Home Health & Hospice Week

Physician signature requirement will be a major obstacle to payment under demo.

Home health agencies in pre-claim review demonstration states have received their marching orders for the program, but that doesn’t mean they like them.

Clarification: As agencies feared, part of the requirements for the review is a physician signature on the plan of care. That means the physician must review and sign the POC before the agency can even submit the review request, the Centers for Medicare & Medicaid Services specifies in its newly released operational guide for the demo.

HHH Medicare Administrative Contractors then have a target of 10 business days to return a decision — affirmed or not affirmed. For those not affirmed, the MAC will tell agencies what docu mentation or other elements they are missing, and then the agencies can start the process all over again but with a 20-day decision timeline for the MACs.

“There’s no room to even breathe,” says Chicago-based regulatory consultant Rebecca Friedman Zuber of the demo’s Aug. 1 start date in Illinois. In the new guide, CMS confirms the start date for that state, and repeats the start dates for Florida (Oct. 1), Texas (Dec. 1), and Michigan and Massachusetts (Jan. 1). However, the latter four states get a “TBD” designation as well, indicating possible flexibility.

“This is sure to create major cash flow issues,” worries reimbursement consultant Rose Kimball with Med-Care Administrative Services in Dallas.

Expect “non-affirmed” decision rates to be sky-high, says attorney Robert Markette Jr. With Hall Render in Indianapolis. MACs have revealed denial rates exceeding 90 percent for the Probe & Educate review campaign focusing on face-to-face requirements (see Eli’s HCW, Vol. XXV, No. 11). Preclaim review decisions are bound to be even worse, Markette predicts.

Multiple callers into CMS’s second special Open Door Forum on the program, on June 28, expressed their dismay over the physician signature requirement, attendees report. The mandate will cause significant delays to requests and HHA reimbursement, they protested.

CMS maintains that the program will help agencies avoid claims denials.

Watch for: While it confirms the need for the signed POC, the operational guide is otherwise still rather vague, agencies criticize (see box, p. 201). In the guide, CMS advises agencies to obtain more specific directions from their MACs. But so far, the MACs haven’t issued them.

At press time, MAC Palmetto GBA was slated to begin a series of educational calls about the demo on June 30. For times and registration details, go to www.palmettogba.com/event/pgbaevent.nsf.

Texas HHAs are anxious to know exactly what documentation their MAC will expect, Kimball says.

Note: Links to the new guide and an updated set of Frequently Asked Questions about the demo are at www.cms.gov/Research-Statistics-Dataand-Systems/Monitoring-Programs/Medicare-FFSCompliance-Programs/Pre-Claim-Review-Initiatives/Overview.html.