Home Health & Hospice Week

CMS ‘confident that you’ll be able to pull it together’ for demo, official says.

What happens when Medicare officials implement a nearly impossible documentation requirement? Home health agencies are going to start paying the price under a new demonstration.

Medicare’s payment error rate skyrocketed from 17.3 percent in 2013 to 51 percent in 2014, then up further to 59 percent in 2015, the Centers for Medicare & Medicaid Services notes in a June 10 Federal Register notice implementing the “preclaim review demonstration for home health services,” formerly known as prior authorization (for demo details, see Eli’s HCW, Vol. XXV, No. 22).

That staggering increase is largely due to the confusing and difficult face-to-face physician encounter documentation requirements CMS implemented, maintains attorney Robert Markette Jr. with Hall Render in Indianapolis. CMS fails to recognize “that the reason the error rate continues to be so high is not because providers are incompetent or fraudulent, but because physicians are not documenting appropriately and reviewers are reviewing face-to-face documentation very critically,” Markette tells Eli.

HHAs undergoing Probe & Educate review of F2F documentation have seen big problems with the quality of reviews, notes Chicago-based regulatory consultant Rebecca Friedman Zuber.

Even aside from F2F issues, “medical review for sufficient documentation to support medical necessity and evidence of homebound has always been very subjective and inconsistently applied by the MACs,” says the National Association for Home Care & Hospice. Under the demo, HHH Medicare Administrative Contractor reviewers will conduct the pre-claim review. “‘Sufficient documentation’ that CMS insists is lacking in HHAs’ medical records, causing high rates of denials, will remain at issue until CMS sets clear standards that all parties can understand and agree upon,” NAHC maintains in its member newsletter.

In a special Open Door Forum on the demo that CMS held June 14, an agency official acknowledged “there is a learning curve and we know that.” HHAs will “get up to speed” and figure out what’s needed, documentation-wise, under the demo, the CMS staffer insisted.

An HHA caller to the forum insisted that the F2F documentation requirements often are beyond agencies’ control, as they rely on the physician. “We do understand that there is a burden sometimes in getting that information from physicians,” but F2F is a requirement agencies should have been collecting all along, the official told the agency. “We will do our part to help educate physicians the best we can to help support you … in your efforts to get that documentation,” she added.

10-Day Turnaround Timeline For Demo Unrealistic

Multiple HHA callers in the forum expressed skepticism that the MACs would be able to meet the 10-business-day timeline for reviewing and issuing a decision on initial pre-claim requests, or 20 days for resubmitted requests. HHAs in the five demo states will be submitting thousands of requests per day, one caller emphasized.

MACs will “be hiring staff to work just on this demonstration,” a CMS official assured the caller. “We’re very confident that they’ll be able to handle the influx of requests.”

But industry experts aren’t so sure. HHAs should brace for potentially major cash flow disruptions under the demo, they predict. “The burden associated with a 100 percent pre-claim review program will be significant for agencies,” NAHC warns. “Furthermore, the increased workload for both the agencies and MACs will undoubtedly result in delayed payments.”

“My concern is that the pre-payment reviews will take more than the 10 days in the notice,” Markette says.

Result: “This program will, at a minimum, result in delayed payments to agencies,” Markette believes. “Worst case, is that this will result in a significant percentage of claims being denied.”

Callers in the forum echoed Markette’s worries about denials. One agency rep pointed out that most of the claims they’ve had reviewed were denied and are on their way to the Administrative Law Judge — which has a backlog of years.

Under the demo, a great number of agencies that are unable get their pre-payment submissions approved will have to appeal, Markette fears. That “could be devastating to the industry, because even a 10 percent denial rate will greatly reduce reimbursement to providers who are already having difficulty surviving,” he says.

But in the forum, a CMS official insisted that the demo should actually limit appeals. “We’re really hoping … that this demonstration is really going to have a big impact on reducing appeals,” she told listeners. “You’re going to know up front what information wasn’t provided and be able to correct that information and resubmit, so that you’ll have the claim right at the time that you’re submitting your final claim.” There’s no limit on the number of times an agency can resubmit its pre-claim review request under the demo.

Not likely: But the process of submitting, and resubmitting, and resubmitting again will just further delay payments, forecasts finance expert Tom Boyd with Simione Healthcare Consultants in Rohnert Park, Calif.

And remember, absolutely all of an agency’s claims will be reviewed under the demonstration.

The sheer number of claims undergoing scrutiny will be staggering, with even relatively small percentages of claims “not affirmed” adding up to major reimbursement delays and losses.

HHAs that are unable to secure reviewers’ approval after repeated requests will be forced to submit the final claim and receive a denial to access their appeal rights.

Big Burden, No Benefit, Critics Say

In the forum, the CMS officials argued that the demo shouldn’t add a significant burden on agencies, because HHAs should have all of this documentation on hand anyway. “The demonstration does not create any new documentation requirements,” a CMS staffer insisted. “They’re all thesame. So the same things you’ve been collecting all along will be needed now.”

The agency may already have the documentation, but the process for submitting and tracking the demo requests will require more manpower, one agency told CMS in the forum.

“This is not new documentation; this is information that the home health agency should already have,” the CMS official repeated. “We’re confident that you’ll be able to pull it together to send in with the pre-claim review.”

HHAs might be more sanguine about taking on this significant burden if the requirements would actually rid the industry of fraudulent and abusive providers. But the demo is poised to do just the opposite, experts insist.

“CMS doesn’t seem to understand that entities intent on fraud will manufacture documentation that will meet the requirements,” Friedman Zuber laments. “It is compliance-oriented home health providers who will suffer from this new program, as they struggle to ensure that physicians document homebound status and need for skilled care in a manner that satisfies the MAC.”

“As a fraud and abuse-prevention measure, this seems about as useful as F2F,” Markette criticizes.

“Fraudulent providers will have documentation that meets the requirements,” he says. “The fraudulent providers will not be impacted, while compliant providers will see it become even more difficult to survive.”

The demo “is neither an appropriate nor effective vehicle to find and eliminate fraud in home health care,” the Visiting Nurse Associations of America insists. CMS should employ “targeted interventions focused on likely fraudulent practices evident from the analysis of Medicare claims. A targeted approach would be more effective at addressing fraud and abuse, less costly and less detrimental to the good actors in home health care, as well as to patients.”

NAHC decries “CMS’s failure to take a targeted approach,” in its member newsletter. “CMS could design a more manageable and meaningful demonstration by targeting agencies at risk for improper payment rather than casting a broad net over the entire state,” the trade group argues.

One caller in the forum broached the idea of HHAs with high pre-claim review approval rates being removed from the demo. CMS has no plans for such a move, but could consider it later, the CMS staffer replied.

Ignored: Critics also took aim at CMS’s method of implementing the demo. VNAA is “extremely disappointed” that CMS “dismissed the comments and concerns of 120 Members of Congress and almost 250 different health care service providers — physicians, hospitals, home health — and pushed forward a prior authorization demonstration for home health care in five states,” it says in a release. “CMS advanced this demonstration outside of a traditional and responsible rulemaking process and has fast-tracked implementation of a far-reaching and high-impact program over the strong concerns and objections of multiple stakeholder groups.”

CMS’s earlier Federal Register notice in February introducing the prior authorization demo idea was very brief with nearly no details. Now this Federal Register notice has no comment period, Boyd points out. “Clearly the Department of Health and Human Services does not want to hear from the industry,” he says.

However, the CMS officials in the forum insisted the agency did listen to agencies’ comments on the February notice and incorporated changes accordingly.

Note: See the Federal Register notice at https://federalregister.gov/a/2016-13755.