Home Health & Hospice Week

But the expedited review notices aren't yet ready for prime time, experts protest.

Get ready to ready, set, GO on the new termination notice requirement starting July 1.

The Centers for Medicare & Medicaid Services has issued reams of new information on the notices, which it's now calling expedited review notices. But you have only a few short days to wrap your head around them before the implementation date arrives.

As proposed last November, CMS is requiring home health agencies and other providers to issue these notices every time a patient's Medicare-covered services end, Tony Culotta, director of CMS' Medicare En-rollment and Appeals, said in a June 20 special Open Door Forum that drew a staggering 2,000 callers

The Office of Management and Budget approved the forms June 20 and CMS posted them June 22. However, providers can use the proposed forms rather than the finalized ones until Oct. 1 in any case.

The new requirement is an administrative hassle and a big cost to home health agencies, fumes Gene Tischer with trade group Associated Home Health In-dustries of Florida. (For an outline of the two-step notice process, see the insert article at the end of this issue.) "This is going to cost agencies a bundle," Tischer says.

The requirement "just isn't in the real world," laments Burtonsville, MD-based health care attorney Elizabeth Hogue. "They're trying to cram a square peg in a round hole."

The notices are just one more thing Heritage Home Care of Broward Inc. in Davie, FL, has to monitor, notes Administrator David Rodriguez. The HHA plans to change its computer system to track these forms, Rodriguez says.

The requirement will add more "paper shuffling," and agencies could have trouble giving the notices on time, worries consultant M. Aaron Little with BKD in Springfield, MO.

Tell Doc He's Wrong, CMS Instructs

The new expedited review notice requirement dumps a whole new paperwork burden in HHAs' laps with a plethora of logistical problems and unanswered questions, experts protest. One of the most pressing concerns is lack of physician orders. A chief complaint on the proposed rule was that agencies can't furnish home care without a physician's orders, so how can they continue care during the 72-hour expedited review period, or longer, when ordered care ends after 48 hours?

HHAs can't furnish care without a physician's orders, CMS confirms. But in CMS' instructions to intermediaries in Transmittal 577 (Change Request 3903) issued June 3, the agency says the QIO should work with physicians if it decides Medicare will cover prolonged care. The QIO "should contact an ordering physician if this occurs, preferably the same physician who has been ordering care in the case under consideration," CMS says.

Then the QIO should "present to that physician its decisions and the impact regarding reconsidering his/her own termination of orders - or writing new orders," CMS continues.

Contradiction: But during the forum, CMS said in fact that the QIOs wouldn't conduct this outreach, but instead would require providers to do so.

Tischer scoffs at the idea of an agency telling a referring physician that another physician at the QIO has overruled his decision. "It's ridiculous," Tischer maintains.

And expedited review without a physician's order shouldn't be allowed, Tischer argues, because agencies can't provide care without the orders.

Doc Risk Certification No Longer a Barrier

Another major problem area is physician certification of risk. CMS minimized HHAs' fears about the new expedited review process when it said in the proposed rule that an expedited review would require the beneficiary to obtain a physician's certification that the termination of services would put her health at "significant risk."

Now CMS says beneficiaries don't have to have that certification to get the expedited review ball rolling. Benes can produce the certification later - after the HHA already has issued the second-step notice and submitted all the records to the Quality Improvement Organization, Culotta said in the forum.

It's a "huge waste of time" for agencies to scramble to do their part before the physician certification comes through because the chances of most physicians certifying such risk are slim, Tischer argues.

The provision will allow benes to "shop around" for certification from different physicians, Hogue says.

But even if patients can't obtain such a certification, the QIO physician reviewing the case may furnish it for them, CMS suggests in the transmittal.

You Must Explain Notices

Home health agencies will be the ones to explain "the notices they provide in the context of the overall review process" to the beneficiaries, CMS says in the transmittal.

This is going to prove a major challenge, Rodriguez expects. "Beneficiaries are so confused," he notes.

Most frail, elderly beneficiaries won't comprehend the complex Medicare appeals system, and these forms' role in it, Tischer expects. But CMS says your job is to make sure the bene understands it.

HHAs may have trouble explaining the forms if they can't even find them. Numerous callers in the forum said they were having trouble locating the forms and guidance referenced. CMS has reorganized its beneficiary notice Web site in response.

For now, agencies should do the best job they can with the information provided, Little advises. Read the regulations and train staff on them, he suggests.

"We're going to have to move quickly on these," Rodriguez acknowledges.