Home Health & Hospice Week

Tip:  Avoid human error with pre-printed information.

You'd better make sure your mandatory expedited determination notices pass muster--or you'll pay the price.

If the Quality Improvement Organization finds that the first-step, generic expedited determination (ED) notice you give patients is invalid, the liability clock restarts when you deliver a second, corrected notice, the Centers for Medicare & Medicaid Services explains in newly issued questions and answers on the notices.

"If a provider fails to correct an invalid notice, the provider may be held liable for subsequent noncovered care," CMS explains in the Q&A. "QIOs will not address whether coverage should end or continue until beneficiaries receive valid notice."

In other words, you can't bill the patient for any services until two days after you give the corrected, valid notice, explains consultant Judy Adams with LarsonAllen Health Care Group based in Charlotte, NC.

Watch out: This clarification "potentially prolongs the amount of time that a beneficiary receives care before the determination is made," warns Casey Blumenthal with MHA...An Association of Montana Health Care Providers. "It leaves everything in limbo, and an agency may end up providing several days of non-reimbursed care."

Fortunately, the first-step ED notices are straightforward and don't lend themselves to many errors, experts say. Home health agencies have to insert their own identifying information, the patient's name and Medicare number, the types of services that will end, the date the services will end, and the name and contact information for the QIO that will review the determination if requested.

Agencies' main problem with invalid notices is getting them delivered in the correct timeframe--at least two days before discharge, notes consultant Pam Warmack with Clinic Connections in Ruston, LA. Predicting the date of discharge "is not always an easy task," making an accurate delivery time difficult, War-mack tells Eli.

HHAs may also incorrectly list the services being terminated or the QIO information, suggests attorney Robert Markette Jr. with Gilliland Markette & Milligan in Indianapolis. But "if an agency is careful, it should not be a real problem," Markette expects.

Do this: Pre-print the QIO contact information on the forms so you minimize the chance for human error, Markette suggests. "This will reduce the possible areas for mistakes."

You can also hand out notices earlier than the two-day deadline to give yourself extra wiggle room should the QIO rule the notice invalid, Adams notes.

Many HHAs "are giving patients the ED notice when they anticipate the discharge and not waiting until two days prior to discharge," Adams reports. That way, "the patient is often receiving several days advance notice, but is not 'charged' for any services until after the discharge date."

Handing out notices a bit early may be easier for agencies now than it used to be. HHAs in the last few years have gotten used to thoroughly explaining expectations to patients, Blumenthal points out.

An out: HHAs can avoid financial liability and other regulatory dilemmas altogether, argues Burtons-ville, MD-based health care attorney Elizabeth Hogue. They can decline to provide additional services after they think patients should be discharged, Hogue maintains.

CMS has admitted that it can't require agencies to furnish services that aren't ordered by a physician (see Eli's HCW, Vol. XIV, No. 23).

Demand Billing on the Wane

Another new Q&A shows home care providers should be doing a lot less demand billing these days.

CMS expects beneficiaries to request either an expedited review or demand billing for a discharge. "Generally, there would be no need for demand billing in the typical situation where the precise end date for covered services is in dispute," the Q&A explains. That's because "the QIO can provide a fast decision through the expedited process in contrast to the more lengthy intermediary demand bill process."

The ED process "is much quicker than the demand bill process," Adams explains. "The beneficiary will receive her answer within two days."

In contrast, an agency can't even submit a demand bill to its intermediary until the end of the episode. And then "it might take several weeks for the beneficiary to learn whether the intermediary believes the service to be covered," Adams notes.

Don't forget: HHAs may need to use demand billing when they reduce rather than terminate services, however, Adams reminds providers. The ED notices and review process apply to termination of all services only, not a reduction in services.

To understand when a demand bill is required, agencies must understand the ED notice process versus the advance beneficiary notice (ABN) process, Warmack advises. CMS requires ABNs when reducing covered or non-covered care (see Eli's HCW, Vol. XV, No. 8).

ED, ABN Questions Persist

CMS' new Q&As have clarified a few points, but HHAs are still hungry for more information on ED notices and ABNs, says Karen Hinkle with the Kentucky Home Health Association. Agencies want "reassurance that they are handling the notices correctly," Hinkle notes.

In particular, providers have lingering doubts about when to issue ED notices versus ABNs, says Andrew Koski with the Home Care Association of New York State. "In some cases, home health agencies are expected to use both forms," Koski points out.

"The majority of home care clients I encounter remain extremely uncomfortable with providing the expedited review notices," Warmack laments. "This task needs a lot of education in the home care community." 

Note: The Q&A, including what to do if a QIO rules your notice invalid, is at www.cms.hhs.gov/BNI/06_FFSEDNotices.asp  scroll down to the Q&As link.