Home Health & Hospice Week

7 steps for using this essential benchmark to avoid throwing thousands of dollars down the drain.

Many home health agencies are claiming more SCICs than they should, and losing big bucks as a result--are you?

First, HHAs must determine if a significant change in condition has occurred clinically. Then, the agency can calculate whether claiming the SCIC is fi-nancially beneficial--if it's not, the HHA usually does not have to claim it. 

Warning: Agencies often claim the SCIC even when it loses them money, experts warn. That's either because they don't know how to calculate the SCIC payment properly or don't realize they don't have to claim a money-losing SCIC except in rare cases.

The stakes: And billing unnecessary SCICs can be a costly affair, warns consultant M. Aaron Little with BKD in Springfield, MO. One BKD client lost about $80,000 by doing so, only recovering the money with the consultants' help.

Cost report data analysis shows an average SCIC-adjusted episode pays about $300 to $600 less than a non-SCIC-adjusted episode, Little says. And the cost for an unnecessary SCIC can rise to as much as $3,000 per episode, he warns.

Little offers these tips to help you figure out if you're losing money on unnecessary SCICs:

• Compute your SCIC stats. Two figures are important when benchmarking yourself against SCIC norms, Little tells Eli: (1) your total percent of billed SCICs and (2) your average SCIC episode payment versus your average episode payment overall. The average episode payment overall should include all episodes, including SCICs, PEPs, etc.

HHAs can compute these figures from their costs reports, Little notes. Or some agencies' software systems may offer them more up-to-date SCIC data.

• Compare your stats to benchmarks. Al-though it's not surefire, you can be pretty certain you're claiming too many SCICs--and throwing away hard-earned dollars--if your percent of billed SCICs is higher than the norm, Little advises. He puts the average SCIC amount at 2 to 3 percent.

Likewise, you can compare your average SCIC episode payment to your average episode payment overall. If your SCIC episode payment is lower, you're probably losing money by claiming unnecessary SCICs, Little warns.

"The intent of the SCIC adjustment is to allow additional payment when a patient's condition declines," Little urges. "The typical SCIC-adjusted episode should pay more on average than the other episodes." That's true despite the rare cases where the agency has to claim an unfavorable SCIC when a patient's condition unexpectedly improves, he adds.

More information: HHAs that want a more specific SCIC figure to compare with can look to benchmarking reports, such as the one offered by Eli Research and BKD, for specific benchmark figures for the nation, their provider type, their local area, and other specific pools.

• Investigate your SCICs. If your billed SCIC percentage is higher than average or your average SCIC episode payment is lower than your overall episode payment, it's time to delve deeper into the issue.

First, you should identify the SCIC episodes that are still open for reimbursement adjustment under Medicare's timely billing rules, Little counsels. Right now, those are episodes that ended on or after Oct. 1, 2004.

• Review SCIC accuracy. Once you gather your eligible pool of SCICs, you should review them for accuracy. Make sure they were profitable. Or ensure prospective payment rules really required you to bill them anyway.

"The key consideration is what happened with the case-mix weight," Little explains "If it increased but the SCIC paid less than it would have without the SCIC," it's probably time to rebill to correct the error.

• Adjust faulty SCICs. For SCICs you billed in error, adjust the claim to remove the SCI--and get back your rightful reimbursement.

• Set SCIC policy going forward. If you find you continue to bill a number of unnecessary SCICs, you need to either revise your SCIC decision-making policies or to educate staff on them, experts advise.

Red flag: While you don't want to be over the SCIC average without justification, you also don't want to be at the other end of the spectrum.

"If an agency discovers there were no SCIC adjustments billed, that could be a problem," Little warns. "Start investigating by questioning both the billing and clinical staff as to what their process is once a SCIC is identified. It's possible there is not a clear process, which would explain why none have been billed."

Timeline: HHAs should benchmark their vital stats, including SCICs, at least annually, Little recommends. Quarterly or monthly is even better, he says.

Note: For information on Eli's 2006 Home Health Operations Dashboard, which includes the agency, local, regional and national benchmarks discussed in this article, call 1-888-779-3718 x326 or email dashboard@eliresearch.com.