January 14, 2015

Be Prepared: Patient Eligibility Must Support Home Health Claims

By Thomas Gangemi, PT, DPT, MBA

The Recovery Auditor (RAC) and U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) 2015 work plans will focus on compliance with patient eligibility criteria, which must support home health claims for services. 

The OIG will also be looking to verify that home health agencies (HHAs) conduct timely criminal background checks for all employees and contractors, as well as agency owners. They will continue to scrutinize certain business activities such as compensating physicians for certifying plans of care. They will also look for arrangements in which HHAs provide discharge planning and home care coordination services to hospitals, and situations in which they contract with senior communities with the intent to induce referrals. Connolly, the new home health RAC, will monitor RAP-only claims and incorrect billing of PEP claims.

Modifications to the face-to-face rule represent new challenges to home health agencies. They must now rely even more on other groups and entities to have documentation completed to ensure that it will support the agency’s claims. It is vitally important that agencies provide education and support to their certifying physicians, and that they collaborate with them to ensure that proper documentation exists and is readily available when requested.

The Centers for Medicare & Medicaid Services (CMS) has provided good examples of acceptable documentation for a few different scenarios in its publication “Medicare Learning Network Special Edition 1405." 

In addition to enforcing the face-to-face requirement, RACs will be focusing on adherence to all patient eligibility criteria for home health services, including homebound status, documented and continuously supported need for skilled services, that the patient be actively under the care of a physician for the condition for which they are receiving services, and that there is a plan of care established and reviewed by a physician that defines the scope of services to be provided.

Medical necessity will continue to be scrutinized. The certifying physician must document why the services are medically necessary, but the HHA’s clinicians can supply much of the relevant information, which physicians can incorporate into their patient records to establish medical necessity.

Documentation of the need for skilled services is required not only at the start of care, but with every individual encounter between the patient and a qualifying professional. Each visit note must clearly illustrate the skill performed and tie it directly to the plan of care and the physician’s orders.  Furthermore, a problem identified in the OASIS must be addressed. Providers must clearly describe what the clinician did, why it was a skilled service, and what the patient’s response was.

On a very positive note, the change in the therapy reassessment rule is welcome news! However, do not let your guard down in monitoring reassessments. The new requirement of a reassessment by each rehabilitative discipline at least once every 30 days will make the process easier and less punitive. There will still be a need to limit costly omissions.

Be certain that the new rules are implemented for cases with a start-of-care date on or after Jan. 1, 2015. For cases started prior to Jan. 1, the old rules remain in effect. This may be tricky if your software revisions cannot accommodate both rule sets.

Spend time wisely when it comes to assessing your processes. Provide adequate and accurate education and training on an ongoing basis so that all of your staff and your community partners are adhering to all of the requirements. Pay particular attention to how your electronic health record (EHR) presents the facts. If every visit looks the same or if clinicians fail to paint themselves into the picture, there is a chance that your documentation will not support the need for the services provided.

I am sure that over the next few months we will hear more from Connolly, and we will keep you informed.

About the Author

Thomas is a physical therapist with 36 years of experience. He has been the founder of Rehab Agencies and outpatient therapy practices in multiple states. Tom has developed clinical protocols and compliance criteria for local, regional and national therapy providers and home health agencies. He currently provides consulting services in areas of program development and Medicare compliance.

Contact the Author

tgangemi55@gmail.com

Comment on this article