Home Health & Hospice Week

One intermediary's answer to a common ABN question may surprise you.

Your responsibility to furnish home health advance beneficiary notices may be even broader than you think.

A new question and answer from regional home health intermediary Cahaba GBA spells out yet another circumstance under which an HHABN is required--and it may not be what you expect.

In its October newsletter to providers, Cahaba told agencies "that if a HHA had orders for PT 3 x wk x 3 weeks, then obtained further orders to continue 2 x wk x 1 more week, the agency would have to provide an HHABN because this was a decrease," a new Q&A in the RHHI's December newsletter to providers says.

The question: The directive confused at least one HHA. "From my previous understanding of the instructions, I would have interpreted this as not having any need for the HHABN because it was extending the care beyond the original plan rather than considering it a decrease," the agency says in the December Q&A. "Am I missing something?"

The answer: But Cahaba stands by its instruction. "The Centers for Medicare & Medicaid Services ... clarified that providers must look at the care as a 'continuum', from the patient's point of view," Cahaba says. "The patient, who is familiar with the therapist coming three times per week, is seeing the therapist less often now under the new orders. The patient must be notified of the reduction by utilizing the HHABN."

This answer is likely to surprise many providers, expects consultant Pam Warmack with Clinic Connections in Ruston, LA. "My clients have had a tremendous amount of trouble grasping this concept."

Agencies aren't likely to view this scenario as a reduction in care, notes consultant Laura Gramenelles with Simione Consultants based in Hamden, CT. "It is logical to view this scenario as an increase in ordered services," since the subsequent orders add more PT services, Gramenelles contends.

Providers "have difficulty differentiating the different rules for orders versus HHABNs," says consultant Judy Adams with LarsonAllen based in Char-lotte, NC.

"This is one of the many examples of how the home health ABN process is troubled at best," says attorney Robert Markette, Jr. with Gilliland, Markette & Milligan in Indianapolis.

Look At It This Way

The trick is to look at the services from the patient's point of view, Gramenelles recommends. "It is often difficult for us to separate the 'physician orders' from the level of service that the patient has been receiving," she tells Eli. But "it is how CMS views the patient expectations that drives the need for an HHABN."

Adjust your view: "In the scenario posted, the patient's care was being continued but at a reduced frequency," Warmack explains. "The clue is in the reduced frequency, not the continuation of the care."

Q&A Highlights Common Misunderstanding

Figuring out when services are reduced for the purposes of an ABN is very challenging to providers, Markette points out.

"It is a very confusing issue," Warmack agrees. "Providers are struggling with this issue daily."

The same problem occurs at recertification, Warmack says. Agencies see a recert as a continuation or increase to the original plan of care, but CMS does not. "If a patient was being visited three times a week and is recertified to receive services two times a week, an HHABN must be issued," Warmack explains. This "is perhaps the most difficult instruction to remember because it seems a contradiction to most clinicians."

At least with a recert, agencies can understand it's a reduction because the second episode often is presumed from the start, so the recert is a continuation of expected care, Markette observes. When orders add more services to an original plan of care, it's even harder for providers to understand why CMS considers that a reduction in services.

"Honestly, I think they're wrong," Markette says of the interpretation. But CMS and its contractors have erred on the side of caution in making ABN calls. "CMS seems to think more is better," he tells Eli.

Note: The Q&A is on p. 29 at www.cahabagba.com/part_a/education_and_outreach/newsletter/1206_rhhi.pdf.