Stop risking reimbursement by understanding coverage rules and properly training and supervising staff.
With reviewers examining medical necessity more closely than ever, you need to heed what the experts have to say on fending off denials:
1. Read the manual.
The
Medicare Benefit Policy Manual (Pub 100-02) Chapter 7 is your Medicare coverage bible, and you should know it practically by heart, experts agree. Consultant
Lynda Laff with Laff & Associates in Hilton Head Island, S.C. also recommends reading the
Medicare Claims Processing Manual (Pub 100-4) "to better understand the rules and criteria for billing." Home Health Agency billing is covered in Chapter 10 and hospice billing in Chapter 11. Links to the manuals are online at.
www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Internet-Only-Manuals-IOMs.html.
2. Understand homebound doesn't equal automatic coverage.
A patient must be homebound to qualify for the Medicare home care benefit, but that isn't the only requirement, cautions Chicago-based regulatory consultant
Rebecca Friedman Zuber. "Many agencies don't understand that just because a patient has a chronic condition and is homebound, doesn't mean they are automatically eligible for nursing Observation and Assessment," she laments. "If that is the only skilled nursing service being provided and the patient is stable for three weeks, you have to have a really good clinical reason (supported by the physician) to believe that they will not be able to maintain stability in order to keep them on service."
Problem:
"Agencies will pair Observation and Assessment with Teaching and spend each visit reviewing one of the patient's medications -- regardless of how long the patient has been on the med and how impaired they may be cognitively," Zuber says. "Patient is stable, loves the attention, and the agency wants to stay in because the patient is still homebound, regardless of the fact that there really is no skilled need."
3. Train on coverage.
To avoid scenarios like those, it's not enough for HHA managers to understand the coverage criteria themselves. They also must then train their assessing clinicians on them, experts urge.
4. Supervise service delivery.
After training staff on coverage criteria, managers then need to make sure staff follow through and apply them. Agencies need to "implement appropriate quality review activities and processes to ensure that all patients on service actually qualify for services," Laff advises. That will include ensuring that you have sufficient resources to oversee clinical care delivery.
Try this:
Laff recommends a primary (field) nurse clinical model. Under that set-up, each nurse case manager must be able to "clearly identify with measurable indicators and/or specific clinical evidence how each patient meets home health criteria at admission and ongoing through the episodes."
5. Use case conferences.
You can make sure the primary nurse can justify the patient's eligibility by using a one-on-one case conference process, Laff offers. Under that system, clinicians review each patient at specific intervals.
Note:
CGS's CERT article is at
http://cgsmedicare.com/hhh/pubs/mb_hhh/2012/06_2012/index.html#004.
