CMS Issues Home Health Claims Processing Fix

NAHC Report

The Centers for Medicare & Medicaid Services has issue Change Request 13684 that provides instructions to the Medicare Administrative Contractors (MACs) to ensure home health claims submitted more than 24 months from the date of admission are not returned in error due to Notice of Admission records being purged from the Fiscal Intermediary Shared System (FSS).

During the processing of a Home Health (HH) prospective payment system claim, the claim is matched to the corresponding Notice of Admission (NOA) to determine the NOA receipt date. The NOA receipt date is then used to apply any applicable late NOA penalty to the claim payment. The NOA receipt date is stored in FISS in the HRAP (Request for Anticipated Payment) file). If an NOA receipt date is not found in the HRAP file, the claim is returned to the provider with reason code 19963.

Previous instructions stated where a corresponding NOA cannot be found and the claim From date is 24 months or more after the claim Admission date, the contractor shall send the claim Admission date to the HH Pricer in the RECEIPT DATE field.” In these cases, the NOA is assumed to have been received in the past and subsequently purged. However, a claim may have a From date within 24 months of the Admission date but a Through date that falls after 24 months. In these cases, the claim cannot be processed because the NOA will be purged.

This CR revises the criteria for reason code 19963 to send the claim Admission date to the HH Pricer in the RECEIPT DATE field in these cases also. Several home health agencies have reported a significant number of claims impacted by this issue claims and have had to rely on intervention by the MACs.

Home Health Certifying Provider Change

NAHC

The MACs have issued [the following] article titled, “Home Health Certifying Provider Change.” The article outlines CMS' policy regarding the requirements for a certifying practitioner to authorize a change in provider at recertification, regardless of the reason for the change. We have some concerns and questions regarding the instructions and are seeking clarification from CMS. We will keep the membership updated as we learn more.   

[Article Posted on CGS’ website]

Home Health certifying physician or nonphysician practitioner (NPP) changes can occur anytime for a variety of reasons. Some examples may include practitioner retirement or vacation and patient choice.

Regardless of the circumstance, if the recertifying physician or NPP is different from the certifying physician or NPP, home health agencies (HHAs) are required to document in the medical record indicating they have ensured a different physician or NPP has been authorized to care for (including recertifying and signing the plan of care) the original certifying physician's or NPP's patients in their absence.

For example, if "Dr. A" signed the initial certification and "Dr. B" signed the recertification, the HHA should ensure and document that this has been authorized by "Dr. A"; however, there does not need to be written or signed documentation from the physician or NPP.

There is no designated format or form that must be used to show the change in provider. Documentation can be anything from the HHA that shows the HHA has confirmed the change(s) in certifying physician or NPP. HHAs are encouraged to include any documentation that support attempts to contact the original practitioner when changes occur.

Reviewers will confirm that all elements of the certification are included in the documentation sent for the recertification claim review. If the submitted certification documentation (submitted with the recertification documentation) does not support home health eligibility, the claim associated with the recertification period will not be paid.

Without Proper Post-Acute Care Relationships, MA Plans Are Leaving Money on The Table

Home Health Care News | By Andrew Donlan

Health plans generally do not have great visibility into their members’ care after an acute health event. Even when they do, many aren’t confident in the post-acute care provider that’s serving their member.

These findings come from a new survey of health plans conducted by the post-acute care technology company WellSky.

Specifically, the survey found that:

• Only 37% of respondents (health plans) manage members in a post-acute setting after discharge from acute care. The majority attempt to manage care internally rather than partnering with vendors or other post-acute networks.
  
  
• Just 33% of respondents reported that “the majority” of their members are discharged to “high-performing” post-acute care facilities.
  
  
• 43% of respondents expressed “moderate confidence” that their members receive the appropriate level of care post-discharge.

The health plan respondents – which were Medicare Advantage (MA) plans – ranged from those with 115,000 members to those with over seven million members.

“These findings reinforce what we continue to hear from payers regarding how important it is for MA plans to have greater visibility and proactive influence into their members’ discharges to ensure they are being sent to not only the right level of care, but to high-performing post-acute providers for a member’s specific conditions,” Andy Eilert, president of payer and emerging markets at WellSky, said in a statement. “This will help plans achieve lower total cost, enhanced quality of care and improved member outcomes.”

This is noteworthy information for home health providers, who are trying to negotiate on higher ground with MA plans. Quality home health care can reduce the Medical Loss Ratio for health plans. If those plans don’t have much visibility into where their members are getting post-acute care – in other words, lacking solid partnerships – or are having members use subpar providers, that leaves room for opportunity.

Home health providers that can establish relationships with MA plans, where they can take a certain number of patients in a given market, can negotiate for better rates or a better payment setup than they currently have.

That, in turn, can help bridge the gap between MA’s rates for home health services and traditional Medicare’s rates…

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Neuroscientists Discover Brain Circuitry of Placebo Effect for Pain Relief

Neuroscience | By University of North Carolina Health Care

The placebo effect is very real. This we've known for decades, as seen in real-life observations and the best double-blinded randomized clinical trials researchers have devised for many diseases and conditions, especially pain. And yet, how and why the placebo effect occurs has remained a mystery. Now, neuroscientists have discovered a key piece of the placebo effect puzzle.

Publishing in Nature, researchers at the University of North Carolina School of Medicine—with colleagues from Stanford, the Howard Hughes Medical Institute, and the Allen Institute for Brain Science—discovered a pain control pathway that links the cingulate cortex in the front of the brain, through the pons region of the brainstem, to cerebellum in the back of the brain.

The researchers, led by Greg Scherrer, PharmD, Ph.D., associate professor in the UNC Department of Cell Biology and Physiology, the UNC Neuroscience Center, and the UNC Department of Pharmacology, then showed that certain neurons and synapses along this pathway are highly activated when mice expect pain relief and experience pain relief, even when there is no medication involved.

"That neurons in our cerebral cortex communicate with the pons and cerebellum to adjust pain thresholds based on our expectations is both completely unexpected, given our previous understanding of the pain circuitry, and incredibly exciting," said Scherrer. "Our results do open the possibility of activating this pathway through other therapeutic means, such as drugs or neurostimulation methods to treat pain."

Scherrer and colleagues said research provides a new framework for investigating the brain pathways underlying other mind-body interactions and placebo effects beyond the ones involved in pain…

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