Home Health & Hospice Week

CERT reviews turn up problems proving skilled need for home health patients.

More reviewers than ever are poring over your claims, and home health agencies are vulnerable on a key point -- medical necessity.

Lack of medical necessity was among the top denials for home health agency claims in the latest Comprehensive Error Rate Testing (CERT) results, notes HHH Medicare Administrative Con-tractor CGS in its June newsletter for providers. Medical necessity denials can be particularly pain-ful financially, since reviewers then can deny the entire episode instead of just downcoding its case mix category.

Example #1: One CERT case focuses on a diagnosis MACs have been running edits for, hypertension. For this HTN patient, "no blood pressure parameters were noted in the plan of care (POC), and there were no changes to the Coumadin dosage," CGS tells providers. "Documentation supported that the patient was stable with no changes in diagnosis, medications, treatment plan of care, and there was little risk of exacerbation." Medicare recouped payment in full for the episode.

Example #2: "The primary diagnosis was cellulitis," CGS says. "Documentation noted that an abscess was unchanged in 6 months, there were no signs/symptoms of infection, no falls were noted, and there was no new or changed medications or treatments." Again, Medicare recouped payment in full for the episode.

"The CERT findings are very, very accurate as to what agencies are seeing, and unfortunately accurately reflect what I find when I audit records," says consultant Lynda Laff with Laff & Associates in Hilton Head Island, S.C. "There are many agency administrators, directors and owners who just really do not know the rules."

Not understanding medical necessity and other basic coverage criteria has always been troublesome for HHAs, says Chicago-based regulatory consultant Rebecca Friedman Zuber. But the problem has gotten worse due to infrequent claim review under the home health prospective payment system, she believes.

"Since the HHPPS system was initiated, home health providers pay insufficient attention to the coverage requirements," Zuber tells Eli. "They really don't understand how Medicare defines skilled care in the home health benefit, and believe that because they get an episode rate they can provide more or less whatever services they want, at least until the patient gets in the car and drives away."

Bottom line: Many agencies these days have "a lack of understanding and acceptance of the Medicare coverage requirements," Zuber concludes.

Even when agencies understand coverage criteria, they may still court denials because the criteria are open to interpretation. "Denials for medical necessity and homebound status [are] difficult," says Betty Gordon with Simione Consultants in West-borough, Mass. "They are both somewhat interpretive and can be argued."