Whoa! Slow Down! (the disease process….)
Many thanks to one of my internet friends, Guy Davis who works with the HomeSight Programs, I have received a Palmetto notice that I obviously missed earlier. This one, unlike thousands of others, is actually important. It tells us that skilled services can continue to be provided as long as they are required for the maintenance of the patients current condition or to slow down the progress of a disease state. Based on the Jimmo settlement, there are now updates to the Medicare Coverage Benefits Manual for home health that read:
…Coverage of skilled nursing care or therapy to perform a maintenance program does not turn on the presence or absence of a patient’s potential for improvement from the nursing care or therapy, but rather on the patient’s need for skilled care. Skilled care may be necessary to improve a patient’s current condition, to maintain the patient’s current condition, to prevent or slow further deterioration of the patient’s condition. Medicare Benefit Policy Manual, Ch. 7, 20.1.2
…Skilled Nursing services are covered where such skilled nursing services are necessary to maintain the patient’s current condition or prevent or slow further deterioration so long as the beneficiary requires skilled care for the services to be safely and effectively provided. … MBPM, Ch. 7, 40.1.1
Maintenance Therapy – Where services that are required to maintain the patient’s current function or to prevent or slow further deterioration are of such complexity and sophistication that the skills of a qualified therapist are required to perform the procedure safely and effectively, the services would be covered physical therapy services. … MBPM, Ch. 7, 40.2.2.E
This does not mean that you can adopt patients for life or continue to teach and re-teach the same material. It does not extend Observation and Assessment beyond three weeks if there is no documented real potential of an exacerbation.
It does mean that patients who respond to therapy and suffer less pain because of therapy may continue to receive it as long the therapy is of a complexity that it can only be rendered by a skilled therapist.
The case that comes to mind is one that was denied a couple of years ago. The patient suffered from multiple skeletal deformities which compromised the space in her thoracic cavity and gut for her organs. Without regular therapy, she would have spasms to the extent that she fell off her scooter. Nobody else could perform the therapy which consisted of deep tissue massage among other modalities because of the skeletal deformities.
This is an extreme case but maybe not so extreme in light of Jimmo. Remember, you can see a patient to maintain a condition or slow the progress but ONLY when the complexities of the skill require a therapist.
Does anyone have any patients they think they may have discharged prematurely in the past that met the Jimmo criteria?
I wonder about some wounds that simply will not heal. If it requires the skills of a nurse to safely render care to prevent infection or expansion in wound surface area, would it now be covered? Speaking of Guy and Homesight, what about the visually impaired patient who requires regular checks for macular degeneration to quickly identify opportunities for laser therapy and thus, prevent further deterioration?
I do not expect any colleagues to take advantage of these changes to the coverage manual without bringing needed benefits to the patient. I think if you take the time to read my blog, you passed up that level of sleaze a long time ago. On the other hand, I have been heartsick at some discharges in the past where a patient was not going anywhere. It was like they were suddenly stable at the lowest level of functioning they could reach. They needed home health nursing or therapy but according to our guidelines, they simply did not qualify.
Many thanks to those who fought long and hard for the Jimmo settlement. It isn’t going to open the doors for abuse of the Medicare benefit but it will make a world of difference for a small group of patients who genuinely need us.
I think it will take time for many people to even try. I heard somewhere today that if you are appealing a denial, the wait for an ALJ date is 2.5 years. Will make this interesting to see where it goes
My two biggest fears are documentation that doesn’t support a blanket statement of how the patient is benefiting from the services and that some agencies will take this as carte blanche to keep patients forever like M & E in the past. When that happens, we will avoid it completely due to high scrutiny.
That’s about right on the length of current delays in getting an ALJ hearing date set. It’s becoming a due process problem. The QICs (who handle the second level of appeal) are also WAY behind schedule and are starting to miss their decision deadlines on all (or nearly all) appeals. We are getting “escalation” letters giving us the option of skipping the QIC level to go straight to the ALJ level on almost every appeal now. That doesn’t mean you will get that ALJ hearing scheduled much sooner though. That said, QIC denials are usually a little better supported than the original denial or the one from redetermination, so if I am appealing a particularly frivolous redetermination level denial and the QIC offers the escalation option, I might consider opting to do just that so the other side doesn’t get another opportunity to improve their rationale for denying the claim before I get to argue the case to an ALJ. However, we’ve seen more success at the QIC level in large cases involving extrapolated overpayments over the last few years compared to our success rates at that level prior to that, so escalating a case just to make sure you make it to the ALJ level with a frivilous or not well supported denial in tow might not always be the best idea. In those kinds of cases the overpayment is usually very large so delaying recoupment is often very important (recoupment starts back if we escalate). Skipping the QIC level can further compound the problem by taking away your last opportunity to win the reversal of a few denials and therefore reduce the extrapolated overpayment before reaching the point where we can no longer stop recoupment. Every case is different though, so the escalation question has to be evaluated based on the specifics of the facts of your case and how each option might impact your cash flow situation.
By far the scariest audit trend to me is the massive increase in the use of 6 month (or sometimes 1year) payment suspensions DURING an audit and BEFORE they even issue the initial results of their review. There are no “denials” to appeal at that point since they haven’t issued any yet, and therefore there is no way to defend yourself or even understand what the auditors concerns are, but that won’t stop them from justifying a payment suspension on the basis that shortly after beginning their review they found some claims that they will eventually deny (for reasons you won’t know until they issue their findings though) and therefore they believe an overpayment exists. They argue that the suspension is necessary to prevent potential loss to the Medicare program. Six months or a full year with ZERO Medicare revenue is difficult to survive, and having no right to defend yourself or challenge the basis for the suspension while it is still in place is infuriating.
Les, what annoys me beyond belief is that when a perfectly good claim with a sufficient F2F document gets denied and is immediately overturned on appeal BUT the QIC finds another reason – legit or not – to deny the patient. In those cases, and there are tons of them, the careless, sloppy work of the MACs are causing further delays in payment which are completely unwarranted and they are costing providers a full round of appeals. I had a MAC deny a wheelchair bound patient with Alzheimer’s Dementia as not being homeboud. How do you argue that? I think I went with, ‘Have you lost your tiny little minds?’ and prevailed only to be told services were not skilled.
The section about payment suspensions is a joke. For those of you who do not spend serious time with the Program Integrity Manual, it says that providers must have a 30 day advance notice that payment will be suspended unless there is credible evidence that the billing patterns of the provider will change. Well, I must be fraudulent because if I thought that I wouldn’t be paid by a client after 30 days passed, I would spend some serious time getting all my invoices straight and bill more frequently and follow up with greater diligence. Who would have thought? I’m a criminal after all.
Les, I am really swamped right now. If you are up to writing a guest post on how to handle the later levels of appeals, I’m sure my readers would love it.
At least it’s a start. We will NOT adopt every poor soul that we love and know really needs us; it’s a shame that we have to be leary of such a breakthrough in the thought processes of people who stand at a distance and make decisions about the health and lives of people we see regularly.
If I have not personally seen a patient, there is not a lot of decisions I can make for care. For instance, I know that if a patient is intermittently blind, some of the answers are incorrect. I also know that if the patient is diabetic, on several eye drops, etc., it is the nurse who documented the patient could see that is likely in error. On the other hand, maybe the nurse who documented that the patient was blind made assumptions and didn’t actually see if the patient could read with her glasses. The patient who takes oxycontin twice a day may never have pain that interferes with the patient’s activities of daily living. All I can do is ask. As always, there is a high probability that I am right but…..
Only the nurse who assessed the patient and congress know for sure. Sometimes, even the assessing nurse doesn’t know as much as Congress. And I was just kidding about the probability of my being right.