Home Health & Hospice Week

Home health agencies with large outlier populations should avoid knee-jerk reactions to the 10 percent cap or risk facing survey and other troubles.

HHAs that have a large percentage of outlier patients -- often blind, insulin-dependent diabetics who require multiple insulin injections daily -- are managing their outliers with various strategies."Some outlier-focused companies are changing their patient mix," William Dombi with the National Association for Home Care & Hospice tells Eli.

Others are focusing on teaching family members or other caregivers how to do the injections and teaching patients themselves to be more independent, Olson says. (For ideas on minimizing outlier risk, see Eli's HCW, Vol. XVIII, No. 43, p. 331.)

Agencies that are just now getting hit by the cap need to be careful to avoid patient dumping charges that arise from discharging outlier patients, cautions Lynn Olson with billing company Astrid Medical Services in Corpus Christi, Texas. Patient dumping allegations can bring trouble with surveyorsor pricey lawsuits from patients.

HHAs shouldn't have to resort to avoiding admission of all outlier patients either, Olson says. As long as you understand where you stand on your cap, you can make sound financial decisions on outlier patients. To do so, take these steps:

1. Understand your total cap amount. You can do this by comparing the "outlier total" and "payment total" columns in the new DDE option to track outliers. Your outlier total amount needs to be 10 percent or less of your payment total amount.

Tip: In the DDE screen, the "payment total" amount includes the outlier reimbursement, a Centers for Medicare & Medicaid Services official clarifies. "So we calculate 10 percent of that number and compare it to the 'outlier total' to determine whether the limit has been met," the CMS rep tells Eli.

To get to the DDE screen, select Option 01 (Inquiries) from the DDE Main Menu and option 67 (Home Health Payment Totals Inquiry) from the submenu, regional home health intermediary Palmetto GBA says on its Web site. Providers must enter their OSCAR (Provider number) and National Provider Identifier (NPI).

2. Understand how much an individual patient's episode will run you in outlier percentage amounts.

Surprise: Many agencies don't realize that a patient with a low-paying HHRG/HIPPS code will rack up a much higher outlier percentage than a patient with a high-paying episode, Olson explains. That's because outliers are calculated using the low utilization payment adjustment (LUPA) per visit amount multiplied by the number of visits, no matter the reimbursement rate of the episode. So the visit cost is a lower percentage of a high PPS payment compared to a low PPS payment.

Resource: Olson uses a  worksheet from National Government Services to help calculate an individual episode's outlier amount and percentage. For a free copy of the worksheet, e-mail editor Rebecca Johnson at rebeccaj@eliresearch.com with "Outlier Worksheet" in the subject line.

3. Admit the patients with a goal of making them able to inject independently, either by being trained themselves or by having family or other caregivers trained. Olson's clients are finding they often can admit a BID patient who has the usual outlier costs in the first episode, lower outlier costs in the second episode, and no outlier costs in the third episode with discharge thereafter, thanks to training to independence, he says.

Note: More information about how outlier payments and the cap work are in Dec. 23, 2009 Transmittal No. 1883 (CR 6759) and MLN Matters article 6759, which are at www.cms.hhs.gov/transmittals/downloads/R1883CP.pdf and www.cms.hhs.gov/MLNMattersArticles/downloads/MM6759.pdf, respectively.