Home Health & Hospice Week

QIO can't furnish beneficiary risk certification required for review.

The number of work-intensive expedited reviews you encounter may be lower than expected, thanks to a change of heart from the feds.

Quality Improvement Organizations' physicians won't be furnishing beneficiaries with certifications that the lack of continued home care would place the beneficiary's health at significant risk, the Centers for Medicare & Medicaid Services says in a question-and-answer posted this month.

That's big news because beneficiaries require such certification to proceed with the expedited review process. Under those reviews, home health agencies have to issue a second-step, detailed expedited review notice to the beneficiary explaining why Medicare services are ending. Then they must copy records and send the documentation to the QIO - all by the end of the day they were notified (see Eli's HCW, Vol. XIII, No. 43).

In earlier instructions to intermediaries and in the June 20 special Open Door Forum on the topic, CMS said QIO docs could furnish the cert. But now CMS says "it is not appropriate for a QIO to provide both the physician certification statement required in order to request a review and conduct the actual review of the case," according to the Q&A.

"Instead ... the QIO should instruct the beneficiary of the need to either call his or her attending physician to request such a statement or to obtain the required statement from any other physician of the beneficiary's choice," CMS instructs.

"I am very glad to see that CMS has backpedaled on this issue," says Burtonsville, MD-based health care attorney Elizabeth Hogue. "It is a fundamental conflict of interest for QIO physicians to provide the certification required and for the QIO ... to review the coverage issues."

Doc Shopping Threat Minimized

CMS does allow the beneficiary to shop for a physician to furnish the risk certification, but experts think they're unlikely to do so. The tight expedited review timeframe won't give beneficiaries enough time to go fishing for a cert, predicts Debbie Thompson with the HomeCare Association of Louisiana.

"Benes are less likely to shop for a cert than to pressure their original physician [for one]," expects Bob Wardwell with the Visiting Nurse Associations of America.

That's good because patients' own physicians "are likely to have a more complete, balanced picture of patients' clinical conditions than QIO physicians," Hogue maintains. Thus "reviews are likely to be more fair than if they were based on certifications from QIO physicians," she forecasts.

This about-face should spur HHAs to develop even better communication with referring physicians regarding termination of care, Wardwell suggests.

You and the patient's doc should be on the same page about Medicare-covered services ending, advises Chicago-based regulatory consultant Rebecca Friedman Zuber. "This means the patient may have to search for a physician who will provide orders and the statement that discontinuing services will cause harm to the patient. Homebound patients are not able to shop for a physician, and if they aren't homebound then they won't qualify for home health services," Zuber says.

Many beneficiaries probably won't end up making the deadline for expedited review because they won't be able to secure their certs in time from confused or non-responsive physicians, Thompson suspects.

Bottom line: Now that CMS has changed the cert requirement, the number of expedited reviews should be even lower than the 1 percent to 2 percent first predicted, experts say.

On one hand, the good news is that HHAs won't have to rush to meet the same-day review deadlines. On the other hand, agencies are going through all the work of issuing first-step, generic expedited review notices with even fewer results.

VNAA members lament "the amount of needless paper and [are] concerned about staff time being wasted by this mandate with little real effect," Wardwell says. "Perhaps CMS does not grasp the fact that agencies are turning away patients for lack of nursing time, and wasted minutes on needless paper notices add up to have a human impact."

Zuber bemoans "just how unrealistic this whole approach is." The problems that gave rise to the lawsuit that sparked these notices "could have been dealt with within the existing regulations," she protests. "If home health services are discontinued without sufficient discharge planning, there are already mechanisms for addressing that problem with the agency."

Note: The new Q&A, #2, is www.cms.hhs.gov/medicare/bni/EDqsandas.pdf.