Home Health & Hospice Week

MACs urge appeals for CERT denials.

What steps you take to deal with possible claims denials related to advance directive requirements may depend on which Medicare contractor you have.

Reminder: The new Home Health Conditions of Participation that took effect last January 2018 require agencies to have information related to a patient’s advance directives in the Plan of Care.

The National Association for Home Care & Hospice discovered that CERT audits “have uncovered significant noncompliance with this new requirement,” it said, indicating mass retroactive denials could be in the offing (see Eli’s HCW, Vol. XXVIII, No. 2).

NAHC recommended that agencies should review their claims, secure POC addendums when identifying the problem, and submit corrected claims accordingly.

But now, the course is less clear. Each HHH Medicare Administrative Contractor has issued its own notice about the matter, and they don’t necessarily agree.

Palmetto GBA

The MAC serving the largest number of HHAs explains what counts as an advance directive and notes that the CoPs “state that information related to any advanced directives must be included in the beneficiary’s plan of care.”

However, Palmetto GBA fails to tell agencies what to do about claims with POCs that lack this information. But in a message to NAHC, Palmetto says agencies should update their POCs as needed and that claims adjustments aren’t necessary, the trade group reports.

Plus: The POC just must indicate what kind of advance directives are on file for the patient, not contain the details of those documents, the MAC reportedly told NAHC.

CGS

Smallest HH MAC CGS also acknowledges that the CoPs require documentation “on the POC, which signifies that the specific directives from the beneficiary have been obtained and documented in your records.”

But CGS goes further, saying that the Centers for Medicare & Medicaid Services hasn’t directed it to review POCs for the item and “it is not necessary for home health providers to rebill or adjust previous claims submitted without the advanced directives on the POC.”

CGS also suggests that backtracking for advance directive documentation is a waste of time. “The POC is required prior to submitting the claim for payment, so submitting an addendum to the POC to add missing requirements after a claim was submitted would not be acceptable,” the MAC judges.

Plus: CGS also urges agencies “to appeal these types of denials from the Comprehensive Error Rate Testing (CERT) program/contractor.”

National Government Services

Second-largest HH MAC, National Government Services, states flatly that “we are not denying claims for lack of detail about particular advanced directives on the home health plan of care.” It does acknowledge the CoP requirement and advise agencies to document the directives on the POC, although much like Palmetto it indicates that “it is not necessary to duplicate those specifics on the plan of care.”

NGS doesn’t comment on whether agencies should add to previous POCs, but does note that “if a plan of care is updated with an addendum to show advance directive information, it is not necessary to submit adjustments to processed claims.”

Plus: While not explicitly encouraging appeals on the issue, NGS does note that “if you receive a denial from another contractor, you may exercise your appeals rights.”

In the face of the differing information coming from the three HHH MACs, NAHC is working to persuade CMS to “weigh in” on the issue, NAHC’s Mary Carr tells Eli.