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Home Health & Hospice Week

ABNs:

TACKLE THESE 3 TOP ABN TROUBLE SPOTS

Published on Mon Jul 10, 2006

"Reduction in services" could be clearer, agencies say.

If you're wise, you'll make the feds' "ready or not" call regarding the new home health ABNs your cue to step up training, not cower in your hiding place.

Home health agencies have their work cut out for them in the week leading up to the Sept. 1 start date for using the new home health advance beneficiary notice (HHABN), allows Judy Adams of LarsonAllen in Chapel Hill, NC.

Keep these hot spots in mind as you review your staff's ABN educational needs:

1. Change in frequency. "Reductions in services are likely to cause the most confusion for home health agencies," predicts Elizabeth Hogue, a health care attorney based in Burtonsville, MD.

Unanswered question: Most intermediaries allow home health agencies to use ranges of visits in patients' plans of care, explains Bob Wardwell of the Visiting Nurse Associations of America. But many agencies still wonder how this "real world" care-plan practice meshes with the Centers for Medicare & Medicaid Services' instructions to issue any ABN upon any reduction in service.

"If the plan of care stipulates 4-6 visits for physical therapy in a week, and you don't make six visits, does that constitute a reduction?" posits Wardwell.

Best tactic: Until CMS clarifies the issue, the best course of action is to "deliver when in doubt," say Hogue and others. Though CMS prohibits unnecessary use of the HHABN, an agency won't be faulted if it can make a case for why it delivered the form.

Point of confusion: Rather than clarify, CMS unintentionally introduces confusion in one example on how to fill in the third line of the first section of the form (i.e. Body Section): "For example, entering 'wound care supplies weekly (now to be provided monthly)' would be appropriate to describe a decrease in frequency of this nature."

The problem is "monthly delivery" doesn't necessarily mean a reduction of services, notes Hogue. The agency could simply be delivering the same amount of supplies per month on a monthly basis to cut delivery costs.

Bottom line: CMS doesn't seem to understand the complexities of home care and the relatively fluid nature of the services provided by agencies in order to avoid unnecessary care and to be cost effective, Hogue says.

2. ABNs upon recertification. Agencies were surprised in June when CMS directed them to issue an ABN for reduced services when plans of care change upon recertification. But the instructions stand.

"If reductions occur at the time of recertification, the HHA should convey that information with an HHABN," CMS instructs in Q&A #10 of the June Questions and Answers document.

Cheat sheet: Remember that no matter what, the agency must issue an ABN for a service reduction, even if it is on the recert plan of care, stresses Robert Markette Jr. with Gilliland Markette & Milligan in Indianapolis. Only service reductions included on the original, first episode POC are exempt from ABNs, he advises.

3. Option Box 1 form. HHAs face the most work when they need to issue the ABN with Option Box 1 inserted, so be thorough in training clinicians and other staff in filling out the various blanks.

One agency's concern: Is it okay to simplify the process by preprinting the appropriate language for the Step 2 blank in the body of the HHABN? Probably not, experts say.

Why? The instructions do supply four phrases that are appropriate for the Step 2 blank. In CMS' words, "If Option Box 1 is being used, HHAs should insert the most appropriate of the following phrases in the Step 2 blank in the body of the HHABN:

• will not provide you (if choosing Box 1 below)
• will no longer provide you (if choosing Box 1 below)
• believe Medicare will not provide you
• believe Medicare will no longer provide you."

The catch: An ABN preprinted with either of the first two phrases could be construed as steering the beneficiary unfairly to Box 1, which states in part, "I don't want the items and/or services listed above," advises Wardwell.

Don't make this mistake: Agencies can invalidate an ABN if they "pre-select" for beneficiaries one of the three beneficiary-choice boxes on the Option Box 1 form.

Double whammy: Invalidating an Option Box 1 form means more than noncompliance concerns: HHAs also loose their ability to seek payment from a beneficiary if they provide care that winds up not being covered by Medicare.

Bottom line: Home health managers must carefully monitor HHABN compliance, particularly in the transition to the new form.

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