Home Health & Hospice Week

Late notice, overwhelmed staff head up HHAs' challenges in implementing new rule.

The new expedited review notices set off fireworks in the home health industry over the July 4th weekend, leaving many agencies yearning for independence from the taxing new paperwork burden.

Having the July 4th weekend as the implementation date for the new requirement to give every Medi-care beneficiary a Notice of Medicare Provider Non-Coverage when Medicare-covered services end made the new requirement even harder for home health agencies to implement, notes Jean McDonald with the Indiana Association for Home and Hospice Care. Holiday weekends are "hard enough to staff anyway, plus this," McDonald tells Eli.

And HHAs are juggling vacations from staff during the summer months, notes one hospital-based agency in the Cincinnati area. "Trying to get everyone trained is even more of a challenge when you have to work around vacation schedules," the HHA laments.

The Centers for Medicare & Medicaid Services made HHAs' preparation for the new regulatory requirement much more difficult by furnishing final instructions and forms at such a late date, multiple HHAs complain. "There was very little notice given from the final regs and forms for a project of this magnitude," blasts one agency in Western Kentucky. "It was ridiculous that the forms were still changing as late as June 22."

"The rules and form were very late in coming, which makes it difficult to get information out about it or to do any training on it," criticizes Neil Johnson with the Minnesota HomeCare Association.

"It would have helped to have the [Open Door] Forum longer than only 10 days in advance of the effective date," adds Casey Blumenthal with the Montana Hospital Association: An Association of Montana Health Care Providers (for Forum details, see Eli's HCW, Vol. XIV, No. 23).

On-the-ball agencies knew the requirement was coming after CMS put in place the analogous expedited review procedure for Medicare Advantage beneficiaries last year, notes Gwen Toney with the Ohio Council for Home Care (see Eli's HCW, Vol. XII, No. 20).

But despite the vigorous education campaign launched by national and state trade associations, many agencies were caught by surprise on the July 1 implementation date, industry representatives say.

"More notice would have eliminated some of the stress," says Marcia Tetterton with the Virginia Association for Home Care. "CMS did not provide ample dissemination of the form in a timely fashion, nor are they able to answer many questions regarding the appeals process."

Confusion Abounds About New Notices

In fact, HHAs are dissatisfied or confused by many of the answers - or lack thereof - to their questions about the new notices, industry representatives note. "It gets complicated when CMS answers questions with their usual rhetoric instead of just answering the question in a clear way," notes Helen Siegel with the Home & Health Care Association of Massachusetts.

The problem starts with unclear instructions on the new forms, critics say. "The form is confusing [and] the instructions are worse," says Linda Lubensky with the Kansas Home Care Association. "We are still getting questions."

"If you read every piece of information you have six or seven times, you might start to get it," Blumenthal tells Eli. "No one I know understood [the requirements] thoroughly the first time they read the rule."

A major point of confusion is how the new review notices interact with the home health advance beneficiary notice (HHABN), points out Joe Hafkenschiel with the California Association for Health Services at Home.

That goes doubly in states like New York that have a lot of beneficiaries dually eligible for Medicare and Medicaid, says Pat Conole with the Home Care Association of New York State. Right now the regulations seem to require that HHAs furnish expedited review notices and ABNs to dual eligibles whose Medicare-covered services end but whose Medicaid-covered services continue.

In the recent June 20 Open Door Forum on the new notices, CMS said it is holding off on issuing a finalized ABN and instructions. "The HHABN should not still be 'out there,'" complains one HHA in Eastern Kentucky.

Agencies are also confused on an essential part of the requirement - the exceptions to the rule when they don't have to hand out the notices.

Staff Walks Over New Burden

A major challenge in implementing the new requirement is the massive new administrative and financial burden, reps say. "It's one more thing you have to teach staff to do," and those employees already feel overwhelmed with paperwork, IAHHC's McDonald says.

"Many of us are angry that there is even more paperwork to do," says one frustrated HHA. "It will be an additional financial burden [in] education, forms and time. All of these additions continue to take away the time that clinicians get to spend on direct patient care and care management."

In fact, one nurse in this agency turned in her resignation after hearing of the new burden. "It was the last straw," the HHA says. "Now in addition to forms, training, additional time to administer, track, file, etc., I have to replace a nurse."

In addition to the paperwork, HHA staff will have the new job of explaining the notices to mainly frail, elderly beneficiaries. "If [CMS officials] think a home health provider can explain the intended use of this form, the timeline, the process, etc., in six minutes, I think they have not sat down recently to explain anything Medicare-related with an older, less cognitively sharp individual who is already inundated with health care paperwork," MHA's Blumenthal notes.

Explaining the form alone could add 15 to 30 minutes to a visit, predicts Debbie Thompson with the HomeCare Association of Louisiana. "The burden will be labor and cost intensive," Thompson says.

HHAs find it galling that they must undertake such a huge task that benes are unlikely to understand anyway. "This will be a big burden on providers without providing meaningful information to beneficiaries," CAHSAH's Hafkenschiel predicts.