Home Health & Hospice Week

Medicare officials claim switch won’t increase burden.

It’s no surprise that the Patient-Driven Groupings Model will implement 30-day billing periods, since the change was required by law this year. But that won’t make HHAs’ transition to the new system any easier.

Although the 30-day periods are non-negotiable thanks to their inclusion in the Bipartisan Budget Act of 2018 enacted in February, home health industry commenters shared their criticism of the change in their comment letters on the 2019 HH PPS proposed rule, prominently noting the extra red tape and burden the transition will entail.

Extra burdens the change will cause, according to commenters, include:

• increased overhead costs due to doubling billing;
• more documentation errors;
• increased administrative burdens to both providers and to CMS due to an increase in claim submissions, resubmissions, and appeals; and
• a need for updated or new software and related additional training.

Perhaps most significantly, “many commenters expressed concern that switching to a 30-day period would cause undue burden because of the current difficulty in getting physicians to sign the plan of care in a timely manner,” CMS notes in the final rule released Oct. 31.

And “commenters remarked they did not have the manpower to implement this change and that it goes against the Secretary’s goal of reducing burden,” according to the final rule scheduled for publication in the Nov. 13 Federal Register.

The Centers for Medicare & Medicaid Services responds by insisting that the change won’t be much bother. “This change should not result in a measurable increase in burden, as many of the data elements that are used to populate an electronic claims submission will remain the same from one 30-day period to the next,” CMS says in the rule. “HHAs are required to line-item bill each visit performed and whether each visit is recorded on a single 60-day claim or the visits are recorded on two different 30-day claims should not result in a measurable burden increase.”

CMS isn’t totally wrong, acknowledges Julianne Haydel with Haydel Consulting Services in Baton Rouge, Louisiana. “If claim number one is ready to bill, it shouldn’t be an issue for claim number two in the same episode,” Haydel muses.

CMS confirms that the Plan of Care and certification/recertification requirements will continue to be on the same 60-day timeframe.

This is good news? Another point CMS makes may not be as welcome. “Data for CY 2017 suggests that nearly 1/3 of all 60-day periods would not produce a second 30-day period and would not require a second bill to be submitted,” CMS says, failing to point out that agencies’ reimbursement amount for the same amount of billing as under current PPS would be roughly half.

CMS reminds providers that “prior to the inception of the HH PPS, HHAs also billed on a monthly basis even though the plan of care and certifications were completed every 60 days.” Of course, that was before Medicare required the extensive face-to-face documentation that it does now. And trimming some OASIS items helps counterbalance the billing change, CMS contends.

Will Appeals Be Worth It Under 30-Day?

CMS is way off base on this burden justification, industry experts agree.

“I definitely think it will be an adjustment in the billing process,” offers consultant J’non Griffin, owner of Home Health Solutions in Carbon Hill, Alabama. Current HHAs “will still be having to collect orders prior to final bills, but rather than having 60 days to do it, they now only have 30 days,” Griffin tells Eli.

Implementing 30-day billing periods essentially will “double billing,” says reimbursement expert Melinda Gaboury with Healthcare Provider Solutions in Nashville, Tennessee.

The list of billing factors brought about by the change is long, says Joe Osentoski with QIRT in Troy, Michigan. “The changes in payment, the more frequent billing, the tracking of LUPAand outliers differently, the possibility of more claims (by volume) undergoing medical review, the unknown effect of 30-day payments to Targeted Probe and Educate, the unknown effect in Review Choice Demonstration (RCD) states, and needing to track all billing requirements are met for a 30-day period instead of 60 days may add to the administrative burden in an agency,” Osentoski predicts.

Osentoski is also doubtful of the claim that appeals shouldn’t change appreciably. “With close to double the number of payment periods billed compared to 60-day episodes, simply applying a current MAC denial rate would indicate more actual denials will be issued, albeit for less money per claim,” Osentoski notes.

Hidden impact: The potential claim payment amount “may then affect home health agencies’ decision to appeal, since the effort to file and appeal will not be half the cost of appealing a 60-day episode denial,” Osentoski says.

Bottom line: “We believe that the 30-day period is appropriate even if some requirements in home health have 60-day timeframes, as a 30-day period of care under the PDGM better aligns home health payments with the costs of providing care,” CMS concludes in finalizing the change.

Note: CMS addresses the 30-day billing switch in pp. 129-135 of the 682-page rule at https://s3.amazonaws.com/public-inspection.federalregister.gov/2018-24145.pdf.