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. 

Read Full Article

CMMI’s Proposed TEAM Model Offers Another Risk-Based Opportunity For Home Health Providers

Home Health Care News By Andrew Donlan
 
Last week, the Centers for Medicare & Medicaid Services (CMS) Innovation Center announced a new proposed model that will undoubtedly affect home health providers, and also allow them the opportunity to get more involved in value-based care initiatives. 
 
The Transforming Episode Accountability Model (TEAM), which would eventually be mandatory if finalized, would have selected acute care hospitals put under full responsibility for the cost – and quality – of care from surgery up until the first 30 days after hospital discharge. 
 
CMS said that the model would build on the already existing Bundled Payments for Care Improvement Advanced (BPCI-A) and Comprehensive Care for Joint Replacement models. The proposed model would launch on Jan. 1, 2026, and run for five years, ending at the end of 2030. 
 
“TEAM would be a mandatory episode-based alternative payment model in which selected acute care hospitals would coordinate care for people with Traditional Medicare who undergo one of the surgical procedures included in the model (initiate an episode) and assume responsibility for the cost and quality of care from surgery through the first 30 days after the Medicare beneficiary leaves the hospital,” CMS wrote. “As part of taking responsibility for cost and quality during the episode, hospitals would connect patients to primary care services to help establish accountable care relationships and support optimal, long-term health outcomes.”
 
Given those all-important 30 days post discharge involved in the TEAM model, home health providers will naturally play a role in helping hospitals achieve high-quality outcomes. 

The National Association for Home Care & Hospice (NAHC) is still awaiting further details, but sees home health agencies as squarely involved in the Innovation Center’s proposal. 

“Much of the specifics are still to be decided,” NAHC President William A. Dombi told Home Health Care News. “Home health agencies can be expected to be significantly involved with the participating hospitals given the nature of the surgical patients that will be targeted, such as hip fractures and joint replacement patients.”…

Read Full Article

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…
  
  

Read Full Article

The New Frontier of Healthcare: Bringing Hospital Care Home

Health Data Management | By Fred Bazzoli

Like many “new” trends in healthcare, the hospital at home movement is not new. The foundational research goes back nearly 30 years, to work by Bruce Leff, MD, of Johns Hopkins to flesh out the concept of providing acute-level care to patients in their own homes.

It seems to harken back to the notion of doctors carrying black bags into patients’ homes to do house calls, but multiple advances in technologies and trends in healthcare have thrust hospital at home programs to the forefront.

When those pressures converge, change happens. And providing hospital services in the home is gaining new attention.

Provider Realities

From the hospital side, several factors are forcing providers to get creative. Census levels are high nationwide, often near full capacity and beyond. Staff rolls are shrinking as growing numbers of clinicians quit because of burnout or unmitigated stress. There’s not enough money to build new brick-and-mortar facilities. And then, lordy, there was the pandemic – many organizations had a crash course in virtual care, forced by restrictions on in-person encounters, full COVID caseloads and nearly instantaneous changes in reimbursement policy that enabled virtual care.

And patients – well, they weren’t big fans of being in the hospital before. The pandemic opened their eyes to the possibility of virtual care, and nascent hospital-at-home programs revealed alternatives to traditional delivery of acute care services.

As one chronic care patient told Leff in his early formulation of a hospital at home strategy, “You run a great hospital, doc, but it’s a lousy hotel.” Factor in the risks of hospital-acquired infections, falls as unsteady patients exit unaccompanied from hospital beds, loneliness and disorientation in a strange clinical environment, harried hands-on caregivers managing multiple patients and … well, it’s clear that an alternative would be welcome.

And inpatient facilities are in no position to fix these ills. Capacity is strained at many hospitals, says Colleen Hole, vice president of clinical integration and chief nurse executive for Atrium Health Medical Group. “Our hospitals are running at 110 percent to 120 percent occupancy in this market,” she says. “And Charlotte is a growing market, and we really can’t afford nor spend the time to keep building brick-and-mortar beds to manage the growth. Money and time are precious, and it doesn’t make sense to keep building beds. But we can deliver hospital-level care in the home and with the same – or in some cases, better – outcomes.”…

Read Full Article