Home Health & Hospice Week

Know the rules when it comes to coverage, or lose your hard-earned reimbursement.

Follow this expert advice to head off medical necessity denials:

1. Read the manual. The Medicare Benefit Policy Manual (Pub 100-02) Chapter 7 is your Med-icare coverage bible, and you should know it practically by heart, experts agree. Consultant Lynda Laff with Laff & Associates in Hilton Head Island, S.C. also recommends reading the Medicare Claims Pro-cessing Manual (Pub 100-4) "to better understand the rules and criteria for billing." HHA billing is covered in Chapter 10 and hospice billing in Chapter 11. Links to the manuals are online at. www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.

2. Understand homebound doesn't equal automatic coverage. A patient must be homebound to qualify for the Medicare home care benefit, but that isn't the only requirement, cautions Chicago-based regulatory consultant Rebecca Friedman Zuber. "Many agencies don't understand that just because a patient has a chronic condition and is homebound, doesn't mean they are automatically eligible for nursing Observation and Assessment," she laments. "If that is the only skilled nursing service being provided and the patient is stable for three weeks, you have to have a really good clinical reason (supported by the physician) to believe that they will not be able to maintain stability in order to keep them on service." (For more about O&A denials and tips for avoiding them, see Eli's HCW, Vol. XXI, No. 17).

Problem: "Agencies will pair Observation and Assessment with Teaching and spend each visit reviewing one of the patient's medications -- regardless of how long the patient has been on the med and how impaired they may be cognitively," Zuber says. "Patient is stable, loves the attention, and the agency wants to stay in because the patient is still homebound, regardless of the fact that there really is no skilled need."

3. Train on coverage. To avoid scenarios like those, it's not enough for HHA managers to understand the coverage criteria themselves. They also must then train their assessing clinicians on them, experts urge.

4. Supervise service delivery. After training staff on coverage criteria, managers then need to make sure staff follow through and apply them. Agencies need to "implement appropriate quality review activities and processes to ensure that all patients on service actually qualify for services," Laff advises. That will include ensuring that you have sufficient resources to oversee clinical care delivery.

Try this: Laff recommends a primary (field) nurse clinical model. Under that set-up, each nurse case manager must be able to "clearly identify with measurable indicators and/or specific clinical evidence how each patient meets home health criteria at admission and ongoing through the episodes."

5. Use case conferences. You can make sure the primary nurse can justify the patient's eligibility by using a one-on-one case conference process, Laff offers. Under that system, clinicians review each patient at specific intervals.

Note: CGS's CERT article is at http://cgsmedicare.com/hhh/pubs/mb_hhh/2012/06_2012/index.html#004.