Home Health & Hospice Week

Recent documentation change in budget law amounts to no change, experts say.

With Targeted Probe & Educate audits ramping up, the home health Recovery Audit Contractor applying its first home health audit topic, and other Medicare contractors zeroing in on home health claims, it's time to make sure your documentation can withstand scrutiny on multiple fronts.

Good news: Denials of home health claims in the Comprehensive Error Rate Testing program have dropped by nearly half in the last few years. The Centers for Medicare & Medicaid Services reported a 59 percent payment error rate for 2015 home health claims and a 42 percent rate for 2016. But earlier this year, the 2017 CERT report put the home health error rate at 32 percent (see Eli's HCW, Vol. XXVII, No. 4).

Bad news: The 32 percent rate is still higher than the average 9.5 percent rate for all Medicare providers. And home health payments continue to be viewed as a major Medicare risk area (see Eli's HCW, Vol. XXVII, No. 9).

Certification is a big medical review target for Medicare contractors, and particularly the face-to-face physician encounter requirement. Recovery Audit Contractor Performant recently announced "Documentation and Medical Necessity" as its first home health audit topic approved by CMS. Part of the problem is that the documentation requirements for home health claims are riddled with flaws, industry veterans contend.

For example: When CMS eliminated the reviled F2F physician narrative in 2015, agencies cheered. But the replacement is worse in some ways - basing certification determinations on the referring physician's or facility's documentation only.

Inadequate documentation by physicians is "substantially outside the agency's control," notes Joe Osentoski, reimbursement recovery & appeals director for QIRT in Troy, Michigan (although there are steps HHAs can take to combat the problem - see story, p. 76).

Despite vigorous education efforts, "even after all this time, I rarely ever see an encounter document from a physician that is inclusive of all the required narrative content," notes clinical consultant Pam Warmack with Clinic Connections in Ruston, Louisiana.

"Any time a directive is not specific, there will be poor compliance," notes clinical consultant Anna Doyle with McBee Associates in Hilton Head, South Carolina. That "has most certainly been the case with F2F documentation," Doyle tells Eli.

Don't Assume Reviewers Will Use The New Option

HHAs are hopeful that a provision included in the Bipartisan Budget Act of 2018, enacted last month, will ease their documentation woes. The language would allow Medicare to use HHA documentation to help support the certification (see box, p. 75).

But the language that says Medicare can use HHA documentation instead of must use it may render the change useless. "If it remains 'may' instead of 'shall,' then I really see little functional difference or improvement," Osentoski laments.

Under the law, "we must continue to do what we currently do," Warmack judges.

Some agencies may opt to risk it, notes Beth Noyce with Noyce Consulting in Salt Lake City. Agencies will "choose whether to continue acting as if the qualifying documentation must be in the physician or facility record for the patient."

HHAs may favor switching to the new option if their HHH Medicare Administrative Contractor says it will take advantage of the ability to use HHA documentation in reviews. But those agencies may be blindsided when other contractors or authorities come in with a different review standard, Warmack warns.

Danger: If the documentation standard remains optional, "I fear audit bodies like the RAC may not even make an attempt to apply the HHA documentation," Warmack says. "Since they are paid on a contingency basis, would it be in their best interest to do so?" (Performant is paid 8 percent of its recoveries.)

The same could happen if auditors from the Unified Program Integrity Contractor, HHS Office of Inspector General, Government Accountability Office, etc., hit your doorstep.