Home Health & Hospice Week

Are your home health advance beneficiary notice practices in compliance with federal regulations?

If not, you're probably not alone.

In paperwork supporting the Centers for Medicare & Medicaid Services' proposed minor changes to the HHABN this fall, CMS says it expects home health agencies to be issuing two ABNs per episode, on average, due to care changes that occur resulting from doctors' orders.

"The 200 percent estimated use of Option Box 3 [on the HHABN] during annual 60-day episodes of care reflects the high number of care changes that occur due to doctor/provider orders,"

CMS says in its supporting statement (see Eli's HCW, Vol. XVIII, No. 20, p. 158).

Combined with ABNs from Option Boxes 1 and 2, HHAs should be issuing more than 12 million notices a year, CMS says.

The two ABNs per episode for Option Box 3 sounds right, says consultant Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C. "Option Box 3 is used whenever there are physician orders -- even if the HHA requests them -- to decrease service frequency or to discharge a patient earlier than the duration listed on the plan of care," Adams explains.

That estimate may even be low for the number of HHABNs agencies should be issuing, expects Chicago-based regulatory consultant Rebecca Friedman Zuber.

One example of Option Box 3 use is when "HHAs still project visits and services for the entire 60-day period," Adams says. "If a patient progresses and meets their goals sooner than the end of the episode, the agency must obtain an order from the physician to decrease frequency or discharge the patient. If this happens with therapy, but nursing is still seeing the patient, then the HHABN is used."

Another scenario: Consider "a patient with wound care who received orders to change the dressing protocol," Adams tells Eli. That dressing protocol change may result in decreased frequency of skilled nursing visits, necessitating an HHABN.

Those are 12 million "mostly useless and ignored pieces of paper," laments Bob Wardwell with the Visiting Nurse Associations of America.

Issuing the ineffective notices "inevitably diverts staffing and financial resources from patient care," says Wardwell, a former top CMS official.

"It is a cumbersome process that ... pretty much nullifies the intended effect," Friedman Zuber agrees.

"That's a lot of paper," notes attorney Robert Markette Jr. with Gilliland & Markette in Indianapolis.

The litigation driving the ABN process contributed to the notices' inefficiencies, Wardwell maintains.

Non-CompliantAgencies Court Penalties Heads up: HHAs should pay attention to this requirement, Adams advises. "Any agency that is not providing HHABNs in accordance with the expanded provisions...does need to be concerned,"

she says. "They are not complying with the regulatory requirements for oral and written notification of the patient with any changes in the plan of care."

Agencies could also be liable for payment related to the decreased services, Markette adds.

But the fact is "there is no one checking ... whether agencies are issuing the notices in accord with the policy," points outMary St. Pierre with the National Association for Home Care & Hospice.

HHAs aren't seeing much enforcement of this requirement, and that is reducing their motivation to put resources into HHABN compliance, Markette observes.

Non-compliance isn't surprising, considering the unrealistic requirements placed on providers, Wardwell says. "Demanding a level of ABNs that exceeded what it was practical to provide [results] in non-compliance even by agencies that were historically very compliant."