Home Health & Hospice Week

Avoid Friday and Saturday notice deliveries for questionable cases.

Warning: Your requirements under new termination notice and expedited review rules could hang you if you don't know the ropes.
 
The Centers for Medicare & Medicaid Services will require home health agencies to deliver a termination notice every time a beneficiary's Medicare services come to an end, the agency said in the Nov. 26 Federal Register (see Eli's HCW, Vol. XIII, No. 43, p. 338). Then beneficiaries can appeal the termination, receiving a decision under an expedited 72-hour timeframe.
 
The deadlines under expedited review, which will start in July, will be tight, notes consultant Judy Adams with the LarsonAllen Health Care Group in Charlotte, NC. That will leave HHAs no room for error.
 
When a beneficiary elects expedited review, the Quality Improvement Organization contacts the agency the day after it issues the first-step, generic termination notice.
 
Once contacted by the QIO, the HHA must issue a second, more detailed notice to the beneficiary explaining the reason for termination by the end of the day, CMS spells out in the final rule. And the agency must forward all relevant records to the QIO that day as well.

Industry Protests Timeline

That timeline has the industry up in arms. "The one-day turnaround ... does not appear to be practical or workable," criticizes Ann Howard with the American Association for Homecare. The timeframe may be "impossible" for some agencies to meet, Howard insists.
 
"The turnaround time to submit all of the relevant documentation to the QIO ... seems unrealistic and needs to be revised," charges Patrick Conole with the Home Care Association of New York State.
 
A same-day turnaround simply doesn't give agencies sufficient time to respond, agrees Mary St. Pierre with the National Association for Home Care & Hospice.
 
And if agencies can't meet the timelines, the punishment will hit them square in the wallet. The QIO can delay the decision until it receives the agency's documentation - and the agency has to continue and pay for services for that period. That will be a financial burden, notes consultant Pat Sevast with American Express Tax & Business Services in Timonium, MD.
 
Or the QIO may overrule the agency's termination decision, CMS indicates. That could put the HHA on the financial hook if the intermediary later denies the claim.

Beware Weekend Notices

Generating and delivering a detailed notice and sending records to the QIO all during one day will be hard enough during the week, St. Pierre points out. If the QIO's message about the expedited review goes astray - into an absent worker's voice mail box, for example - the timeline is shot, Sevast notes.
 
And having to deliver a same-day detailed notice will almost certainly mean an extra, non-covered visit to the patient, St. Pierre laments.
 
But on the weekends, meeting the deadline could especially difficult, St. Pierre predicts.
 
HHAs generally don't have staff to handle such responsibilities on the weekend, Sevast notes. To maintain such staff would place a major burden on agencies, Howard adds.
 
Even if you have a supervisor on call for such situations, she might not be able to gather the relevant records in time, Sevast warns. The involved nurse may be out of touch for the weekend and the record may not yet be updated, for example.

Protect Yourself By Thinking Ahead

There will be one way to cut down on these weekend emergencies for expedited review, Sevast suggests: Don't give termination notices to risky cases on Fridays or Saturdays.
 
HHAs should have a pretty good idea of which beneficiaries are likely to elect expedited review, Sevast expects. The expedited review rules for agencies require a patient to obtain a doctor's certification saying her health will be put at risk by the termination. Thus, it's likely that most patients electing review will have a doctor's order that the agency doesn't agree with.
 
With these types of patients, agencies tend to do some case conferencing or management meetings about the situation, Sevast says. As part of these meetings, agencies should plan on delivering termination notices Monday through Thursday, she suggests. That way, an expedited review notice would be received during the work week.
 
"Agencies will need to maximize their planning time, and try to give impending discharge notices in advance of the two-day time frame to avoid having these requests come through on weekends," Adams instructs.
 
While the rule requires the first notice's delivery on the next-to-last visit, it doesn't prohibit agencies from giving out the notice earlier than that, Sevast says.
 
In risky cases, agencies might want to document their decisions and assemble supporting evidence for them ahead of time, counsels attorney Mark Langdon with Arent Fox in Washington, DC. Responding to the QIO request quickly will be less burdensome "if the HHA has assembled the necessary evidence and other paperwork before making the non-coverage decision," Langdon tells Eli.
 
Agencies should be "in a position to defend their actions if necessary," he says. 
 
Editor's Note: The final rule is at www.access.gpo.gov/su_docs/fedreg/a041126c.html.