Home Health & Hospice Week

Home Health Compare, DRA claims reprocessing also broached in Open Door Forum.

You can save on precious time and resources if you know when you don't have to issue the new ABNs--but figuring that out may not be so simple.

The Centers for Medicare & Medicaid Services has issued newly revised advance beneficiary notices and instructions that "significantly broaden" the circumstances under which you'll issue the forms, a CMS official noted in the Feb. 28 Open Door Forum for home health providers (see Eli's HCW, Vol. XV, No. 8).

June is the "drop dead date" for home health agencies to adopt the new forms and instructions, the CMS staffer explained.

But even though you'll be handing out a lot more ABNs, you don't want to make extra work for yourself. Agencies can take advantage of the list of exceptions CMS issued in its ABN instructions, the CMS official advised.

HHAs don't have to issue ABNs when care increases; the duration of care shortens; patients transfer to other covered care; service reductions are anticipated in the plan of care; patients' goals are met; physicians' orders are completed; the beneficiary chooses the care change; emergencies like natural disasters disrupt care; personnel change; visit times change; or product brands change, CMS spells out in the instructions.

Question: But those exceptions may not always be cut and dried. For example, a West Virginia HHA calling into the forum asked whether it could secure interim orders for a decrease in services, include the decrease on the plan of care and effect the change a week later without triggering an ABN.

Answer: "As long as [the reduction] is in the plan of care and the beneficiary knows in advance it's going to happen, you should not need to give notice in that case," the CMS official offered. However, the exception for service reductions anticipated in the plan of care "envisioned" the reduction being included on the original order, she added.

Bottom line: The point of the revised ABN is that service changes don't "blindside" beneficiaries, the staffer noted. "But if their physician has talked to them and they are anticipating [the reduction], I think that's the line I would draw about whether you need to give notice or not." In other words, if the change is news to patients, you should issue an ABN.

CMS soon will issue an official transmittal including the new ABN instructions, CMS said.

Other topics addressed in the forum include:

• Home Health Compare. Don't be surprised to see new "consumer-friendly" language on Medicare's home care outcomes Web site, a CMS official noted. The improved text, aimed at helping consumers better understand the outcome measures, will debut along with the usual quarterly data update March 16.

• DRA claims reprocessing. If you haven't seen your claims paid at the old reimbursement rates in January adjusted for the new payment rate changes mandated by the Deficit Reduction Act, you're not alone. Intermediaries have until July 1 to reprocess those claims and have wide discretion to set their own timeframes for doing so, CMS noted. The delay can be good or bad news, depending on whether you expect over- or underpayments to result from the adjustments, experts note.

• Medicare Advantage. Home care providers are having a tough time figuring out if their patients are enrolled in Medicare managed care plans, Bob Wardwell with the Visiting Nurse Associations of America protested in the forum. Often the Common Working File won't show a patient is enrolled in a Medicare Advantage plan until weeks or months after the effective date, which puts HHAs in the position of providing care they can't get paid for.

Patients also come on service with a pending appeal to transfer to an MA plan, then the switch occurs retroactively. "That leaves folks in an awful position," especially if prior approval is required, Wardwell noted.

CMS is working on the issue, it said. 

Note: The new ABN forms and instructions are at www.cms.hhs.gov/BNI/03_HHABN.asp.