Home Health & Hospice Week

Have you adjusted your billing audit process for this requirement?

Two years have gone by since the physician service length estimate went into effect, but home health agencies continue to struggle with it. Use these tips to head off a major reimbursement drain from this fairly straightforward requirement:

1. Bust this common myth. Home health agencies and physicians alike may believe they are complying with this requirement with the recertification dates and frequency orders, notes Patti Zabell, Chief Clinical Officer with Androscoggin Home Care and Hospice in Maine. “They do not understand [the Centers for Medicare & Medicaid Services] is looking for a narrative stating the physician estimates the patient will require home health services until such-and-such a date,” Zabell says. They ask, “Doesn’t the date and frequency say the same thing?” The answer is definitely “No,” experts agree.

2. Don’t use a separate form. “The physician’s recertification estimate should be included on the recertification document along with other required elements of the recertification and not on any separate form or order,” HHH Medicare Administrative Contractor CGS reminds agencies in an Aug. 28 article about this requirement.

The requirement for the estimate statement to be included in the plan of care is good news, because it means there’s not yet another form for physicians to sign, judges Judy Adams with Adams Home Care Consulting in Durham, North Carolina. “Having the recertification statement on the recertification plan of care is less burdensome than having to get a separate statement,” Adams says. The requirement “was designed to make it easier for the physician to add this information,” she adds.

“Physicians do not appreciate getting multiple copies of orders to sign,” Zabell agrees. “Including the recertification estimate on the 485/POC alleviates the duplication of a separate document.”

Bottom line: “The more the agency can get on the 485/POC, the better,” Zabell concludes.

3. Don’t get too helpful. CMS has emphasized that the estimate must be the physician’s, not the home health agency’s. Don’t give in to the temptation to simply furnish the doc with an estimate to sign off on.

However, “the home health agency staff can collaborate with the physician by discussing their expectations for how much longer they expect the patient will need services based on the progress the patient has made,” Adams allows. “But the agency cannot make the determination for the physician.”

Why? “CMS is looking for validation from the physician that the patient requires continued skilled care,” Zabell explains.

4. Pick a route. Adams suggests two different ways to make sure the estimate statement makes it onto the recert POC.

First: HHAs may take the estimate in a verbal order, then include that estimate on the POC for the physician to sign. “If the statement is listed above the physician signature attesting to the overall certification, only one signature is required from the physician” in this scenario, Adams points out.

The pro of this method is that you’re sure you have the estimate timely. But the con is more documentation on your part. “In these situations, the communication with the physician to determine the estimated length of services must be documented in the clinical record to support that this is the physician’s determination and not the home health agency’s independent decision,” Adams stresses.

Second: Or an agency may simply include a prompt on the recert POC for the physician to fill in, such as “I estimate this patient (or insert patient’s name) will require home health services for another ______ weeks/months,” Adams suggests. Then you can place a sticky note/arrow to remind the physician that she needs to complete this statement. The pro is that you don’t have to have additional interactions with the physician about the estimate. But the con is that “if the signed plan of care comes back without the information completes, the home health agency needs to resend it to the physician asking for the flagged information to be completed,” Adams advises.

5. Utilize your software. If your software doesn’t include a prompt for this requirement, you need to ask for one. “I have two groups of clients: Those who are regularly denied for no estimated end of services and those for whom it is not an issue,” relates Julianne Haydel with Haydel Consulting Services in Baton Rouge, Louisiana. “The difference lies in their software,” Haydel maintains. Software that includes an indicator for the estimate “prompts nurses to talk to the MD about it,” Haydel says. “Software that has no such prompt allows the nurses to forget about it or forget about documenting it.”

6. Check the POC. Resolving this problem is “an easy fix going forward,” Haydel insists. “Review every 485 for recerts contemporaneously with the recert process,” she instructs. “Do not let the 485 go out without the statement.”

7. Adjust your billing audits. You can also build a check into your billing audit, Haydel recommends. “Many agencies haven’t changed their billing audits” since this requirement took effect two years ago, she cautions.

8. Focus on training. Educate staff on the specifics of this requirement, Zabell urges. Don’t stop at the nursing staff, Haydel advises — include office staff too. “It does not require a nursing license to ensure that [the estimate] is present,” she points out.

And of course, training your referring physicians on the requirement will boost compliance as well, experts say.

Note: A list of Frequently Asked Questions on recert requirements including the length estimate are at www.cgsmedicare.com/hhh/education/faqs/act/act_qa062415.html. CGS reviewed the FAQs in September 2016.