OASIS Alert

OASIS C isn't the only current challenge agencies face.

Don't take denials lying down. Appeal every time you think you have provided a covered service and it is denied, experts advise.

More than 2,100 attendees gathered in Los Angeles Oct. 10 through Oct. 14 for the 28th annual meeting of the National Association for Home Care & Hospice. In a two-hour general session on Oct. 12th, NAHC staff and home care community leaders outlined their progress in educating Congress on the value of home care and decreasing the amount of money to be cut from the Medicare home health benefit to finance health insurance reform.

They called on providers to continue their grassroots efforts to educate their elected representatives about why home care should be a critical part of any health care reform. NAHC broadcast the session as a Webcast, which is available at www.nahc.org.

Agencies are seeing increased medical reviews and additional development requests (ADRs), said Mary St. Pierre, NAHC's vice president for regulatory affairs. Denials seem to be targeting homebound status, medical necessity and therapy visits, she told attendees at the NAHC session on regulatory issues. You can expect these denials to continue as focus on cost cutting increases. Reviewers require documentation to support every visit, she emphasized.

Strategy: Be sure your clinicians know they must establish realistic goals, have goals with realistic timeframes, and clearly document the patient's condition on each visit. In completing the OASIS assessment, don't stop with checking boxes for the questions, St. Pierre recommended. Also add a narrative explaining any way the patient differs from the description in the box you check, she emphasized.

In addition, your clinicians need to know that even when you get an episode payment, every visit must show the skilled service provided and why the clinician needed to be there.

And appeal your denials, using the regulations in 42 CFR 430-432 to support your appeal. Also use the statute for the homebound requirements and highlight in your documentation the sections that support your position, St. Pierre advised. Look on the NAHC Web site for documents to assist in appeals, she added. I

n other regulatory news:

• Medicare Administrative Contractors are operational in only one geographic jurisdiction. Cs will replace fiscal intermediaries. The other three MACs are still in contract disputes.

New way: Home health agencies will no longer be able to select a contractor outside their geographic area, even if they have agencies in multiple states, St. Pierre said. You must use the MAC for the geographic location of the agency.

• Recovery audit contractors (RACs) will be looking at HHAs for improper Medicare payments, St. Pierre confirmed. CMS has not yet implemented a phase-in strategy because the RAC must first develop the strategy and submit it to CMS for approval, St. Pierre explained. The RAC must then publish the plan and educate the affected provider group about it before the RAC can begin activity, she said. Nothing is available yet for HHAs and hospices.

Be prepared: The money to be made from home care is unlikely to provide the biggest dollar return, she predicted. But agencies can best prepare before RAC action begins by determining where the potential pitfalls are for their agency, educating staff, and performing audits to detect problems, she said. Correct any problems you find. And be sure your staff know who your RAC is and where to direct any mail you receive from them.

• Rumors of revised home health conditions of participation (CoPs) are again circulating, with some mention of publishing them in late 2009 or early 2010, St. Pierre reported. The CoPs will come out again as a proposed rule and there will be a comment period, she noted. St. Pierre predicts a minimum of nine months before new CoPs would be out and CMS would begin any enforcement.

• CMS is developing an alternative sanction regulation for survey deficiencies, to include some oversight and specific improvement requirements, somewhat like nursing homes do, St. Pierre said. There is no release date available yet. CMS is also working on new guidance for surveyors. Providers should download these as soon as they are available, she recommended.

• Red flag rules should require minimal attention, but HHAs need to take some steps, St. Pierre said. Establish a basic program for identifying, preventing, and mitigating identity theft in your organization, she advised. Identify your red flags, respond to them and update your program periodically, she added.