an HHABN would be necessary. This provides a strong indication that a minimum number of visits on the HHABN or in patient communications will be frowned upon by CMS and if you are describing visit frequencies to patients using the minimum visits concept, you should be aware of CMS?s position that notice requires a specific frequency.
One of the ways to do meet the ?specific frequency requirement? is by notifying the patient in advance of specific frequencies and predict how the visits will reduce during the plan of care. Then inform the patient of your projection and document that conversation. (This method is discussed in the transmittal.) If you accurately predict the reductions, you will not need to issue an HHABN during the period. Some agencies feel that they can do this accurately, other are not certain. (Obviously, if the reductions occur other than as you predicted, you will need to issue an HHABN.)
The good news is that CMS is trying to find a way around this. The obvious way around this is to allow ranges. As HHL and others have pointed out and as CMS has repeatedly recognized, ranges are completely acceptable on the plan of care. If they are acceptable on the plan of care, there is no reason they should not be acceptable on an HHABN. It is one thing for patients to have notice of changes in their care, but a fluctuation within a clinically acceptable range of visits should not require an HHABN.
A telephone call or other notification to the patient explaining that the POC has not changed, but the frequency of visits has should suffice. The extra effort required to generate and properly deliver an HHABN, when multiplied by the vast number of POCs where the number of visits reduces within an acceptable range of frequencies makes the HHABN unduly burdensome on home health providers.
Of course, CMS is trying to work this issue out while being watched by the Court and Plaintiff?s counsel. For now, whether or not CMS?s position makes sense does not matter, the point is that CMS expects communications with patients to be in terms of specific frequencies, not ranges. Even though your POC will be in terms of ranges.
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Well today was the deadline for the new HHABN and so I felt an HHABN related post was appropriate. In the last two weeks, I have seen a lot of discussion (or was it dismay) over the issue of ranges. As most home health agencies are aware, the new program transmittal says that you cannot use ranges in an HHABN. Of course, the refusal to allow ranges creates a potential for a much larger number of HHABNs. Unfortunately, CMS has spoken and, no matter how inconvenient, ranges are not allowed in HHABNs.
There has been a number of proposals for working around this issue, because most agencies use ranges in their plans of care and because ranges would reduce the number of HHABNs an agency had to issue. In my opinion, CMS should recognize that ranges are perfectly acceptable. Any concern about meaningful notice being undermined by ranges is misplaced.
If a doctor can sign an order with ranges, (as CMS acknowledges), ranges should be acceptable on the POC. I doubt physicians will sign plans of care with wide ranges, just to save an agency from issuing an HHABN. More importantly, most state regulatory agencies limit the use of ranges. Because an HHABN could only contain ranges that are within the limits of what is acceptable on the Plan of Care, the limitations on frequencies in a plan of care further protect beneficiaries. The beneficiary may experience slight variations from week to week in the frequency of visits, but that really doesn?t mean the beneficiary needs a detailed written notice every time this results in a decrease in visits within an acceptable POC range. Nevertheless, for now, don?t use ranges in your HHABN.
One of the best suggestions I have heard is to use minimum visits on the HHABN. This creates a situation where future changes are increases. The reasoning is that because the HHABN only lists a minimum number of visits, an HHABN does not need to be issued unless the frequency of services drop below the minimum. I anticipate that CMS will disagree, but a number of people have suggested it to CMS.
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Well, I have to change the answer I posted here yesterday about Telemonitoring. Some of you may have read the e-mail NAHC sent out regarding Telemonitoring services and the use of an HHABN. Under the original instructions and guidance, the telemonitoring service required an HHABN. My discussion yesterday was based upon that original guidance.
However, after I received a copy of an e-mail from the National Association for Home Care (NAHC) I called Elizabeth Carmody to clarify the point. (I must say thank you to Ms. Carmody, for taking a few minutes out of her busy day to call me back with some clarification.)
CMS has changed its position on the use of HHABNs for telemonitoring in some circumstances. For those of you who provide telemonitoring as a free service, there is no longer a need to provide the HHABN. Under section 60.2 D of the new transmittal, if a service is never covered under Medicare and you are not going to charge the beneficiary for the service, no HHABN is necessary. This means for telemonitoring, even if it is on the plan of care and integrated with the Medicare covered care, you do not need to issue an HHABN if you do not charge the beneficiary.
However, that does not mean that all non-covered care does not require an HHABN. If you serve dually eligible clients and the client will receive care reimbursed by Medicaid, you still need to issue an HHABN upon initiation of the care. This is made clear in Section 60.2 D of the transmittal. The point is that for dually eligible patients receiving Medicaid covered care or other care that is covered by insurance, but not by Medicare, the beneficiary must receive an HHABN upon initiation of care, but not for any other triggering events, until Medicare coverage again becomes an issue..
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I could not help but start the week with one more HHABN post. During a teleconference last week, I was asked about telehealth and HHABNs. I have posted on this topic previously, but the questioner raised a point that I found interesting. The question had to do with the use of option box one to notify the patient that the telehealth service is not covered by Medicare upon initiation of the non-covered care.
The issue in this case is that most providers do not charge for telehealth monitoring of home health patients. The service is provided as a free service, because it can lead to improved outcomes. (Or at least that is how it was explained to me.) Of course, this leads to a potentially confusing situation, because the HHABN using option box one is designed to explain the beneficiary?s potential liability and then allow the beneficiary to either choose to pay for the care, refuse the care, or direct the agency to another insurance coverage.
The first think to keep in mind in this case is that if you do not intend to charge the beneficiary, you may estimate the beneficiary?s cost at $0. CMS made that point clear in the question and answer documents they published this year.
However, the HHABN does not provide a spaces to for the beneficiary to say, ?Yes, I choose to receive these free services.? Instead, they are left with the option of saying they choose to receive the services and will pay for them. The obvious concern is that the beneficiary will wonder why they have to complete any paperwork stating they will agree to pay for a service that they have just been told is free.
The key in this situation is explaining to the beneficiary that they will not have any costs from receiving this service. If you have estimated the charges at $0, you can point out to the beneficiary, that they are agreeing to pay $0.00 for the service. (You could then jokingly offer to send them a bill each month.) When the beneficiary asks why you are explaining to them the details of a free service and asking them to agree to pay for it, you can explain to them that CMS requires the form. You can then explain that CMS did not design the form to account for free services. If you carefully explain to the beneficiary that you do not charge for this service, but that CMS requires you to use the form, the beneficiary might better understand why you are doing this.
You will run into other situations where the HHABN does not seem to ?fit? the circumstances. CMS limited the number of options boxes and specified what had to be included and you will have to live with that. That is why it is important that you train your staff to carefully and thoroughly explain the HHABN to the beneficiaries. When you run into situations where the HHABN does not quite ?fit?, you will rely upon your field staff to explain the situation in a way that the beneficiary understands. Frankly, even in ?simple? HHABN situations, your field staff will need to be able to clearly explain HHABNs, otherwise you may find yourself with a large number of unsigned HHABNs.
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Well, after a great deal of waiting, we finally saw the Program Transmittal relating to the HHABN. It appears to include everything from both Q&As as well as additional details. Having just participated in two seperate HHABN seminars, I wish CMS would have issued this transmittal a week or two ago. The transmittal tries very hard to calrify when an HHABN is appropriate, and even contains a number of charts that break down the need for an HHABN by whether the care is covered, if it is in the home health benefit, and which notification provisions apply. This is far more detail than any of the previous documents CMS has issued. This illustrates the problematic nature of this whole process. More than five months into this "process" and with only a couple of weeks until the compliance deadline, we get the detailed instructions. A couple of things jumped out at me as I read through the transmittal. (Yes, I actually read it.) First, CMS says you cannot use ranges in an HHABN. This is a major change, because all previous indications were that reasonable ranges would be acceptable. CMS cautiioned providers on the use of broad ranges, but there was never any indication that ranges were not acceptable. Apparently, CMS has decided they are. Therefore, the use of ranges to avoid issuing HHABNs is not an option. The HHABN will need to state specific frequencies and when reductions occur, HHABNs may be necessary. Also, preplanned reductions, an exception in the original instructions, are clarified in this transmittal. The preplanned reductions exception now requires the reduction be part of the initial POC and communicated to the beneficiary. Reading further into the transmittal leads to the conclusion that CMS intends for this communication with the beneficiary to be through an HHABN. CMS says that if an agency is comfortable with it, the agency may provide advance notice of all triggering events to the beneficiary. (Be sure not to use ranges when doing this, even if ther are in the POC.) This advance notice would then eliminate the need for HHABN's upon the occurrence of the triggering events as outlined in the original HHABN. However, if any triggering events occurred during the period that were not outlined in the original HHABN, a new HHABN would need to be issued. In my opinion, this means if you want to rely upon the "preplanned reductions" exception, you would have to issue an HHABN upon initation of covered care. Of course, this eliminates the need to issue HHABNs for preplanned reductions, but does undermine the "no HHABN upon initiation of covered care" rule. Once again, I think the transmittal answers some questions, but I beleive it will leave beneficiaries with more questions. That is not unusual with any new regulatory requirement, as every provider is afraid of doing something wrong and with anything new like this, that fear is greater. But like every other new regulatory requirement, the new HHABN shall become familiar to you in no time at all.
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I have not read it yet, but the HHABN program transmittal has been issued by CMS. I will comment after I have had a chance to review it. You can download it from the link below.
Attachments:
R1025CP.pdf
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Well, the revised HHABN instructions were posted on Friday. I do not think they added anything that was not added in the two previous questions and answers. The new instructions do include a more detailed chart that lists a number of situations and which HHABN option box should be used in the situation. Beyond that, CMS tried to do as they indicated in previous Q&A responses ? clarify the instructions to reflect the Q&A.
Reading through the revised instructions and the two questions and answers still leaves the new HHABN unclear. For example, in my opinion, the April Q&A and the revised instructions indicate that providers do not need to provide HHABNs for reductions or terminations of non-covered care. The new chart on the revised instructions lists a series of situations and which Option box is appropriate in each case. For one type of reduction, the use of an option box is listed as ?voluntary?. My reading of this is that the HHABN is voluntary in that context. The context is services which are not Medicare benefits. In my opinion that means if you are reducing non-covered care you no longer need to issue an HHABN.
However, for something that is potentially that big, I have not seen anything really discussing this change. This is most likely because the instructions are not clear and the safest approach in the face of an unclear regulatory burden is ?overcompliance.? What I mean is, when in doubt ? give HHABNs.
In a bulletin that went out shortly after the revised instructions were released, NAHC commented on the need for greater clarity from CMS. NAHC is absolutely correct. Specifically, CMS needs to make it clear when do non-covered services require an HHABN, if at all. They could also clarify a few issues regarding reductions vs. terminations.
One area that seems to confuse a lot of providers is that you must give an HHABN upon initiation of non-covered care, but if you add non-covered services, say private pay companion care, you do not provide an HHABN upon ?initiation? of that care. The difference in these two cases is that CMS considers initiations differently from increasing services during the plan of care. A simple set of definitions (not what they put in the revised instructions, but definitions that make these distinctions clear), would help providers, because a lot of providers are using the terms, but are not clear on what they mean.
This lack of clarity reinforces the need for the promised update to the program manuals and, in my opinion, regulations. Because CMS has been reacting to a law suit, the HHABN ?update? has been moving forward in an unusual fashion. This has resulted in a very confusing implementation effort and lots of questions by providers. Furthermore, even as September 1 approaches, everybody expects that we will hear more from CMS regarding the new HHABN. The potential for more clarification has some providers waiting until the last minute to implement the new HHABN. This makes some sense, because you may better understand what CMS requires, if the manual revisions are issued before September 1.
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I have now had a chance to review the new HHABN FAQ and the new form HHABN. The FAQ contains a few clarifications.
The only new HHABN form is the Option Box 3 version. This version specifically addresses the lack of physician?s orders for care. It simply states that the services which you have indicated are being reduced or terminated are being reduced or terminated because the doctor has changed the patient?s orders. It also explains that you cannot provide the reduced or discontinued care without a doctor?s order.
The FAQ resolves a few more issues. There is an interesting Q&A regarding the use of pre-printed forms for common treatment scenarios. This is going beyond the simply pre-printing forms with your agency name and contact information and CMS?s information, but pre-printing forms for reductions that are ?routine?. This allows the agency to simply provide the patient with the appropriate HHABN, with out need to fill in only a few blanks, such as patient name and information. In this discussion, CMS mentions that you can use different colored forms to differentiate between the preprinted versions. Of course, they should still be high contrast light paper and dark ink combinations.
The Q&A reiterates that an HHABN is only necessary when a reduction in care occurs.
The FAQ does spend time on wound care, supplies, and how the HHABN should be used in those situations. There are two questions regarding the inclusion of supplies on the HHABN. One question addresses the need to include supplies that are outside the home health benefit. For example, the patient obtains the supplies themselves from the pharmacy. These supplies, which the patient has no obligation to obtain from the agency, do not need to be listed on the HHABN.
However, if the supplies are provided by the agency, say for example for wound care, these supplies do need to be recorded on the HHABN. Furthermore, if the supplies are reduced, because the woundcare is being reduced, the agency must issue an HHABN.
In discussing this issue, CMS is responding to a provider?s question. In the question, the provider asks about a reduction in wound care ordered by the doctor to the patient. The more interesting point here is that even though the doctor has informed the patient of the change in ordered care, the agency must still issue an HHABN. While I understand that the patient may not make the connection between the reduced care and the reduced supplies, it seems repetitive to have to issue an HHABN to a patient who received the ordered reduction from the doctor personally. (I know, the agency is notifying the patient of the reduction in supplies, but still. This seems like a waste of agency time and paper.)
Two more points on supplies, according the FAQ, you do not need to list the covered supplies in detail on the HHABN. At the same time, if you are issuing an HHABN upon a reduction of supplies, you must provide enough detail in the reduction HHABN to ensure the patient understands the nature of the reduction. I suppose this means you can say, do to the reduction in the frequency of your wound care, we are reducing the wound care supplies we provide you. These supplies are:.... It may not require that much, the key will be what it takes to "ensure the patient understands." One final note, if you reducing supplies as part of the normal "modality" of treatment, say for example a reduction of supplies in wound care that is normal. For example, POC orders visits for wound care and at the start includes orders for a debriding agent. As the wound heals, the debriding agent is unnecessary so the agency receive orders discontinuing the agent, but maintaining the same frequency of wound care. In this case, their is no need for an HHABN, because the change in supplies used for the same frequency of treatment is not a reduction. In other words, the frequency of visits stays the same, but the supplies used during the visit change is not a reduction. I am not sure how often this situation arises. But you should be aware of the CMS?s distinction between changes in frequency of services and modality of services.
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I have not had a chance to read it yet, but this afternoon CMS posted the new HHABN form and a new frequently asked questions to its web page. The scheduled deadline for implementation of the new HHABN is September 1, 2006. Public notice of the new proposed HHABN was published in the June 23, 2006 Federal Register. The biggest change is the introduction of a new form. This is a third option box for the HHABN that addresses the lack of doctor's orders problem. There proposed new HHABN would include a third option which will states: ?By signing below, I understand that I received this notice because my doctor has changed myorders and so my home health plan is changing. This Home Health Agency hasexplained to me that they cannot provide home care without a doctor?s order.? This is a welcome change, that most providers anticipated. The two option boxes just did not address this problem. I have not yet read the FAQ or the Proposed HHABN Notice. Check back later for more information on the new HHABN. I am posting the FAQ with this entry. Enjoy your weekend.
Attachments:
HHABNsQsandAsJune202006.doc
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Back on December 23, 2005, CMS published a new OASIS reporting regulation that is due to go into effect today. Under the revised regulation, the requirement to lock OASIS data was removed. This allowed HHAs to change their OASIS data without receiving an edit warning. However, without the lock, you would have to transmit your OASIS data before you could submit a request for anticipated payment ("RAP"). This created the potential for more frequent OASIS transmissions in order to submit RAPs. CMS has now decided to allow HHAs to continue "locking" their data in order to transmit RAPs before submitting OASIS data. CMS (after prodding from NAHC) has offered three ways to do this: Option 1 - Continue to Use Software Other than HAVEN That Locks AssessmentsIf your HHA billing software is integrated with OASIS data and contains an internal locking feature, you may continue to use that locking feature. You may continue to submit RAPs when that data is locked. If your software has not been changed in anticipation of OASIS changes, this option will mean no change to your current process is necessary. Option 2 - Continue Using HAVEN 6.2 (version 1.40) Software to Lock AssessmentsWhen your HHA receives HAVEN 7.0 (version 1.50), you may choose not to install this new software. You may continue to lock and transmit data using HAVEN 6.2 (version 1.40), submitting RAPs when the data is locked. CMS has analyzed the short term impact of HHAs continuing to use HAVEN 6.2 (version 1.40). There will be a small number of records that were previously accepted that will now be rejected due to inconsistencies among the pressure ulcer, stasis ulcer, or surgical wound items. These records can be corrected by the user and re-submitted. New warnings will be issued if the record is submitted more than 30 days after the completion date or if there is an inconsistency between the primary diagnosis code and severity code. Otherwise, these HHAs will be unaffected by not implementing HAVEN 7.0 (version 1.50) in the short term.Agencies who continue to use HAVEN 6.2 in the short term must be aware that this software does not support the submission of a National Provider Identifier (NPI). Therefore it cannot be used on or after the NPI effective date of May 23, 2007. You should migrate to HAVEN 7.0 or begin to use other software that includes a lock feature by May 22, 2007. Option 3 ? Migrate to HAVEN 7.0 (version 1.50)Upon receipt of HAVEN 7.0 (version 1.50) software, your HHA may choose to install that software. If you do so, you will need an agency procedure to ensure that all assessments are in a "Locked (Export Ready)" status before submitting the corresponding RAP. If your HHA has already made changes to your software to remove the OASIS lock date and the locking function, you should temporarily develop internal procedures for establishing that OASIS data is finalized for transmission to the State, equivalent to the prior state of being locked, before submitting your RAPs. This internal procedure should include a date the OASIS data was finalized, which could be compared to the dates of submission of RAPs in any future audit of your records. As soon as possible you should revise your processes to use one of the compliant options described above.
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