To date, this column has, for several years, addressed Home Health issues that affect quality care. While initially focusing on efficient and best therapy practices required for success under the Prospective Payment System (PPS), the Home Health Forum has evolved to address broader industry issues, such as the New Rule refinements, progressive clinical programming concepts, and proposed reforms or funding reductions that currently confront our industry. The latest challenge is the audit/denial experiences currently seen in areas across the country that seem to foretell the impending Recovery Audit Contractor (RAC) era. These audits and subsequent denials are implemented by The Center for Medicare and Medicaid Services (CMS) via use of Fiscal Intermediaries (FI) or Quality Improvement Organizations (QIO).They serve as a means of protecting beneficiary rights, care quality, or program integrity. They are reflective of current and specific efforts to prevent Medicare fraud including the formation of Prevention and Enforcement teams focused on areas of concern regarding compliance (CA, FL, TX, and MI).    

When CMS introduced The 2008 New Rule nearly two years ago, they outlined audit red-flag areas of concern in the PPS refinement. Some examples that come to mind were the warnings about excessive 20+ therapy visit episodes (in response to payment changes), or increases in 14 visit episodes (also in response to payment) as a means of retaining income comparable to that of the previous 10-visit, high therapy threshold. Many agencies and programming clinicians have, nonetheless, found themselves creating care plans that are responsive, directly or indirectly, to the payment modifications of The New Rule. These trends may serve to present obstacles when agencies attempt to re-wire care in response not only to the audits, but additional reforms such as Pay for Performance and Post-acute Bundling.

The author has recently had the opportunity to review audited claims from three Medicare certified Home Health providers located in two of the states mentioned above. Most of the audited cases received some level of denial of care; either the entire case or a partial claim rejection resulting from rejection of a portion of the care provided. When reviewing audits and subsequent denials of claims from separate Medicare certified Home Health agencies, many questions are raised that will have a profound effect on how homecare services are delivered in the near future. We scanned 40-chart samples that had been requested from each agency; one specific provider had multiple samples of this size reviewed. Denied care was provided by many types of clinician including nurses, physical and occupational therapists, and homecare aides. The bulk of the denials revolved around therapy; not surprising since therapy volume is the only factor in designation of the service “S” level of the HHRG score. The individual clinicians involved in these visits are of no concern when we are reviewing these audit/denial episodes. The sole intent is to determine where FIs are defining care that is skilled in contrast to care that they deny for coverage. It is presumed that the lack of an active audit mechanism in Home Health to date has left us with a fuzzy, at best, level of insight in this area.

The primary denial response from the FI was that services provided were not “reasonable and necessary”. Though many of the denials were seen at the re-certification level for two of the agencies involved, the agency that experienced partial denials (for the same reasonable and necessary reasons) was particularly interested in identifying at what point the FI determined that skilled care ceased and subsequent visits were denied. This logical response seeks to understand the definition of “skilled” as currently enforced by the FI as a means of adopting future care to fit. Where and how CMS determines skilled coverage ends will identify the first step providers and clinicians must take when altering care to fit the current Home Health requirement interpretations. Progressive agencies will not wait for audits to reach their offices to begin examination of their care delivery for in-efficiencies or other areas of concern.

The next several columns of Home Health Forum will cover the audit issues discussed today in terms of clinical specificity. Audit results will be discussed in narrative form, intended to prompt thought and discussion regarding the coverage questions for therapy claims. Though conclusions drawn from this level of review are anecdotal, hopefully trends will emerge that will serve to guide reform of our care delivery.