Home Health & Hospice Week

Don’t expect to bill patients for denied services.

Illinois home health agencies that didn’t achieve a 90 percent or higher “affirmation” rate under the previous Pre-Claim Review demonstration, therefore earning lighter review options, have a second chance.

“After a six-month period, HHAs demonstrating compliance with Medicare rules through pre-claim review or postpayment review will have additional choices, including relief from most reviews except for a review of a small sample of claims,” Review Choice Demonstration contractor Palmetto GBA explains in a recently released question-and-answer set from the contractor’s May 2 Ask the Contractor Teleconference.

Once they reach the 90 percent threshold for that duration, RCD agencies can choose from PCR, “selective” postpayment review of a random sample of claims every six months, or “spot check” prepay review every six months.

But the jury is out on whether RCD agencies will even want to choose the selective or spot check options. Last month, about 60 percent of Illinois HHAs were eligible to choose one of the advanced options that would require less claims review, a Palmetto spokesperson recently told Eli. But only 24 percent of agencies actually opted for selective postpay review or spot check prepay review (see Eli’s HCW, Vol. XXVIII, No. 20).

RCD agencies may continue to opt for the full prepay review option, since it gives them a chance to resubmit the claim with documentation that was originally missing, among other reasons.

That’s especially true, since the Centers for Medicare & Medicaid Services has made clear that Illinois agencies can’t bill beneficiaries for services shot down in RCD review, unless the agency issued a valid Advance Beneficiary Notice (ABN).

To be valid, an ABN must “notify a beneficiary in advance of furnishing an item or service when such item or service is considered not medically reasonable and necessary, or when a beneficiary is not considered homebound, or when the beneficiary does not need physical therapy, speech-language pathology, skilled nursing care on an intermittent basis, or have a continuing need for occupational therapy, in order to shift financial liability for non-covered care to the beneficiary,” CMS says in a recently updated RCD question-and-answer set. “In accordance with CMS policies, if an ABN was not issued when required at the start of care and the pre-claim review is non-affirmative, the beneficiary is not financially liable for the care that the HHA provided while awaiting the pre-claim review decision.” (Emphasis added.)

The only ABN scenario that applies: “If the HHA believes that the pre-claim review will be non-affirmative for any of the reasons listed, the provider may issue an ABN in accordance with CMS policy which would allow the beneficiary to choose to receive the service and accept financial liability,” CMS explains in the Q&As. “The ABN would be effective for denied services furnished after receipt of the ABN.” (Emphasis added.)

No-no: “If the HHA expects Medicare to cover the services, an ABN should not be issued. Blanket or routine issuance of ABNs is prohibited under Medicare policy,” CMS stresses in one Q&A. In another answer, CMS emphasizes that “Home Health Agencies will not be allowed to require that benefi­ciaries sign an ABN,” and tells beneficiaries “who feel as though they are being inappropriately asked to sign an ABN” to contact Medicare to report it.

Note: More on the ABN issue, as well as a wide array of other RCD topics, is in the 101-question set at www.cms.gov/Research-Statistics-Data-and-Systems/Monitoring-Programs/Medicare-FFS-Compliance-Programs/Review-Choice-Demonstration/Downloads/RCD-FAQs.pdf.