How Home Health Providers Can Avoid Payment Denials

Home Health Care News / By Joyce Famakinwa

Payment denials can be costly and time consuming for home health providers, and they’re often self-inflicted. 
 
In order to avoid this all together, home health leaders should educate themselves on the common reasons behind denials, and also adopt documentation techniques that will help their organizations stay compliant with Medicare’s coverage criteria.
 
That was the main takeaway of a recent webinar hosted by WellSky, an Overland Park, Kansas-based company that utilizes software and analytics to help providers across the continuum achieve better outcomes at lower costs.
 
One of the most prevalent claims errors is not including the signature of a certifying physician. Documentation not meeting medical necessity is another top claims error that providers make. 
 
Other common claims errors include encounter notes that don’t support all elements of eligibility, and missing or incomplete certifications or recertification documents.
 
“If you get a SMRC, or a supplemental Medical Review contractor, request for additional information, and you don’t comply … they will notify your Medicare Administrative Contractor. That can initiate claim adjustments and/or overpayment recoupment actions through their standard recovery process,” Beth Noyce, of Noyce Consulting, said during the webinar presentation. 
 
Providers are able to appeal, but this can be a lengthy and cumbersome process.
Noyce noted that providers looking to find the home health coverage and documentation requirements, in order to stay on the right side of compliance rules, should be aware that all of the information is available to the public.
 
“All of the things are published, everything’s available to you without having to spend a dime of extra money, and it’s all in the public domain,” she said. 

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CMS Finalizes ‘Fast-Track’ for Patient Appeals of MA Plan Home Health Denials

McKnight’s Home care / By Adam Healy
 
The Centers for Medicare & Medicaid Services finalized a rule Thursday that aims to expedite the process by which beneficiaries could appeal home health claims denied by Medicare Advantage plans.
 
Traditional Medicare utilizes a Quality Improvement Organization (QIO) to review fast-tracked appeals, whereas MA plans do not. Rather, the MA plan itself is responsible for reviewing appeals for denied services. In its new rule, CMS will require QIOs to also review MA appeals, which should make fast-track appeals more accessible to MA enrollees.

“CMS is revising regulations to require the QIO, instead of the Medicare Advantage plan, to review untimely fast-track appeals of a Medicare Advantage plan’s decision to terminate services in a skilled nursing facility, comprehensive outpatient rehabilitation facility or by a home health agency,” CMS stated. 
 
The rule would also “fully eliminate the provision requiring forfeiture of an enrollee’s right to appeal a termination of services from these providers when they leave the facility,” it said. These changes will more closely align MA regulations with traditional Medicare, expanding MA enrollees’ ability to take advantage of the fast-track appeals process, according to CMS.
 
The final rule will also update standards set for Supplemental Benefits for the Chronically Ill (SSBCI). New regulations hold that MA plans must be able to demonstrate that these benefits “meet the legal threshold of having a reasonable expectation of improving the health or overall function of chronically ill enrollees,” CMS said. To prove that the benefits meet all requirements, MA plans must compile databases of research to back up their claims that SSBCI can meet beneficiaries’ heath needs.
 
Finally, CMS’ rule updated MA marketing policies to protect customers from misleading advertising. Plans must now include disclaimers in all marketing materials that mention SSCBI to ensure enrollees are aware of the benefits they can access, encourage greater utilization of these benefits and “ensure MA plans are better stewards of the rebate dollars directed towards these benefits,” CMS said in the rule.

New Study Calls Home Health Star Ratings into Question

McKnight’s Home Care / By Adam Healy
 
A comparison of agency-reported functional measures and claims-based hospitalization measures raises doubts about the value of star ratings as a means of evaluating home health agency (HHA) quality.
 
The study, published Wednesday in JAMA Network Open, analyzed differences between claims-based and agency-reported outcomes for nearly 23 million patient episodes before and after the introduction of the star ratings system to compare changes over time. The researchers found that observed improvement in agency-reported functional measures had corresponding increases in hospitalization rates and less timely initiation of care. The data included claims-based hospitalization measures (both during the patient spell and 30 days after HHA discharge). Agency-reported functional measures included improvement in ambulation, bathing and bed transferring.
 
“The observed functional improvement was dampened by corresponding increases in more objective measures, such as hospitalizations and declines in timely initiation of care,” study authors Amanda C. Chen, Christina Xiang Fu, PhD, and David C. Grabowski, PhD, wrote. “This raises concern about how HHA-reported outcomes should be interpreted and used to assess quality.”
 
These discrepancies are not a surprise to home care providers. The Centers for Medicare & Medicaid Services uses Outcome and Assessment Information Set (OASIS) survey responses, an agency-reported measure, and medical claims data, to determine agencies’ star ratings. The OASIS portion is not objective, affirmed Mary Carr, vice president for home health regulatory policy at the National Association for Home Care & Hospice.
 
“The disparity in OASIS-based measures [versus] claims-based measures is not surprising,” she said in a statement to McKnight’s Home Care Daily Pulse. “Responses to the OASIS items for the functional measures can be very subjective and influenced by the accuracy of the assessor when completing the item.”
 
“And, as the author(s) noted, data does not capture more recent changes for HHAs, such as the Patient-Driven Groupings Model or nationwide expansion of the Home Health Value-Based Purchasing Model, which might contribute to changes in HHA behavior and performance,” she added. 
 
The study also found that the introduction of the star ratings was associated with sustained increases in the hospitalization rate and functional improvement measures for patients with Alzheimer’s disease, those who are dual-eligible, and those who are Black and Hispanic. 
 
A widening gap between self-reported and objective measures
 
CMS launched the 5-star rating system on Care Compare to provide summary information using the number of stars to denote quality. The system began with a quality of patient care star rating in July 2015 and added a patient satisfaction star rating in January 2016.
Since the introduction of quality of patient care star ratings, the differences between agencies’ self-reported measures of patient improvement and more objective measures has only widened, study co-author Amanda Chen told McKnight’s Home Care Daily Pulse.
“In the pre-period before the star ratings were introduced, we kind of see some of these trends,” she said. “But it’s really magnified after the star ratings were introduced.”
 
Agencies might be incentivized to inflate functional improvement scores on OASIS surveys to achieve higher scores, according to the researchers. 
 
“Once these star ratings were introduced, I think there was an incentive for home health agencies to prioritize perhaps, achieving high performance on some measures that allow them to have a higher star rating,” Chen said. “Particularly, we see these in terms of self-reported measures by the agencies. So again, it’s these OASIS-based measures. And so I think it’s a little bit easier to move the needle on measures that you’re reporting yourself as a home health agency versus something that is collected — what we’re calling a little bit more of these objective measures — like hospitalization rates.”
 
She added that these issues are not unique to home care. Other healthcare sectors that use self-reporting to inform quality measures, such as nursing homes, have also seen subjectivity influence results…
 
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Change Healthcare Attack Sheds Light on Industry's Weak Points

Axios / By Tina Reed

The expansive impact of the Change Healthcare cyberattack was a wake-up call for a health care system that's now racing to safeguard itself against another industry-rattling hack.
 
Why it matters: There's recently been increased focused on defending individual health care organizations against bad actors as the vulnerable sector increasingly finds itself under attack. 

• But the Change Healthcare hack that disrupted payments to providers for weeks revealed the industry's heavy reliance on just a few technology companies to keep day-to-day operations running.
  
  
• That essentially creates what The Atlantic's Juliette Kayyem recently described as a "single point of failure" — and experts warn Change Healthcare likely isn't the only one.

 
What they're saying: "Change is the canary in the coal mine," said Nate Lesser, chief information security officer at Children's National Hospital.

• "We need to find out where the others are or we're just going to collapse."

 
Between the lines: Experts who spoke with Axios say there are a number of companies that offer critical infrastructure to pockets of the health care industry, creating major vulnerabilities in the event of an attack.

• Companies often create that kind of market share through mergers of smaller companies that later get acquired by bigger companies.
  
  
• "There are some of these pieces of software that have just been consolidated over and over and over, and it turns out like 50,000 pharmacies, usually within hospitals, use the same piece of software," said Kyle Hanslovan, CEO of cybersecurity firm Huntress.
  
  
• The way some of those products have been stitched together along the way, potentially pairing old and new technologies, could also introduce weaknesses that are difficult to completely engineer away, he said.

 
The Change Healthcare hack also showed how contracting practices within the industry even exposed health care providers who didn't have direct relationships with the company and initially didn't expect to be affected.

• That was the case for Children's National, which discovered that some insurers it worked with have exclusive relationships with Change Healthcare and wouldn't allow for claims to be submitted through any other vendor.
  
  
• These sort of opaque agreements can make it hard for providers to know exactly where their data is being shared, said Shawntea Gordon, a member of the Medical Group Management Association's government affairs council.
  
  
• "It made it very difficult for people to just say 'OK, let me bounce everything through somewhere else,'" Gordon said.

 
Some experts said the federal government quickly needs to do a sector wide accounting to understand where health care's biggest systemic cyber risks are and address them — before hackers beat them to it.

• The Change Healthcare attack "caught us all by surprise and shouldn't have," Lesser said.
  
  
• He pointed to actions the government took in the aftermath of the 2007-08 financial crisis to designate some banks as "systemically important," making them subject to tougher oversight and standards because their failure would jeopardize the entire banking system. 
  
  
• If nothing else, the industry needs to take its own inventory to understand where catastrophic failure would be most damaging so health systems and smaller providers can better evaluate their risks and create appropriate backup plans, Hanslovan said…
  
  

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