Home Health & Hospice Week

Reviews will hit in 4 months.

If your claims aren’t in tip top shape face-to-face-wise by August, you could pay big under a new medical review initiative.

On its website, the Centers for Medicare & Medicaid Services briefly reviews the new F2F requirements contained in the 2015 final rule, then announces that it “will conduct pre-payment reviews of home health claims for episodes beginning on or after August 1, 2015. CMS contractors will conduct these reviews using a Probe and Educate strategy.”

Target: “The purpose of this Probe and Educate process is to ensure that HHAs understand the new patient certification requirements,” CMS says.

Timeline: “Because home health episodes have a 60-day certification, CMS anticipates the first documentation requests will be sent on or about Oc-tober 1, 2015,” it says. “CMS contractors will conduct these reviews … through an end date to be determined.”

The reviews, which may occur at every HHA in the country, could catch agencies by surprise. HHAs have generally been glad that CMS yanked the much-reviled physician narrative as of Jan. 1. But a new requirement took its place, CMS reminds agencies in announcing the new medical review. The 2015 final rule requires home health agencies “to obtain documentation from the certifying physician’s and/or the acute/post-acute care fa-cility’s medical record for the patient that served as the basis for the certification,” CMS says. “Home health agencies should obtain as much documentation from the certifying physician and/or the certifying acute/post-acute care facility as they deem necessary to substantiate that the home health patient eligibility criteria have been met.”

Remember: “Home health agencies are required to provide this documentation to CMS upon request,” CMS emphasizes.

HHAs may get a hint of what’s to come by looking at the “probe and educate” reviews CMS imposed for hospitals regarding the controversial 2 midnight rule, notes reimbursement consultant M. Aaron Little with BKD in Springfield, Mo. (See details of that initiative, p. 155).

The National Association for Home Care & Hospice “recommended that CMS implement a period of test audits prior to issuing claim denials related to the F2F encounter requirement,” the trade group says. “Hopefully, CMS will ensure adequate education is provided prior to denying any claims related to [an] F2F encounter.”

But just because CMS includes “educate” in the description, doesn’t mean the probe won’t include denials. Under the hospital initiative, Medicare contractors denied all claims that didn’t meet the applicable criteria. They just furnished explanations of why they denied them.

Little will be surprised if Medicare Admini-strative Contractors review all the claims, as they did for hospitals. MACs most likely won’t have the re-sources to review claims from every HHA in the country, due to the large number of agencies.

However, CMS might elect to have Supple-mental Medical Review/Specialty Contractor Strategic Health Solutions conduct such review of every HHA in the nation, under the probe and educate initiative. SHS performed a similar review last year, Little notes (see Eli’s HCW, Vol. XXIII, No. 15).

Stay tuned: CMS did not respond to questions about the program by deadline. On its website, the agency says it “plans to provide additional de-tails and information on the Probe and Educate pro-cess shortly,”

Probes Will Often Lead To More Review

HHAs don’t know many details about the program yet. But it’s a good bet that if your MAC or other contractor finds problems with your initial claims for face-to-face, you’ll get hit with a whole lot more scrutiny over your F2F practices.

Under the hospital P&E program, MACs selected 10 or 25 claims per hospital to review, based on size. Then they gave hospitals a grace period to fix systemic problems related to billing. At the end of the review period, if “continuing major concerns are identified, MACs will select 100 claims (for providers with 10 sampled claims) and 250 claims (for providers with 25 sampled claims) for additional review,” CMS says in a MLN Matters article about the procedure.

Take action: You’ve got less than two months to go until the review period starts. Take that time to shore up your policies and practices under the new F2F rules, experts advise. (For resources to bone up on the rule, see box this page.)

Honing your F2F skills may include adopting the new F2F form CMS has furnished (see Eli’s HCW, Vol. XIV, No. 16).

However, industry experts fear that even the best F2F practices still may result in denials under the P&E program.

The intermediaries may not be consistently applying the F2F requirements, rues Chicago-based regulatory consultant Rebecca Friedman Zuber.

“The MACs have been giving webinars on F2F and have done a poor and confusing job of explaining it,” contends finance expert Tom Boyd with Simione Healthcare Consultants in Rohnert Park, Calif. “Providers who have listened to them were not happy nor felt they were instructive.”

“What is going to change with this new review?” Boyd asks. “Rarely, if at all, has any of the MAC staff worked in home health care or even seen a patient.”

CMS’s instructions on the topic are not helping, Boyd insists. For example, the review notification points out that agencies should acquire the documentation they “deem necessary” from the phy-sician. “Nothing like vague instructions and giving the MACs authority to second guess, as always, the decisions of the providers,” Boyd tells Eli.

Bottom line: “The ones who need educating are really CMS and clearly the physicians,” Zuber maintains.

Note: See CMS’s announcement at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Medical-Review/Home_Health_Medical_Review_Update.html