The real reason your claim was denied.
Posts from the ‘Medicare Coverage’ Category
What is MedPac and why should you care?
Before I answer that question, I will admit that for years I thought MedPac was a Political Action Committee – you know, those huge organizations that use political contributions to try to win favor from lawmakers. I was wrong. Oops. Or maybe it was just a bad name for the committee.
MedPac is a committee created pursuant to the Balanced Budget Act of 1997. They are tasked with presenting information and recommendations to congress each year on payment to providers from Medicare. There are eleven commissioners with impressive titles and yet they seem to know very little about the home health industry and show very little interest in learning. I bet they are boring cocktail party guests if this lack of curiosity is pervasive. Just yesterday, they posted their March report which, as always, includes chapter about Home Health payments.
It is a long and boring document so please allow me to share with you the highlights. Here’s the big one.
MedPac recommends another five percent reduction to your payment and the elimination of therapy as a contributor to payment as we know it.
To support their position, various factoids taken out of context are posited as evidence. They note, for instance, that most beneficiaries can leave the home to go to the doctor and yet, Medicare does not provide any incentives for beneficiaries to receive services elsewhere.
Just to be clear, a trip to the physician for an elderly patient with congestive heart failure, COPD, a surgical wound, a recent CVA, etc. is necessary on occasion. In terms of difficulty, getting a cat to the vet is probably easier (although to their credit, Medicare beneficiaries don’t howl). It can take the better part of a morning to help the patient bathe and dress. Getting into the car is like directing an elderly person through a Cirque du Soleil rehearsal and upon arrival at the doctor’s office you might find that helping them out of the car makes getting into the car seem like child’s play. Of course, all of this must be repeated in reverse after the office visit and elderly people who are confined to the home are often eager to have a meal out somewhere since they’ve already endured the torture associated with automotive travel. Everyone is exhausted after the outing but it is worth it. The patient gets medical care and the family spends some time providing their loved one with a good meal and company. Passing a good time is not always easy. MedPac doesn’t quite get that.
Having said that, lives would be in danger if this was a twice weekly occurrence and not just the patient’s life. Even if a family had the will to survive such an ordeal several times a month, where would they take a patient for medication and diet teaching? Does MedPac believe it would be less expensive to send a patient to the ER for IV medications? About the only alternative I can think of is a skilled nursing unit or rehab facility that costs more and deprives the patient of the comforts of their home.
Patients requiring therapy often do go to outpatient therapy as suggested by MedPac, upon discharge from home health once the patient is no longer homebound. We should not have to be the ones to inform MedPac of how this works.
The report talks about a 2015 CMS review of home care services that revealed that almost 60 percent of claims were missing information that satisfied Medicare criteria. The report does not address all in the information sent to their contractors that is lost so neither will I. I could but I won’t. What’s important is the time frame of the report which resulted in an expansion of Medical review and the Preclaims Review Process. MedPac uses cost report data that doesn’t not include the added expense of being under scrutiny or having to participate in the PCR process. There are no home health leprechauns who put together charts and ensure that all the right pieces are put together so that the chart can be sent to the Medicare contractor that requested it. Paid employees do this work.
Another thought that occurs to me unbidden, as I hate to be unkind, is that when 60 percent of claims are found to be lacking one or more elements of documentation that satisfies Medicare requirements, maybe the problem is with the reviewer. Maybe there should be more education available to providers. Hell, I’d be happy if there were a number I could call and ask a question. (CGS is excepted from this last comment. Lately, I’ve been calling them for questions even though most of my clients bill Palmetto GBA).
There is so much more in this report that illustrates with utter clarity how little insight MedPac has into our industry but the therapy issue really gets under my skin like scabies. MedPac believes the increase in therapy is not justified in the very same report that notes that hospitalizations in home health patients has decreased from 28.8 percent down to 25.4 percent.
Another way of saying that is that an increase in therapy visits coincided with a decrease in hospitalizations. Even I know that correlation does not equal causation but MedPac presents no hard numbers to demonstrate that the lower hospital rates are not related to increased therapy although they speculate a little.
So, MedPac wants home health to take another hit. Bully for them.
Back to the original question: What is MedPac and why you should care? The first part of that question has been answered. More info is on their website if you are still curious. The second answer is that this information is prepared for the US congress. Unless they hear other points of view, our industry will continue to die a slow death by strangulation. Our state and national associations have lawyers and lobbyists who can construct arguments with greater legal authority than most of us and I have no doubt that they will. But if I were a senator or a representative (fat chance of that ever happening), I would want to hear directly from the people affected by these proposed cuts. So, take a few minutes and let your congressmen know how very myopic and well, stupid this report is and suggest they put it in the recycle bin. There’s no point in killing trees, too.
Nurses have been trained to not bother physicians, especially referral sources with petty concerns. But, there is a balance between irritating a physician to the point that your competitors gain a new referral source and responsible patient care. If you have to choose, go for responsible patient care.
We have looked and have been unable to find specific guidance on the new CoPs. There was a phone conference scheduled with NGS that was cancelled and nothing so far from Palmetto GBA. Help us out if you know anything.
Meanwhile, some people who are very knowledgeable and well respected in the industry differ from us in how we interpret what ‘estimating how much longer the patient will be on service at the time of recertification’ means. Look for it below in larger bold text.
§424.22 Requirements for home health services.
Medicare Part A or Part B pays for home health services only if a physician certifies and recertifies the content specified in paragraphs (a)(1) and (b)(2) of this section, as appropriate.
(a) Certification—(1) Content of certification. As a condition for payment of home health services under Medicare Part A or Medicare Part B, a physician must certify the patient’s eligibility for the home health benefit, as outlined in sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act, as follows in paragraphs (a)(1)(i) through (v) of this section. The patient’s medical record, as specified in paragraph (c) of this section, must support the certification of eligibility as outlined in paragraph (a)(1)(i) through (v) of this section.
(i) The individual needs or needed intermittent skilled nursing care, or physical therapy or speech-language pathology services as defined in §409.42(c) of this chapter. If a patient’s underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient’s care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the certification form, then the narrative must be located immediately prior to the physician’s signature. If the narrative exists as an addendum to the certification form, in addition to the physician’s signature on the certification form, the physician must sign immediately following the narrative in the addendum.
(ii) Home health services are or were required because the individual is or was confined to the home, as defined in sections 1835(a) and 1814(a) of the Act, except when receiving outpatient services.
(iii) A plan for furnishing the services has been established and will be or was periodically reviewed by a physician who is a doctor of medicine, osteopathy, or podiatric medicine, and who is not precluded from performing this function under paragraph (d) of this section. (A doctor of podiatric medicine may perform only plan of treatment functions that are consistent with the functions he or she is authorized to perform under State law.)
(iv) The services will be or were furnished while the individual was under the care of a physician who is a doctor of medicine, osteopathy, or podiatric medicine.
(v) A face-to-face patient encounter, which is related to the primary reason the patient requires home health services, occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care and was performed by a physician or allowed non-physician practitioner as defined in paragraph (a)(1)(v)(A) of this section. The certifying physician must also document the date of the encounter as part of the certification.
(A) The face-to-face encounter must be performed by one of the following:
(1) The certifying physician himself or herself.
(2) A physician, with privileges, who cared for the patient in an acute or post-acute care facility from which the patient was directly admitted to home health.
(3) A nurse practitioner or a clinical nurse specialist (as those terms are defined in section 1861(aa)(5) of the Act) who is working in accordance with State law and in collaboration with the certifying physician or in collaboration with an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.
(4) A certified nurse midwife (as defined in section 1861(gg) of the Act) as authorized by State law, under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.
(5) A physician assistant (as defined in section 1861(aa)(5) of the Act) under the supervision of the certifying physician or under the supervision of an acute or post-acute care physician with privileges who cared for the patient in the acute or post-acute care facility from which the patient was directly admitted to home health.
(B) The face-to-face patient encounter may occur through telehealth, in compliance with section 1834(m) of the Act and subject to the list of payable Medicare telehealth services established by the applicable physician fee schedule regulation.
(1) Timing and signature. The certification of need for home health services must be obtained at the time the plan of care is established or as soon thereafter as possible and must be signed and dated by the physician who establishes the plan.
(b) Recertification—(1) Timing and signature of recertification. Recertification is required at least every 60 days when there is a need for continuous home health care after an initial 60-day episode. Recertification should occur at the time the plan of care is reviewed, and must be signed and dated by the physician who reviews the plan of care. Recertification is required at least every 60 days unless there is a—
(i) Beneficiary elected transfer; or
(ii) Discharge with goals met and/or no expectation of a return to home health care.
(2) Content and basis of recertification. The recertification statement must indicate the continuing need for services and estimate how much longer the services will be required. Need for occupational therapy may be the basis for continuing services that were initiated because the individual needed skilled nursing care or physical therapy or speech therapy. If a patient’s underlying condition or complication requires a registered nurse to ensure that essential non-skilled care is achieving its purpose, and necessitates a registered nurse be involved in the development, management, and evaluation of a patient’s care plan, the physician will include a brief narrative describing the clinical justification of this need. If the narrative is part of the recertification form, then the narrative must be located immediately prior to the physician’s signature. If the narrative exists as an addendum to the recertification form, in addition to the physician’s signature on the recertification form, the physician must sign immediately following the narrative in the addendum.
(c) Determining patient eligibility for Medicare home health services. Documentation in the certifying physician’s medical records and/or the acute/post-acute care facility’s medical records (if the patient was directly admitted to home health) shall be used as the basis for certification of home health eligibility. This documentation shall be provided upon request to the home health agency, review entities, and/or CMS. Criteria for patient eligibility are described in paragraphs (a)(1) and (b) of this section. If the documentation used as the basis for the certification of eligibility is not sufficient to demonstrate that the patient is or was eligible to receive services under the Medicare home health benefit, payment will not be rendered for home health services provided.
(d) Limitation of the performance of physician certification and plan of care functions. The need for home health services to be provided by an HHA may not be certified or recertified, and a plan of care may not be established and reviewed, by any physician who has a financial relationship as defined in §411.354 of this chapter, with that HHA, unless the physician’s relationship meets one of the exceptions in section 1877 of the Act, which sets forth general exceptions to the referral prohibition related to both ownership/investment and compensation; exceptions to the referral prohibition related to ownership or investment interests; and exceptions to the referral prohibition related to compensation arrangements.
(1) If a physician has a financial relationship as defined in §411.354 of this chapter, with an HHA, the physician may not certify or recertify need for home health services provided by that HHA, establish or review a plan of treatment for such services, or conduct the face-to-face encounter required under sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act unless the financial relationship meets one of the exceptions set forth in §411.355 through §411.357 of this chapter.
(2) A Nonphysician practitioner may not perform the face-to-face encounter required under sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act if such encounter would be prohibited under paragraph (d)(1) if the nonphysician practitioner were a physician.
[53 FR 6638, Mar. 2, 1988; 53 FR 12945, Apr. 20, 1988; 56 FR 8845, Mar. 1, 1991, as amended at 65 FR 41211, July 3, 2000; 66 FR 962, Jan. 4, 2001; 70 FR 70334, Nov. 21, 2005; 72 FR 51098, Sept. 5, 2007; 74 FR 58133, Nov. 10, 2009; 75 FR 70463, Nov. 17, 2010; 76 FR 9503, Feb. 18, 2011; 76 FR 68606, Nov. 4, 2011; 77 FR 67163, Nov. 8, 2012; 79 FR 66116, Nov. 6, 2014]
The following is from a denial a client sent last week. The clinical record was originally requested as a routine ADR and payment was denied related to the Face-to-Face document. That denial was overturned in favor of my client but the claim was denied again for a new reason. You have to see this in order to believe it:
Documentation submitted by the provider included a valid face to face encounter form that supported the beneficiary’s skilled need and homebound status. The submitted documentation further suppo1ted skilled nursing services to be reasonable and necessary as evidenced by documentation supported an acute functional and mental decline, recent hospitalization and the need for assessment and observation of condition. However, in review of the physical therapy and occupational therapy evaluations it has been determined the evaluations failed to include short term and long term goals stated in measurable terms with expected dates of accomplishment. Therefore, the six physical therapy visits and the six occupational therapy visits rendered as billed from March 25 to April 12, 2013 will be denied due to invalid/incomplete evaluations.
So, what we end up with a patient that everyone agrees needed services, met Medicare’s eligibility requirements and the agency received no payment because of failure to state long and short term goals.
Did you happen to notice that the entire course of therapy was three weeks?
Have you figured out yet that there were no long/short term goals differentiated on the original chart submitted? That really gets under my skin.
In essence, the denial related to a Face-to-Face document should have never occurred but it did in spite of a perfectly fine document. They agency lost a full round of appeals before the reviewers found something else wrong with the chart. Now the agency is going to the QIC with what amounts to a first round appeal for the PT goals that were never mentioned in the first denial.This example stood out because the reviewer actually wrote that all other requirements were met. I don’t know why she felt compelled to point out how very much the patient’s need for services was supported and payment would have been made save for lack of a long or short term goal. In actuality, there were five of these I worked last week.
You have two choices. First, you can write a short term goal or you can write a very long term goal. The problem with a long term goal is the ability to assess progress towards goals after the patient is discharged. I supposed you could set a goal of swimming the English Channel because I think there is a published list of all who have successfully crossed. Outside of publically available information, how would you verify completion of the goal without violating HIPAA rules?
An alternative solution would be to write a goal or two for the first visit or first week of therapy. Some examples that come to mind from who knows where because I am not a therapist are:
- The patient will agree to participate in their course of therapy by the end of the first visit. (Chances are this is pretty accurate if the patient allows you in for a second visit).
- The patient will have all prescriptions for pain filled prior to next visit. (I do not like the way it sounds when therapists work with un-medicated patients.)
- The patient will have DME delivered by end of day 4 of episode. (If nothing else, this will serve as a reminder to follow up and ensure that DME was delivered.
I have shared this information with several clients who think I have loaned my brain out to someone who needed a laugh. I assure you that is not the case. All of you who receive a denial such as the one described above should include in your argument for payment that whatever new deficiency was identified after the initial denial was overturned was also present in the original submission of documentation. Be bold about it. Include page numbers.
I would be interested to hear what is happening in your offices. Has anyone else seen denials like these? If so, what contractor? (Palmetto, NGS, CGS, etc.) Email me if you don’t want your denials plastered all over the internet or better yet, be loud about them and post them below.