Home Health & Hospice Week

Avoid a last-minute scramble to comply.

Like face-to-face, another confusing requirement can cause you to lose an entire episode’s reimbursement based on the physician. Unlike F2F, the physician service length estimate is relatively easy to get right.

Background: Back in May 2015, the Centers for Medicare & Medicaid Services implemented a new requirement for the physician to include on the home health recertification an estimated length of time that the patient will need home care services. In the Home Health Prospective Payment System final rule published in the Nov. 6, 2014 Federal Register, CMS stated that “in recertifying the patient’s eligibility for the home health benefit, the recertification must indicate the continuing need for skilled services and estimate how much longer the skilled services will be required.”

CR 9119, the transmittal issued April 22, 2015, that put this requirement into regulation, similarly stated that “the physician must include an estimate of how much longer the skilled services will be required.” Then in July, CMS reinforced the requirement in CR 9189. “The contractor shall review for the certifying physician statement which must indicate the continuing need for services and estimate how much longer the services will be required,” CMS said in the transmittal that updated the Medicare Program Integrity Manual.

However, CMS and its HHH Medicare Administrative Contractors at first were unclear on how the estimate should be documented (see Eli’s HCW, Vol. XXIV, No. 25). But in fall 2015, MAC CGS said it had consulted CMS, which clarified that “the physician’s recertification estimate should be included with other required elements of the recertification and not on any separate form or order.”

Fast forward two years, and home health agencies are still having trouble with this requirement — leading to losing the reimbursement for an entire episode regardless of the patient’s medical necessity, homebound status, and other documentation. “The Home Health Provider Contact Center often receives calls from providers asking about the recertification requirement for physicians to include an estimate of how much longer the skilled services will be required,” CGS says in an Aug. 28 website post.

HHAs Rely On Docs, Again

“This requirement, like the F2F, requires that the physician make the determination,” notes Judy Adams with Adams Home Care Consulting in Durham, North Carolina. “While the requirement is not as involved as the F2F documentation, physicians often do not add the statement as part of the recertification process.”

As with F2F, agencies are on the hook for the physician’s documentation. And “the major issue is that physicians do not automatically see this requirement as one that they are responsible for,” Adams tells Eli. “Most physicians believe their only responsibility is to sign the orders — or at recert time, the updated plan of care.”

Also like with F2F, “the home health agency is held responsible for ensuring this requirement is met and is the entity that will be penalized financially if it is not completed,” Adams protests. “The physician is not held accountable nor receives any penalty if it is not done.”

Some agencies themselves are unaware of this requirement until it knocks out an entire episode’s reimbursement. Or agencies get the details wrong, such as one HHA director who told consultant Julianne Haydel that they use a separate order to capture this requirement, when Medicare requires it to be on the recert.

This isn’t on many agencies’ radar because they simply haven’t gotten hit with denials for it yet, believes Patti Zabell, Chief Clinical Officer with Androscoggin Home Care and Hospice in Maine. Or survey deficiencies for that matter.

Plus: “Agencies are overwhelmed with the continuing changes in requirements,” Zabell says.

“Because we are faced with change after change, it is difficult to stay compliant with each one.” “We simply have not given this requirement the attention it needs to be fully and completely implemented,” says Haydel, with Haydel Consulting Services in Baton Rouge, Louisiana.

Bottom line: The length estimate requirement won’t “rise to a level of great attention until payment denials or survey findings take place,” Zabell says. “Then people will scramble to comply.”

Note: See CR 9119 at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R92GI.pdf and CR 9189 at www.cms.gov/Regulations-and-Guidance/Guidance/Transmittals/Downloads/R602PI.pdf. See CGS’s recent post on the topic at www.cgsmedicare.com/hhh/pubs/news/2017/0817/cope4275.html.