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News Roundup: October 7, 2016

A New Model For Aging At Home: Care Management — Every Step Of The Way

Published by The Huffington Post
By Hany Abdelaal, DO
October 7, 2016

The vast majority of older Americans, 90 percent of them, want to age at home. Many have lived in their homes for decades, where they are surrounded by the familiar — from photos on the wall to shops on the street — and can visit or receive visits from family and neighbors. Today, there’s no reason anyone should have to compromise on this wish for their later years. Thanks in large part to the growing popularity of Managed Long Term Care (MLTC) health care plans, we now have the ability to keep even the sickest elderly patients stable and comfortable at home.

MLTC plans do this by coordinating all the various elements of an older person’s care in a responsive and collaborative fashion, taking into account his or her psychosocial as well as physical well-being. They make sure doctor’s appointments are made and kept; arrange necessary home care services from visiting nurses, home health aides, social workers and behavioral health counselors, as well as speech, occupational and physical therapists. They also connect people to community resources such as transportation and support organizations focused on vision impairment and other special needs. They support family caregivers and educate each individual to better manage his or her own health as well.

The MLTC program offered by my company, VNSNY CHOICE Health Plans, provides members with an entire array of services that are overseen and revised as necessary by a nurse care coordinator/manager who is attentive to all the details, large and small, of each plan member’s daily life. In addition to what we typically think of as home care, such as visits by a home health aide, the nurse care coordinator coordinates with interdisciplinary team members to ensure that medical treatment plans are being followed and behavioral health needs met. The care coordinator makes sure a support system is in place, prescriptions are being filled, and medications are being taken properly, and, on the most basic level, checks that there is enough food in the refrigerator.

Deepening Partnerships, Advancing Care
In this remarkably comprehensive and human way of thinking about care, we are always looking at where, in the day-to-day life of our members, we can improve their health and wellbeing. Recently, we stepped up efforts to collaborate with their physicians to identify potential gaps in care and ensure that the medical treatment of at-risk members is being coordinated effectively.

As a first step in this process, we are identifying members who have gaps in recorded health data for conditions such as asthma, diabetes or cancer. We then reach out to the physicians treating our members to review data and prescribed care protocols. “This keeps us all on the same page and makes sure no health needs are being overlooked,” explains Dr. Lisa George, Medical Director for CHOICE.

We also touch base with physicians on other aspects of members’ care, including any pharmacy issues, such as difficulty filling prescriptions and taking medication as prescribed, as well as health conditions that might have been addressed by the physician without being fully noted in the member’s medical record. “For example, a doctor might treat an MLTC member for a bronchial infection without noting that the member’s underlying emphysema was also addressed, or check on a patient’s diabetes management without recording that the patient was also treated for a diabetic foot wound,” Lisa says. “By assessing the member’s disease burden more accurately, we’ll be able to do a better job of improving their care and ensuring appropriate reimbursement for better results.”

Home Is Where the Care Is
As healthcare reform across the country seeks to lower costs of care while increasing quality and access, New York State has adopted Managed Long Term Care as the best system to help the most vulnerable, at-risk elders age in place. Almost all of our members are eligible for nursing home care but would rather live at home. So, we bring the care to them, no matter the level of need or the medical complexity.

Through this approach, we’re able to help MLTC plan members like Mr. G live at home — despite the fact that he needed dialysis four days a week and, because of his size, had trouble navigating the flights of stairs in his apartment building. Through his care coordinator and other members of his interdisciplinary care team, we arranged transportation for him to and from treatment, assisted him with the stairs, and advocated for him to be moved into a first-floor apartment.

With other members, we’ll make sure critical behavioral health issues are attended to. “I deal a lot with depression, schizophrenia, and other psychiatric conditions,” says Grace Owen, a social worker who assists our MLTC members. Frequently, she’ll administer depression screens over the phone then connect members to additional services as needed. “I also help members and their family caregivers navigate Medicare and Medicaid, make sure their prescription drug plan is in place, and arrange things like food stamps or housing,” she says.

Providing support and resources for caregivers is another vital component of MLTC. For another one of our social workers, Sandra Thomas, a simple phone call about a 96-year-old member’s Medic Alert bracelet led to an extensive counseling session with the member’s daughter, who is in her 70s. “The mother wasn’t sleeping well, and the daughter was exhausted trying to care for her in the night,” says Sandra. She gave the daughter educational materials and a link to a support group. “The entire family is our member,” she says.

Many of New York’s most vulnerable elders are now enrolled in one of the state’s new integrated managed care plans for individuals dually eligible for Medicare and Medicaid. Under these plans, they receive help in obtaining wheelchairs and other equipment, from simple shower grab bars to items as complex as a Hoyer lift. In our own MTLC plan for dual eligibles, we maintain a 24/7 member service customer care hotline for participants, and our social workers help support members with housing issues by linking them to community resources.

Most importantly, our MLTC interdisciplinary care teams are in continuous touch and are consistently focused around the goals of the participant. How do we know? We ask. We recently enrolled a 79-year-old member who was virtually bedbound from a combination of arthritis, congestive heart failure and diabetes. With the help of her interdisciplinary team, she established a set of daily goals, and her MLTC case manager checks in by phone periodically to reinforce these goals. Meanwhile, her home health aide comes in daily to make sure she eats a good breakfast, takes her medications, and gets up and moving.

One person at a time, one day at a time, and one integrated, collaborative system at a time, we are creating a city, state and nation where people can fulfill one of life’s simplest but most profound wishes: to grow old, safely and comfortably, in their own home.

How Home Health Can Ace the Updated ICD-10 Codes

Published by Home Health Care News
By Mary Kate Nelson
October 7, 2016

Big changes are coming to ICD-10 this October, and home health providers need to be prepared.

The extremely large code set was first implemented in the majority of states about a year ago, to the dismay of many home health providers across the country. Then, in June, the Centers for Medicare & Medicaid Services (CMS) added just under 2,000 new codes to ICD-10, as well as revised approximately 400 codes and deleted around 300 codes. This latest round of ICD-10 changes is scheduled to take effect when the FY2017 code set takes effect on October 1, 2016.

In order to ride out the change successfully, there are certain things all health care providers should keep in mind, according to Jennifer Gibson, RN, a certified coding specialist who conducts trainings for Dallas-based home health software vendor Axxess. Gibson shared some last-minute tips for providers with Home Health Care News ahead of the Oct. 1 ICD-10 FY2017 start date:

1. Every coder must have an updated 2017 Code Book or Code Set. “With the thousands of changes to excludes notes, code additions and deletions, it is impossible to code accurately with an outdated code set or code book,” Gibson tells HHCN.

2. Health care providers should guarantee that their software vendor is prepared for the change, and that codes are available based on the date of service. “For example, codes that were deleted in the updated 2017 version should not be available for use before October 1, 2016,” Gibson says. “Likewise, codes that were in the 2016 version and deleted in the 2017 updated set should not be available to choose or enter on or after October 1.”

3. Coders and providers should expect a temporary drop in productivity due to a lack of familiarity with the new code set and guidance. “It will simply take a bit longer to code with the newer set,” Gibson says.

A great coder, Gibson adds, knows that coding is a two-step process: starting in the Alphabetic Index, and then checking the Tabular List to finish the code and to search for associated guidance and conventions. “This is most important as you are navigating through thousands of changes,” Gibson says.

4. Providers and their coders should be mindful of the changes to the updated 2017 Official Guidance for Coding and Reporting. There are several changes that will start October 1, 2016, including new guidance that clarifies the use of the word “with,” Gibson explains.

“This new guidance states ‘with’ should be interpreted to mean ‘associated with’ or ‘due to’ when it appears in a code title, the Alphabetic Index, or the Tabular List,” she says. “New guidance goes on to state that the classification presumes a causal relationship between the two conditions linked by these terms in the Alphabetic Index or Tabular List.”

These conditions should be coded as related, even without provider documentation that explicitly links them, except if the documentation clearly says the conditions are not related, according to Gibson.

“For example, when we first started using the ICD-10-CM code set, we were told that diabetes could not be linked with any other conditions unless the physician or provider explicitly linked the two conditions,” Gibson explains. “Due to the new guidance above, the classification presumes a causal relationship between diabetes and all the conditions listed in the alpha index following ‘with,’ such as Charcot’s, neuropathy, and many more diseases. However, Osteomyelitis is not listed after diabetes “with,’ and thus the classification does NOT presume a link between diabetes and osteomyelitis. Therefore the physician or provider MUST link these two disorders in order for the coder to code osteomyelitis as a manifestation of diabetes.”

Home Health Provider Helps Slash Hospital Readmissions by 60%

Published by Home Health Care News
By Tim Mullaney
October 7, 2016

A home health provider has helped a hospital reduce readmissions of highly at-risk patients by 60%, through a program that relies in large part on community health workers.

Like other hospitals around the country, University of Maryland St. Joseph Medical Center (UMSJMC) has been looking for ways to cut its readmission rate, given that payments are being tied to this metric. As part of that effort, the 232-bed nonprofit hospital just north of Baltimore has been seeking out new partners to help coordinate care across the continuum.

It found such a partner in Maxim Healthcare Services. Based in Columbia, Maryland, the company provides home health, medical staffing, and other services nationwide.


“I think our conversations with the hospital really focused on a different kind of approach,” Maxim’s Vice President of Government Affairs and Product Development Andrew Friedell told Home Health Care News. “One model was to bulk up your typical home care services and look to provide more [of them]. I think we really looked at it from the beginning that the traditional services weren’t working for this patient population, and so we needed to look at what really had to be addressed.”

The patient population in question was one at high risk of readmission based on four factors: psychological factors (anxiety/depression/personality disorders, etc.); social determinants (housing, lack of transportation, etc.); medical comorbidities (such as having hypertension and diabetes); and poor functional status (difficulty with activities of daily living). All the UMSJMC patients who faced risks in all these areas and were being discharged home were candidates to participate in the program that launched in February 2016.

That program involves a visit from a nurse practitioner while the patient still is in the hospital, to begin formulating a post-discharge plan of care. That plan is further refined by a registered nurse who visits the patient at home shortly after discharge. A community health worker (CHW) then gets involved to help with the execution of the plan, particularly with regard to overcoming barriers such as lack of transportation to follow-up physician appointments, Friedell explained.

While all the CHWs make sure there’s a primary care physician in place for the patient, and that the patient has a way to get to a follow-up appointment within the first 14 days at home, beyond that they are providing a variety of case-specific services. For instance, they might be enrolling a patient in an addiction counseling program, or meeting a patient at the supermarket to help shop for nutritious foods, or helping the patient get involved in Meals on Wheels or similar services, Friedell said.

Addressing the psychological factors and social determinants that often cause readmissions separates this program from others, Friedell believes. Others support the view. The strong relationship between these factors and health—both at an individual and population level—is a notion supported by theory as well as empirical evidence, says Steve Du Bois, Ph.D., a clinical psychologist and professor of psychology at Adler University in Chicago. Du Bois teaches the course Social Determinants of Mental Health.

“Programs that emphasize and address these systemic factors, such as continued access to health care, transportation, and health education, likely will facilitate not only acute recovery but also long-term health and well-being,” Du Bois tells Home Health Care News. “Psychology, public health, medicine, and more fields—we’re all understanding more deeply the impact of social determinants.”

So far, it appears that the Maxim program is adding more evidence to support the importance of a multidimensional approach to risk identification and interventions. Maxim and UMSJMC have data through May 2016. In that period, the program involved about 1,800 patients overall. It has driven the readmission rate down for this patient group by more than 60%.

It’s difficult to attach a cost savings to that reduction, Friedell said, because there’s not a control group to compare against. The provider organizations are keeping track of readmission trends to measure success.

A workforce opportunity

While the program is saving money in the form of reduced readmissions, implementing it did come at a cost, including hiring community health workers. Startup costs were covered by the hospital, which viewed this program as an investment, Friedell said. Still, the nurse practitioners, RNs, and community health workers involved all are on Maxim’s payroll.

Home health providers that want to be attractive hospital partner may think about creating a CHW workforce of their own, even if they have to bear the costs themselves. In fact, there’s a tremendous opportunity to develop this workforce across the industry to help drive down costs while improving outcomes, and it’s an area that Maxim is focused on, Friedell said.

However, there are some impediments to developing a CHW workforce, which Maxim noted in a recent white paper prepared with Leavitt Partners.

“Despite CHWs’ increasing use and support, the workforce remains fractured, and there are still many challenges to overcome,” the white paper states. “Training is inconsistent, qualifications vary, and funding mechanisms are few.”

States are starting to address some of these barriers, such as through training/certification standards. But providers that are incorporating CHWs into their workforce may find few models to emulate, and will in effect be creating their own templates for what this role entails and who best fulfills the duties.

It may be possible to find current caregivers who are good candidates to become CHWs, but there are important distinctions between, say, a care aide and a CHW that agencies need to keep in mind, Friedell said.

One major distinguishing characteristic of a good CHW is that he or she is highly engaged in the community and has strong connections there. That not only means that the community health worker will be aware of different resources available in the area, but will have the credibility in the local area to be able to connect patients with the needed services. It also should help the CHW forge a strong bond with patients.

“Part of it is that they come from the communities they’re engaged with, so they’re embraced by and trusted by the patients,” said Friedell. “That’s the value they have, that they relate to the patients and develop a bond with them, while there [may be] barriers between patients and other caregivers.”

In addition to considering the CHW’s community relationships and patient interaction skills and duties, a provider bringing in these workers should consider the organizational structure needed, the white paper advises. This includes training, clinical oversight, team participation, and methods of evaluation.

Lawmakers Urge CMS to Halt Pre-Claim in Illinois

Published by Home Health Care News
By Amy Baxter
October 7, 2016

In the aftermath of a pause on the the pre-claim review demonstration (PCRD) elsewhere, lawmakers in Illinois – where the demonstration has been ongoing since August 3 – have asked for a delay in the Prairie State, as well.

In a letter to Andy Slavitt, acting administrator at the Centers for Medicare & Medicaid Services (CMS), Rep. Tammy Duckworth (D-IL), U.S. Sens. Dick Durbin (D-IL) and Mark Kirk (R-IL) and the entire Illinois Delegation asked PCRD to be delayed in Illinois. Home health agencies have reported high non-confirmation rates for their pre-claim submissions, burdensome and time-consuming administrative demands and inconsistent results since the demonstration got underway. Recently, federal legislators also took a stand by introducing a bill in Congress that would put a one-year moratorium on PCRD.

“Seven weeks into the PCRD, the experience of this pilot in Illinois has resulted in severe burdens on patient access to care and provider capacity,” the letter reads. “We urge CMS to delay further implementation of the PCRD in Illinois, which CMS has already announced they will do for other states.”


The lawmakers noted that while the demonstration is aimed at preventing fraud, the current model is still too burdensome and puts patients in jeopardy. The letter also cited the 60% to 80% rejection rates being reported by home health care agencies in the state.

“We remain concerned that implementing the PCRD as presently structured, and without sufficient education and training, jeopardizes the delivery of care to needy beneficiaries,” the letter says. “Illinois’ experience under the PCRD has been alarmingly burdensome for home health providers, which is harming patient access to care.”

Lack of education has been a key factor in the rollout in Illinois, where home health agencies have reported that getting a physician’s signature earlier in the care process for pre-claim obligations has been challenging. During its delay for Florida, Texas, Massachusetts and Michigan, CMS has since stated that it will double down on education efforts for providers to understand their requirements.

Prior to sending the letter, Illinois lawmakers said they were collecting more information on the impact the demonstration was having on home health agencies and patients. Lawmakers sent a letter in April, prior to implementation, over their concerns the model could have negative effects.

“Efforts to improve Medicare program integrity are critical to the fiscal future of our country,” Sen. Kirk said in a statement. “These reforms must happen in a way that ensures accurate information to patients while not jeopardizing their care.”

Programs keep elderly in homes, with options

Published by Chicago Tribune
By Nancy Coltun Webster
October 7, 2016

Helen Murzyn said she just came from the Bureau of Motor Vehicles.

Though her driver's license wouldn't have expired until November, the 87-year-old said she geared up for renewal a few months ago and figured she should go early and avoid potential bad weather.

"I'm fine with driving," she said and added that while she doesn't like expressway driving, she's not afraid to drive. She was concerned about the renewal and wondered "what are they going to tell me? Because of my age."

Now with her new license in hand, Murzyn is among the 5,568 adults 85 years old or older who have a license in Lake County. About 1,600 adults older than 85 have a driver's license in Porter County. For seniors, a license to drive is no small thing.

Transportation along with nutrition, personal safety and home maintenance are just four critical issues facing senior citizens in their efforts to maintain an independent lifestyle, according to Jennifer Malone, chief operating officer of Northwest Indiana Community Action in Crown Point, a member agency of the state's Inconnect Alliance. The group brings together all resources for aging and disability. Inconnect, in effect, rebrands the state's Aging and Disability Resource Centers.

"Everywhere, universally, people want to stay in their own home and be as independent as possible. The Aging and Disability Resource Center is meant to be a single point of entry. You don't have to be low income to call 211," Malone said.

According to the U.S. Census Random Samplings blog from July 2015, people over age 75 are more likely to live alone than they did in 1967.

There has also been a steep decline in seniors choosing to live with other relatives. This is especially true for women 75 and older. "Today, almost half these women live alone," according to the report.

"What the baby boom population is facing is the increasing number of people with home/community-based support service needs," said Malone. "Persons over age 85 are the fastest growing population. Not all can afford to privately pay for assisted living. Our goal is to keep people independent safely. We are living in a time when family members aren't living in the same communities anymore."

Program for All-incluse Care for the Elderly

Murzyn said she has one child who lives in the area and the others live away. She still lives independently in her own home and does her own shopping, housework and laundry. She gets help with cutting the grass and snow shoveling, because she said her children did not want her do that type of work.

But those people who can't drive, are not getting regular meals because they can't get to the grocery and face daily dangers of falling or worse in their own home, can turn to community support services. NWICA or Porter County Aging and Community Services (PCACS) offer referrals for a variety of home-based services, door-to-door transportation, congregate meal sites and more. Some seniors attend group luncheons at churches and area social services organizations. Some receive home-delivered meals.

Bruce Lindner, executive director for the PCACS, a not-for-profit social service agency, works with the elderly, disabled and low-income residents. Among its various services PCACS operates seven buses for its eligible clientele.

Lindner said the organization provided about 20,000 one-way trips over the past year, but "we need more buses. We need more money for drivers, fuel, etc. We have to turn people down."

Lindner's organization also provides farmers' market vouchers to seniors so they can purchase fresh fruit and vegetables from local farmers' markets.

A restaurant voucher program funded through the Older Americans Act is available through the Greater Hammond Community Services as a way to diversify from the senior center-style meal programs, said Melissa Bohacek, communications manager for NWICA. The program aims to help the elderly do a better job of diversifying their diet.

Murzyn uses the restaurant vouchers and said the program provided her with a life line back to her normal routine after her husband died six years ago. They were regulars at a Highland restaurant on Highway Avenue that is now the location of Maritza's Cafe.

"My husband and I used to come here," Murzyn said. At first she didn't want to go back to the restaurant. But when she saw her restaurant on the voucher list, she decided to go. "I got out and I was with people. The social part helped."

Murzyn has been staying active and connected. She leads chair exercises on Wednesday morning at the Our Lady of Grace senior program in Highland. "I'm more physically fit than most of the people my age," Murzyn said. "I still bowl. There's other people (bowling) as old as me. I'm not the only one."

And yet, there are a number of seniors in Northwest Indiana who wish to remain independent but are in need of services to help them remain in their homes.

According to a feasibility study for the Indiana Family and Social Services Administration by Myers and Stauffer LC there are 104,007 adults over the age of 65 in Lake, Porter and LaPorte counties. Of those, 8,571 are 65 and older with self-care difficulty and 16,240 are 65 and older with independent living difficultly.

The study analyzed populations around the state to determine feasibility for Programs of All-Inclusive Care for the Elderly (PACE), comprehensive medical and social services for frail, elderly individuals eligible for Medicare or Medicare along with Medicaid. The program is meant to permit participants to remain in the community instead of receiving care in a nursing home.

Franciscan Health opened Indiana's first PACE program in 2015 and is preparing to open its second program on its Dyer campus in mid-November to serve Lake County residents. The opening date is dependent on licensing status and staffing. A future program is in the works for Porter County, officials said.

The goal of the PACE program is to give people a chance to live in their homes in the community as long as medically and socially feasible, rather than become confined to a long-term care facility, according to Laurie Matthys, a registered nurse and senior health and wellness center manager for Franciscan Health in Dyer.

According to Matthys, Franciscan will refer to its PACE program in Northwest Indiana as Franciscan Senior Health and Wellness to avoid confusion with the Pace transportation service in Illinois.

The program brings together home health care, personal care, prescription medication services, social services, audiology, dentistry, optometry, podiatry and speech therapy, respite care, hospital and nursing home care along with door-to-door assisted transportation.

While most of those served by the all-inclusive care program are dually eligible for Medicare and Medicaid, Matthys said Franciscan Health will also serve individuals who are Medicare-eligible and able to privately pay monthly premiums equal to the current Medicaid-approved amount.

The setting offers a day room with spacious windows looking out over the Dyer campus green space and walking paths. Participants are given a locker where they can keep belongings such as a coat, a favorite blanket, incontinent supplies or other items. They can eat prepared meals in a group setting and participate in social activities. Other smaller rooms are available for TV viewing or sitting quietly to read or socialize. Participants can opt to use the bathing facilities equipped with a zero threshold shower and a call button for emergencies.

"Let's say you can't get in the bathtub at home. You can come here and bring your stuff," Matthys said. "Here they can pull an alarm. There's someone outside the door listening for them. The elderly would love to take a shower without fear of falling."

For now, Murzyn, who will turn 88 in November, is head of her own household. She finds housework boring, but said she is able to get it done. She continues to drive herself to the doctor, church and the grocery store. Though the subject hasn't come up yet, she said she knows her children would help her, if she needed them to do so. In the meantime, she's maintaining a positive attitude.

"I think we all need to keep an eye on our diet, stay social, stay physically active and to look at life optimistically," Murzyn said.

Nancy Coltun Webster is a freelance reporter for the Post-Tribune.

Resources for elderly

Northwest Indiana Community Action staffs the 2-1-1- Information Assistance call center for Lake, Porter, Jasper, Newton, Starke and Pulaski counties. Individuals in all counties can call the number 24 hours a day, seven days a week to speak with a trained NWICA staff member for information and referrals.

Porter County Aging and Community Services offers a variety of services and referrals including door-to-door transportation for county residents and Medicare counseling. Contact PCACS at 219-464-9736.

Greater Hammond Community Services offers a variety of services for seniors including the restaurant voucher program. Restaurants are located in Highland, Hobart and Whiting. It also offers a Lawn Care Program for low and moderate income elderly and disabled Hammond residents. For information call 219-932-4800.

Home Health Medicare Pre-Claim Review: The Good, the Bad and the Ugly

Published by Home Care
By Carolyn Dean
October 7, 2016

The Pre-Claim Review Demonstration, a recent Medicare home health pilot program from the Centers for Medicare & Medicaid Services (CMS), is one of many new requirements that home health agencies across the country could have to adopt depending on the outcome of recent actions being taken by industry organizations, stakeholders and Congress to extend the delay or withdraw it altogether. Created to enforce a more proactive oversight strategy on Medicare home health coverage in an effort to reduce fraud and abuse, the pre-claim review’s pilot phase was to begin with implementation in Illinois, Florida and Texas in 2016, then Michigan and Massachusetts in 2017—all states with soaring fraud, abuse and over-spending rates.

But since the Illinois implementation in August, the National Association for Home Care & Hospice (NAHC) has described the demonstration as “a complete mess,” after impacts in the pilot state are reportedly “highly negative” and “rife with problems.” These adverse reports prompted Florida Senators Ben Nelson (D) and Marco Rubio (R) to push for a delay in Florida implementation—the next state set to begin the demonstration on October 1. After urging for a delayed expansion “until CMS, stakeholders and Congress have the opportunity to evaluate and understand the impact of the demonstration in Illinois,” CMS announced an indefinite delay on pre-claim review while they focus education efforts on how to submit pre-claim review requests, documentation requests, documentation requirements and common reasons for nonaffirmation.

While the next pilot states are on hold for now—CMS will announce further expansion with at least 30 days’ notice—the demonstration remains in effect in Illinois. And as NAHC and other stakeholders continue the fight to suspend Illinois’ pre-claim review mandates, many agencies in other states are worried CMS will instead resume expansion.

The Good
The intent of the demonstration is good and meant to ensure home health services are funded by Medicare only when criteria for service coverage is met. When successful, this would result in the reduction of improper payments and the cost of additional documentation and resources it takes for CMS to chase them.

According to CMS, the demonstration, “Will test improved methods for identifying, investigating and prosecuting Medicare fraud occurring in Home Health Agencies (HHAs) while maintaining or improving the quality of care provided to Medicare beneficiaries.”

Also, according to CMS, the good news is, there are no new documentation requirements with pre-claim review. HHAs are to submit the same claim supporting documentation to support the Medicare home health benefit as they do now during random post-claim review audits.

But are these changes working?

The Bad
The bad news is that claim reviews are reportedly 40 to 50 times their normal volume—resulting in Medicare Administrative Contractors (MACs) losing electronically submitted documents, incorrectly denying claims and delayed pre-claim affirmations potentially causing providers to postpone care; however, this is not CMS’s intent. CMS is very clear that pre-claim review is not a prior authorization process in that the pre-claim review occurs after the home health services have begun but prior to the final claim submission.

But these are not the only common complaints since the demonstration has gone live. Below is a list of problems that have become a shared frustration among Illinois providers.

No reasons are given as to why some claims get approved and others get denied
Denied claims get re-submitted and approved without any changes made
CMS sends a letter to Medicare beneficiaries informing them of denied claims, causing confusion and fear. The letter also reflects poorly on the agencies, as beneficiaries do not understand the mandated process
Medicare beneficiaries who opt out of home health services due to the CMS letter will likely increase hospital readmissions—resulting in poor customer satisfaction scores in value-based purchasing initiatives
Large, publicly traded providers will likely be able to weather pre-claim review while smaller providers may not—due to non-affirmed claims slowing down cash flow
Delays are lasting between four and seven days
Each submission is extremely cumbersome and time-consuming
Nonaffirmation rates of up to 80 percent have been cited
While “only about 20 of the roughly 900 agencies in Illinois have shared their data and pre-claim review experiences,” the Illinois Homecare & Hospice Council (IHHC) urges others to join the fight. But just because you want to contribute to the end of pre-claim review, does not mean you should stop participating. If providers in Illinois choose not to adopt this new pre-claim review process, final claims submitted for payment will undergo medical review and if approved, will be paid at a 25 percent reduction after a three-month grace period.

The Ugly

The pre-claim review demonstration enforces an increased burdensome process on all Medicare fee-for-service episodes with potential monetary penalties that impact all home health providers in the demonstration states regardless of whether they are “bad actors”
The existing post claim review audits already show that a major contributor to high claim denial rates is due to incomplete physician face-to-face and other certification documentation
A recent CMS proposed rule issued in July is looking to address the tremendous backlog of appeals pending before administrative law judges’ (ALJ) (over 750,000 cases and rising). Under the pre-claim review demonstration program, all appeal rights remain unchanged
CMS provided additional funding to hire more contractor staff to accommodate the increased volume of claims to be reviewed during the demonstration program
This raises the following question:

Why should a demonstration program that is looking to fix a problem for a specific target population implement a solution that:
Penalizes all agencies, when data exists to target more specific populations
Increases the home health agency burden for submitting claim supporting documentation, but also maintains the same underlying failed documentation requirements (i.e., physician F2F clinical encounter note) and review processes that have already been proven to not work during post claim review audits
Enforces an audit on all home health claims with existing failed documentation requirements that risks the probability of increased ALJ appeals when the proposed rule is looking for ways to reduce them
Spends additional money to implement a demonstration with the same requirements that do not work during post-claim review
Are We Targeting the Wrong Problem?
As for those in the other four states hoping CMS abandons this demonstration altogether—stay positive, stay educated on the latest information, and support NAHC in their efforts to call upon Congress to oppose this chaotic program. Despite the outcome, however, it is best to be prepared and implement appropriate processes to ensure the required documentation to support Medicare HH coverage is received accurately and timely for all patients.

If you have not already, you are going to have to improve upon and streamline some processes to stay relevant in these changing times. You will need to have processes in place that ensure continuous cash flow by having tracking mechanisms for obtaining required documentation earlier, and quality review processes to ensure the documentation is comprehensive and accurate.

To ensure accurate and timely documentation (of which much can be automated), see below for suggestions:

The tracking receipt and review of the actual F2F clinical encounter note used by the certifying physician can justify the referral and medical necessity for HH services
Ensure HH generated records that corroborate the physician documentation have been signed, dated and incorporated into the certifying physician’s medical records
Check tracking and review of OASIS visit documentation and Plan of Care (POC) content for accuracy and consistency
Review tracking and receipt of the signed and dated POC from the physician
Review tracking and receipt of the signed and dated physician’s certification of patient eligibility
Review and verify that medical record documentation exists to satisfy Medicare’s two requirements for “Confined to Home”
Has it been thought that maybe there are other alternatives to combatting fraud and abuse?

NAHC and other industry stakeholders believe there are other alternatives and are happy to help find the right alternative solutions. Join in the fight with NAHC, Congress and other industry stakeholders by contacting your representatives and urging them to stand with the 3.5 million Americans who depend on home health services AND support the Pre-Claim Undermines Seniors' Health (PUSH) Act.