The audit scrutiny currently seen in Home Health has identified many changes that will factor significantly into how we provide care. Many of the traditional approaches to utilization and management of services will no longer apply. The real-time effect of the recent denials will be the increased role agencies and clinicians assume as they attempt to craft and deliver care plans that meet qualification requirements in addition to helping their patients. The challenge for many caregivers will be to identify and modify areas of their programming that may inadvertently limit their care outcomes. As we alter care patterns in an ongoing manner, we are mobilized by the concern over claim denials. Home Health providers and professionals alike must realize that in the current homecare landscape, a visit made is not a visit paid.
The implications of having to provide only conscientious and efficient care, or risk non-payment for our work, clash with many of the industry protocols and management philosophies of the past. Even the most quality providers have lagged behind in the areas of quality control over the past decade. The reasons for this are many; struggles with the PPS model, staffing and fiscal challenges, a constantly changing clinical pathway, and other valid factors that confront the Home Health provider. But the primary factor in the lack of attention to quality as it relates to volume and content of care is that until now, we haven’t been required to address these areas. Most of the quality initiatives have focused on outcomes, and the level of care produced by the PPS model has always been productive in results.
Now that we must examine what our care contains in order to deliver qualified services, we are compelled to re-examine some of the approaches to homecare that may no longer apply in the audit era.
1) More visits equals more income – Denied care for many reasons has been seen in many states since early 2009, and the audits continue to spread to additional areas in 2010. These audits, by Regional Home Health Intermediaries (RHHI), deny full or partial claims, leaving the provider with no income to offset his costs of providing care. So the admission of patients to the agency no longer equates to additional income. Rather, it presents the agency with a care concern that may represent a fiscal loss if not managed correctly. The addition of un-needed visits, as defined by the RHHI, will result in increased financial losses. This has been particularly evident in the claims that are partially denied, resulting in a Low Utilization Payment Adjustment (LUPA)claim because not more than 5 skilled visits were required.
2) Non-Compliance is not Skilled – Providers and clinicians can find themselves continuing care with non-compliant patients, especially those who still show some type of clinical improvement. But when in the past we may have been able to extend the length of our programs to complete care in these instances, it will be unlikely that we can produce documentation that would allow the auditor to approve these claims. The compliant patient is required to produce a “reasonable and necessary” claim.
3) Partial Episode Payments (PEP) – Decreased utilization will result in shorter programs due to decreased payment totals. Many providers express concern that their patient programs will be “PEP’d” (a reference to other agencies opening recently discharged patients, or re-referrals to re-open the patient to service after discharge). When this occurs, agencies often experience decreased or partial payments for the initial episode. Acknowledging the problem for providers, a prudent approach would be to examine how the initial program failed to completely address and resolve care concerns. A well-crafted and focused program minimizes the PEP concern by resolving care issues; many agencies presume that this has occurred via delivered visit totals, but the actual care completion is an entirely separate matter.
4) Goals Achieved Equals Discharge – Programs that extend beyond goal achievement will experience partial denials as a result of care that is no longer reasonable and necessary. Providers who seek to assure that goals realized are permanent by performing more visits are experiencing partial denials that decrease claim totals. Extension of programming past goal achievement, for any reason, will prompt denial of care.
So as we move forward, the requirement will be to deliver skilled care that achieves the reasonable and necessary standard, and that standard has been re-defined relative to the last decade’s interpretation. The status quo homecare protocols will no longer achieve success in many aspects; care delivery, patient outcomes, and claim approval. The phrase “A visit made is not a visit paid” references the changing DNA of the Home Health model that will continue to evolve as the system, our system, experiences further refinement.
Special thanks to Arnie Cisneros, PT for supplying the article from Home Health Strategic Management’s newsletter.
