Home Health & Hospice Week

What does your utilization data say about you?

Home health agencies struggling to stay afloat under the Patient-Driven Groupings Model are stuck between a rock and a hard place, with a new warning from CMS making it even harder.

The Centers for Medicare & Medicaid Services released an MLN Matters article on Feb. 10 titled “The Role of Therapy under the Home Health Patient-Driven Groupings Model.” PDGM has not altered eligibility criteria and coverage for the home health benefit, CMS stresses in the article.

“Therapy provision should be determined by the individual needs of the patient without restriction or limitation on the types of disciplines provided or the frequency or duration of visits. The number of needed visits to achieve the goals outlined on the plan of care is determined through the therapist’s assessment of the patient in collaboration with the physician responsible for the home health plan of care,” CMS maintains in the article.

CMS adds that “visit patterns of therapists should not be altered without consultation and agreement from the physician responsible for the home health plan of care. Any changes to the frequency or duration of therapy visits must be in accordance with the home health CoPs.”

CMS insists that “therapy should be provided regardless of the clinical group when included under the plan of care,” as specified by the physician.

“Therapists play an instrumental role in assessing and documenting patients’ functional impairments” and are vital to achieving functional outcomes, as represented on the Home Health Compare website, CMS points out. “High-quality therapy services with a focus on patient outcomes can help HHAs achieve higher patient satisfaction and higher quality scores.”

Managing therapy under PDGM has been a top problem area for many HHAs under PDGM, experts agree (see story, p. 42). And anecdotal evidence suggests at least some agencies are cutting back on therapy in an arbitrary way.

For example: Kaiser Health News published a story on Feb. 4, “What To Do If Your Home Health Care Agency Ditches You,” which many local news outlets picked up. The piece profiles the case of a Connecticut patient with MS who was discharged by her HHA, allegedly because “Medicare was changing its payment system for home health.”

The agency in the story reversed its decision when confronted by the patient — and presumably, the news coverage.

The KHN piece dispenses advice for patients in similar situations, ranging from lodging a complaint with the state survey agency to enlisting the referring physician for help to contacting a patient advocate, such as those at the Center for Medicare Advocacy.

Many therapists whose hours or even jobs have been cut, both by the Skilled Nursing Facility switch to the similar Patient-Driven Payment Model and by HHAs, are being vocal about changes as well.

Beware Whistleblower Lawsuits

“Too many have cut back on therapy,” judges Tom Boyd with Simione Healthcare Consultants in Rohnert Park, California. “Cutting services is dangerous to compliance,” Boyd tells Eli.

“Therapists across the country are worried not only in home health, but in the SNFs, about the lack or revenue drive based on therapy number and having their overall totals reduced by both SNF and HH administrators,” observes Kyle Johnson with Home Health Coding Solutions in Brigham City, Utah.

Whether CMS’ motivation for issuing the article is internal data, complaints from patients or therapists, or something else, the result is the same — HHAs must pay attention to this red hot risk area and make sure they are in compliance (see story, p. 46).

HHAs should take notice of this early message from CMS. “We are only six weeks in and Medicare is speaking against limiting patient access to therapy,” points out Cindy Krafft with Kornetti & Krafft Health Care Solutions. “Beneficiaries are already complaining to advocacy groups,” Krafft tells Eli.

“This communications seems like a proverbial ‘shot across the bow,’” warns Washington, D.C.-based healthcare attorney Elizabeth Hogue. “Agencies have now been officially warned that utilization of therapy services will be scrutinized.”

And it should hardly come as a surprise, considering that in rulemaking going back years, CMS has vowed to keep an eye on therapy utilization and take action if it finds problems, notes attorney Robert Markette Jr. with Hall Render in Indianapolis. “Consider it your final warning,” Markette says of the new article.

CMS may be more eager to jump on — and head off — gaming of PDGM, because it has seen significant therapy utilization swings under SNF PDPM, Markette believes. And don’t be surprised if data issued in coming months shows similar problems in home health.

The next question: What if data mining makes you stick out like a sore thumb? “Many expect audits to occur,” Krafft predicts.

Whether scrutiny comes from your HHH Medicare Administrative Contractor, a Medicare fraud contractor, surveyors, the HHS Office of Inspector General, or elsewhere, it’s almost a certainty that it will come from some federal quarter, experts agree.

Don’t be surprised early on to see the feds pick a few high-profile abusers of the system and “drop the hammer,” Markette predicts. CMS might not be able to catch every abuser, but busting some prominent HHAs that are violating policy will provide an example for the provider community at large.

And: Don’t forget the threat of potential whistleblower lawsuits. An army of disgruntled under- or unemployed therapists can prove fertile ground for qui tam attorneys to find plaintiffs.

Note: The MLN Matters article is at www.cms.gov/files/document/se20005.pdf.