Introducing Home Health 101

Introducing Home Health 101, our new online orientation for home health clinicians and managers, with a focus on compliance regulation.

Have you hired staff new to home health care? Need a refresher on the basics of home health compliance? Due for a review on the latest regulation changes?

As the Alliance’s director of clinical and regulatory affairs, I’m often asked these questions from members looking to ensure that their clinical staff and managers have the tools they need to successfully navigate the regulatory challenges they’ll face in home health. In the past, I’ve done in-person presentations on this material but now—to ensure that even more people have access to it—I’m pleased to announce that Home Health 101 is available digitally for the first time.

In Home Health 101, I highlight the Conditions of Participation standards (COPs), Medicare regulations related to the survey process, and how the survey process works. 5 CEU credits are available (for a small processing fee) to those who complete the course and pass an evaluation.

Objectives include how to:

  • Review the Home Health’s Conditions of Participation (COPs);
  • Identify three of the five criteria for Medicare certification for home health benefit;
  • Understand Requirements for Physician Orders and Face-to-Face (F2F);
  • Identify Medicare’s definitions of “confined to home”; and
  • Review patient notices.

The program is broken into five sections:

  • Part 1: Orientation to Home Health
  • Part 2: Conditions of Participation (CoPs)
  • Part 3: Patient Notices
  • Part 4: Conditions of Participation, Contin.
  • Part 5: Skilled Professional Services and HHA Services

Alliance Comments to CMS on CY2022 Home Health Rule

To ensure that home health agencies in Massachusetts can provide high-quality care to older adults, the Home Care Alliance of Massachusetts has submitted comments to the federal government regarding the proposed rule for next year’s Medicare home health rates. Our comments to the Centers for Medicare and Medicaid Services (CMS) address several sections of the proposed rule, including:

  • CMS’s flawed reasoning behind the -4.36% “behavioral adjustment” to the rates;
  • Concerns about a budget neutrality adjustment based on 2020 data skewed by COVID;
  • A market basket adjustment that does not account for ongoing costs related to COVID;
  • Protections for counties with large wage index reductions;
  • Modifications to the Value Based Purchasing model before it is implemented nationwide;
  • Greater flexibility around the five-day deadline to submit the new Notice of Admission;
  • Greater flexibility to allow therapist to conduct initial assessments; and
  • Expanded allowances for virtual aide supervisions.

Modernizing the Medicare Home Health Benefit—at Last

Please help us advocate for The Choose Home Care Act, which would provide eligible recipients with SNF-like levels of care at home for 30 days post hospital discharge.

Last week, legislation was introduced in the US Senate that would provide the most significant update to the Medicare home health benefit since its inception. A strong bipartisan group of senators filed the Choose Home Care Act, which would provide eligible recipients with SNF-like levels of care at home for 30 days post hospital discharge. Services would include not only traditional nursing and therapy, but also meals, personal care, remote patient monitoring, and non-emergent transportation, if needed.

A study commissioned by NAHC and the Partnership for Quality Home Health care estimates that the Choose Home Care program could generate Medicare annual savings of $144-247 million with $1.6-2.8 billion in savings over 10 years. NAHC President Bill Dombi called this “must pass” legislation. So, we have a bipartisan bill that could save Medicare dollars, with support from AARP and others in the aging advocacy networks. Sounds like a slam dunk. But this is DC, so there are no such things.

While the advocacy focus is currently on the Senate bill, I hope that when the House acts, Massachusetts can lead the way and get our full delegation on board. Please help Choose Home and send a message to our two senators.

NGS Resumes Home Health Medical Record Review

NGS will resume medical record review after suspension from Public Health Emergency

National Government Services (NGS) recently contacted Alliance staff to review details for the resumption of medical record reviews. This follows the suspension of the Targeted Probe and Educate (TPE) audit because of the Public Health Emergency. We expect that this review will start this week. All the Medicare Administrative Contractors (MACs) will publish information indicating that medical reviews will resume.

NGS has shared some details with Alliance staff about this resumption, which are summarized below; however, the details are not yet posted on their website.

    • NGS will resume post-payment medical reviews. This is different than the TPE program. CMS has not provided any direction to the MACs thus far regarding the resumption of TPE.
    • The post-payment reviews are service-specific (as opposed to provider-specific) and will be a random sample. A service-specific review is one where the MAC is focused on the claim and not the provider.
    • CMS has given a resumption date of August 17, 2020. It is anticipated that providers will begin receiving Additional Documentation Requests (ADRs) once NGS posts more information on their website. NGS indicated it will post a brief description of the service-specific audits on its website and ADRs will be sent approximately 2-3 days after this posting.
    • The timeframe from which NGS will pull claims is January 2019 through February 29, 2020
    • The maximum number of claims to be pulled per provider is 20. There is no minimum. This is less than the total number under the TPE program, and a provider may or may not receive ADRs for a full 20 claims. It is anticipated that the majority of hospice and home health providers will not have this many claims pulled. Any providers having difficulty responding to the ADRs on time should contact NGS and they may be able to work with the provider if the provider makes them aware of the situation.
    • Providers should not wait to receive an ADR request in the mail, but should check the status of their claims processing and identify any with the S B6001 status. These are claims that have had an ADR generated.
    • NGS has 60 days to review the provider’s response to the post-payment ADR. Though providers have 45 days to respond to the ADR, a 30-day response is strongly recommended to ensure that the response is received and recorded by the 45th day.
    • A results letter will be sent after each claim is reviewed.
    • A provider may request education and the NGS may suggest education. Providers are not required to participate in education, although the Alliance strongly recommends it.
    • The error rate (payment error rate or claim error rate) is not as important with a service-specific post-payment review as it is with TPE, since there are no “rounds” in post-payment review as there are with TPE. The MACs are not setting error rate thresholds upon which further NGS action is predicated. As with all medical reviews, if NGS identifies a concern, i.e. a quality concern or indication of potential fraud or abuse, NGS will refer to the appropriate entity (i.e., the appropriate QIO or the division of CMS).
    • NGS will continue to make phone calls to providers for missing documentation or questions about documentation submitted.

It is still possible that providers will receive some other ADRs as part of other review programs such as CERT. CMS contractors, including Unified Program Integrity Contractors, may conduct targeted prepayment and post-payment reviews when there is evidence of potential fraud or gaming. CMS has not yet indicated if the results of the post-payment reviews that are resuming this month would be used for future TPE audits.

If you have any questions, please contact Colleen Bayard at cbayard@thinkhomecare.org.

CMS Finally Releases Updated ABN Form!

Providers will need to use the renewed ABN form starting this August.

CMS just released the long-awaited Advance Beneficiary Notice of Noncoverage (ABN). The current ABN form expired in March 2020, so CMS instructed providers to continue using the expired form, since the form’s renewal was on hold at the Office of Management and Budget during the Public Health Emergency. Yesterday, CMS posted the updated ABN Form CMS-R-131 and form instructions (see the Downloads section at the bottom of the linked page).

The renewed form (with the expiration date of June 30, 2023) will be mandatory beginning August 31, 2020.  The ABN is issued by home health and hospice providers to Medicare beneficiaries in situations where Medicare payment is expected to be denied. The ABN is issued in order to transfer potential financial liability to the Medicare beneficiary in certain instances. Guidelines for issuing the ABN can be found beginning in Section 50 in the Medicare Claims Processing Manual, 100-4, Chapter 30 (PDF).

Colleen’s Corner: Targeted Probe and Educate (TPE)

Did you know that National Government Service (NGS) is focusing one of the home health Targeted Probe and Educate on therapy utilization?

Therapy TPE Audits Lead to Home Health Denials

Did you know that National Government Service (NGS) is focusing one of the home health Targeted Probe and Educate on therapy utilization?

NGS is auditing home health rehab service concentrating on medical necessity, the timeliness of the 30-day reassessments that is performed in conjunction with an ordered therapy service, and the required reassessment content by each rehab discipline. For many of the denials, the reasons stem from the therapist not comparing the present assessment results to prior assessment measurements and failing to document the effectiveness of therapy, or lack thereof, as required by regulation.

It may be beneficial to review with your therapy staff the key components to the therapy reassessment documentation as outlined by CMS.

  • Each rehab discipline must document measurement results of functional reassessment compared to prior measurements
  • Each must also document why therapy should be continued or, if applicable, discontinued
    • Document therapist’s determination of effectiveness of therapy
    • Why therapy is beneficial?
    • Why does the patient need more?
  • Remember the re-assessment is only one component of the home visit; there must be evidence of an ordered intervention as well.
    • Document treatment performed the day of re-assessment
    • Re-assessment without care plan interventions is a not covered service

Be Aware…

If measurement results do not reveal progress toward goals and/or do not indicate that therapy has been effective — then, to continue therapy — there must be consultation with the physician and documentation showing why the therapist and physician determined therapy should be continued.

Don’t forget to confirm continuation of the therapy with the verbal order!

I hope to hear from folks who are experiencing any of these issues with the therapy TPE.

Colleen’s Corner: Quality Check

An Update on Quality Reporting Measures.

Did You Know?

The quality measure Improvement in Pain Interfering with Activity is being removed from Home Health Compare as of the April 2020 Compare Refresh. However, home health agencies are still collecting data for this measure through CY2020.

This quality measure will also be removed from the Quality of Patient Care Star Rating which will be calculated using seven measures beginning April 2020. Make sure to check how this will impact your agency’s star rating, so check out your Quality of Patient Care Star Rating Provider Preview Report in your agency’s CASPER Folders

The January 2020 Compare Refresh will be available this week, on January 23. CMS is no longer publicly reporting Emergency Department Use without Hospital Readmission During the First 30 Days of Home Health, and Rehospitalization during the First 30 Days of Home Health on Compare beginning with this January 2020 Refresh.

The OASIS Quarterly Q&As are scheduled to be posted on January 21, 2020.

Make your Star Ratings Rise to the Top

Provide focused education to your clinical staff with Blueprint for OASIS Accuracy training hosted by the Home Care Alliance on April 15-16, 2020 at the Sheraton Framingham Hotel & Conference Center, 1657 Worcester Rd, Framingham, MA.

Registration fills up fast so be sure to register early.

Click Here to Register

Haunted by TPE? Don’t Let It Frighten You!

Many home health care agencies have contacted me over the past few weeks with questions about the Targeted Probe and Educate (TPE). Here are answers to many common questions.

Many home health care agencies (HHAs) have contacted me over the past few weeks with questions about the Targeted Probe and Educate (TPE), so I thought I would review the rules because I am sure others have the same questions. NGS has contacted HCA to let us know that there are new TPE audits in Massachusetts: high therapy utilization, long lengths of stay, documentation supporting homebound for Heart Failure, COPD, Diabetes and Dementia, and medical necessity.

How Will the HHA Be Notified:  Agencies will receive a letter from NGS stating the focus of the targeted probe. Expect to receive between 20–40 ADRs, although every agency targeted so far has received a request for the 40 records. If you are currently in a TPE audit you will not be chosen for another. If for some reason you receive another TPE please contact Colleen Bayard because agencies should only be under one targeted probe and educate for home health at a time.

Additional Documentation Request: The Medicare system will generate ADRs and you have a total of 45 days to respond with the requested medical records. Note: It is best to send in at least 30 -35 days, as NGS considers their time to acknowledge receipt of the documentation into their system as part of the 45-day timeframe. If your ADR is one day late it is considered “no response” and counts as an error.

Calculation: NGS calculates the Percent Error Rate (PER) by taking the dollars Medicare would have paid the HHA versus the dollars denied obtaining a percentage. The PER must be 15 percent or below for the HHA to be released from the next round of TPE.

Results Letter: At the conclusion of a round of review, you will receive a letter outlining the TPE process, the reason for denials including the Medicare regulations, denial rates (PER), release or retention from medical review and offer for one-on-one education information.

Education: Agencies will be notified of one-on-one education between NGS medical reviewers and the provider. It is very important to accept the education from NGS at the end of the audit; accepting the education demonstrates that you are trying to improve documentation and will help with the second round of TPE.

HHAs are Experiencing New Round of Targeted Probe and Educate

National Government Service (NGS) announces two new rounds of Targeted Probe and Educate (TPE) for home health agencies

Last month, the National Government Service (NGS) notified the Home Care Alliance of Massachusetts about two new rounds of Targeted Probe and Educate (TPE):

High therapy utilization. NGS will be reviewing documentation to ensure all CMS requirements have been met on therapy assessments and 30-day reassessments, as well as, medical necessity.

Documentation supporting homebound criteria. The second edit is specific to four diagnoses: Heart Failure, COPD, Dementia, and Diabetes and if the documentation confirms homebound status.

Many HHAs have contacted me over the past few weeks with questions about the TPE, so I thought I would review the rules because I am sure others have the same questions.

How Will the HHA be Notified: You will receive a letter from NGS stating the focus of the targeted probe: high therapy or homebound for one of the four diagnoses listed above. Expect to receive between 20–40 ADRs, although every agency targeted so far has received a request for the 40 records.

Additional Documentation Request: The Medicare system will generate ADRs and you have a total of 45 days to respond with the requested medical records. Note: It is best to send in at least 30 -35 days, as NGS considers their time to acknowledge receipt of the documentation into their system as part of the 45-day timeframe. If your ADR is one day late it is considered “no response” and counts as an error.

Calculation: NGS calculates the Percent Error Rate (PER) by taking the dollars Medicare would have paid the HHA versus the dollars denied obtaining a percentage. The PER must be 15 percent or below for the HHA to be released from the next round of TPE.

Results Letter: At the conclusion of a round of review, you will receive a letter outlining the TPE process, the reason for denials including the Medicare regulations, denial rates (PER), release or retention from medical review and offer for one-on-one education information.

Education: One-on-one education between NGS medical reviewers and the provider. It is very important to accept the education from NGS at the end of the audit; accepting the education demonstrates that you are trying to improve documentation and will help with the second round of TPE.

If you have any questions or concerns about TPE, it would be great to hear from you. Good Luck!

Members Flock to HCA’s Quality Improvement Meeting

Lots of member interest in HCA’s July QI meeting to discuss medical record audits and upcoming proposed rule changes.

With the sundry of regulation changes in the home health industry over the past few months, the July 24th Quality Improvement (QI) meeting had over 45 members participating in-person and by phone. The numerous medical record audits plaguing the industry dominated the meeting’s discussion.

Multiple agencies have received letters from C2C Innovation Solutions informing them that some claims under appeal have been selected for potential reopening as part of the Medicare Appeals Demonstration. The C2C auditors are conducting the analysis of claims previously adjudicated unfavorably by the Qualified Independent Contractor (QIC), that are currently pending at the Office of Medicare Hearings and Appeals (OMHA) and may be resolved favorably by the QIC.

Other audits that agencies are experiencing are new Targeted Probe and Educate (TPE) audits. These medical record requests are for 5-7 visits and lengths of stay greater than 90 days. No agency is in the third round of the Face-to Face TPE.

One agency reported at the meeting that they are facing three audits simultaneously; a hospice General Inpatient care (GIP) Targeted Probe from NGS, a home health PERM request for Face-to-Face (awaiting ALJ) and eight GIP Post Payment Review by Noridian.

During the meeting there was a lot of member engagement related the 2020 Proposed Rule; the proposal to require OASIS for all payors and the 8% behavioral adjustment. Agencies also discussed strategies for management with PDGM and the process for completing OASIS B-1 for January 1st episodes. PDGM will be a standing QI agenda item.

The HCA is planning to host a PDGM Networking Meeting to help our members with the transition to this new payment model. We are hoping to begin the meetings in September and have a guest speakers and consultants to assist with planning for this historic payment change. Stay tune for further details.

Don’t forget to check out our PDGM Bootcamp on September 24th!