Home Health & Hospice Week

Know when to hand off ABNs to frontline staff--and when not to.

It's crunch time for home health agencies implementing home health advance beneficiary notices, with the June 1 due date looming large.

The National Association for Home Care & Hospice dispensed practical advice on getting up to speed on the new ABNs in a May 9 teleconference.

"The kindest way to put it is that the ABN is a burden" for HHAs, William Dombi, vice president for law with NAHC's Center for Health Care Law, noted in the conference.

"It just seems like there could be an easier way," laments Beverly Kelley, Georgia regional director of operations for Guardian Home Care. While keeping patients informed of changes is good, the ABN is an overly complicated--and possibly ineffective--way to do it, Kelley tells Eli.

Watch out: And ABNs seem to get more complicated by the day. HHAs that were relieved to see the Centers for Medicare & Medicaid Services restrict HHABNs to home care services only in a recent question-and-answer set will be disappointed that CMS is backtracking on that exemption.

CMS told agencies "the revised HHABN in-structions do not apply to services outside the home health benefit, such as when HHAs are acting as [durable medical equipment] suppliers, or possibly administering therapy plans of care to non-homebound beneficiaries," according to Q&A #20 of its recently released 25-question set on the new ABNs (see Eli's HCW, Vol. XV, No. 18).

But CMS has told NAHC it made a mistake in that answer and will correct it soon. "In fact, the HHABN is required" for DME and outpatient therapy, NAHC's Mary St. Pierre instructed listeners.

Other guidance NAHC offered in the teleconference included:

• Who makes the ABN call. While HHAs are ironing out their ABN policies and procedures, they should consider one important wrinkle, St. Pierre urged--who completes the ABN when physician orders disagree with the change in care.

Agencies generally can train their visiting staff to accurately determine when ABNs are necessary and fill out the notices when a physician orders the change, she advised. But when the care plan change goes against physician orders and the beneficiary may appeal, agency management should take over and decide when to issue and how to fill out the ABN, she urged. That's because the agency could end up being financially liable for the patient's care.

Try this: Providers also should have management approve ABNs that use Option Box 2, where the agency decides to reduce or terminate services for its own financial or business reasons, rather than Option Box 1, which applies to non-coverage situations, St. Pierre counseled.

• Physician orders. When the physician orders a reduction or termination in care that wasn't on the original plan of care, HHAs must issue the ABN with Option Box 1, St. Pierre reminded listeners (see Eli's HCW, Vol. XV, No. 18). That's true despite the fact that Option Box 1 tells patients they can continue services if they will pay for them.

"We know there are serious problems with Option Box 1," St. Pierre said. Right now the best way to head off beneficiary confusion is to explain in the "because" section of the ABN that the agency can't continue services without physician orders.

Armed with that information, beneficiaries can call their physician, try to get him to issue orders and, if so, pursue an appeal, St. Pierre notes. "The idea is to give the beneficiary the best choice."

• Recert ABNs. Agencies must issue an ABN even when physician-ordered changes are in the recertification care plan. If the change is not on the initial start-of-care care plan, an ABN is required, St. Pierre confirmed.

Timing tip: HHAs can issue such ABNs either when the physician gives the order to reduce or terminate care, or at least two days prior to the reduction or termination, she advised.

• Patient non-compliance. If you have to terminate care due to a patient's non-compliance with the care plan, you'll want to issue an ABN using Option Box 2, St. Pierre explained. That's because it's the agency's decision to end the care.

HHAs are struggling to implement these unwieldy and often confusing forms, the NAHC representatives acknowledged. "We know that this is a difficult time and these are very very difficult situations," St. Pierre said.

Guardian is hoping to head off confusion with its advance ABN implementation date of May 15, Kelley says. That way, clinicians have half a month to "work out the kinks" before the CMS-mandated deadline hits, she notes.

In addition to good training going into implementation, agencies will have to monitor ABN usage to "really stay on top of it," Kelley predicts.

Note: ABN information, including forms and instructions, is at www.cms.hhs.gov/BNI/03_HHABN.asp.