As The Home Health Forum begins to address the audits and denials that are sweeping through the homecare industry, it is imperative that we begin by examining some of the historical reimbursement philosophies employed by CMS for services provided in the home.
The structure of the Home Health industry, and its providers, has been established on previously employed approaches to care that comprise the very core of how we deliver our services. Fee for service experiences, combined with the PPS era (and its refinements), have served to create expectations and beliefs that may inhibit our response to changing coverage standards. As agencies begin to re-consider currently employed models that may be less than adequate when confronting clinical outcome expectations of the future, the first step is to perform a sort of re-examination of the value of homecare in terms of real dollars. What payment levels does CMS provide for the specific Home Health services that we deliver, and how does it compare to other types of payment structures we encounter as providers? As clinicians, are we providing the highest level of quality care that responds to programming changes and evolving best practice directives? Are we able to produce the same results with increased efficiency in our use of the PPS-model? Are we able to find answers to these and other similar questions that may challenge our comfort zone? How do our answers change when we employ a basic “common sense” approach in this self-reflection process? The answers to these questions may determine what levels of success specific Home Health providers will achieve in the future.
The recent audit/denial experience of a Michigan-based, certified Medicare Home Health provider provides an example of how we may use the above questions to gauge future changes. Those familiar with the PPS model are aware that therapy visit totals are the sole determinant in deriving the “S” number of the HHRG score. In most cases involving therapy, the “S” score is the primary factor in the determination of the reimbursement level for that particular claim. The portion of the “S” scale that we will discuss includes:
S1 ------------------------- 0-5 visits
S2 ------------------------- 6 visits
S3 ------------------------- 7-9 visits
S4 ------------------------- 10 visits
In today’s example, the patient was an 80 y/o female living with her daughter. She walked indpendently with a straight cane prior to 3 falls in a 14 day period, one resulting in an ER visit. Though no injuries were sustained, the onset of falls resulted in a homecare referral. The physical therapist's initial evaluation proposed a 10 visit program (3 x 2,2 x 2) of therapeutic exercises and gait training for safe ambulation. The fall risk assessment also identified a “fall risk”. A quick scan of treatment notes report that the patient declined to use a walker for improved safety. In addition, the exercise program was not performed and progressed on a per visit basis because “the patient knew her exercises”. There is little if any evidence that the daughter played any significant role in the program. The patient’s ambulation was described as “safe with a cane with supervision” on visits 4, 5, and 6. In addition, each of the specific notes from those visits contained no skilled gait description, but did describe endurance ranging from 175 – 200 feet. Visits 7 – 10 continued with additional increases in ambulatory distance as the only specific difference noted in the documentation from the previous group of visits. The program was completed on visit 10 with goals achieved, resulting in an “S4” claim.
The claim was partially denied for reasons “not reasonable and necessary” after visit 6; clearly the Fiscal Intermediary felt the program went “unskilled” at that point. The final claim was paid at the “S2”, 6-visit rate instead of the “S4”, 10-visit rate. Areas of concern identified during a review of the denial were: 1) Inadequate therapeutic exercise program lacking skilled progression, 2) Lack of specific skilled gait description, 3) No caregiver involvement or report of compliance with program outside of visits, 4) Lack of walker use for improved gait safety, and 5) “safe with a cane” documentation that may have prompted discharge. None of these concepts are new to Home Health, particularly during the PPS-era. It seems at first glance that these must be addressed for a “skilled program” that would survive audit scrutiny. In the future, will the inclusion of all of these items be required for claim payment?
When continuing the re-examination described earlier, the question is prompted; what will CMS pay for the type of scenario described above? Is it expectable that a 6-visit Physical Therapy program would be considered “reasonable” to achieve safety in the case described above? The therapy portion of the payment for an “S2”, 6-visit claim is approximately $1900. Most private practice therapists would almost certainly accept this clinical program based on the level of payment. The desired goals seem achievable with efficient programming, i.e. correct adaptive device, progressive exercises with daily compliance and caregiver involvement, and appropriate scheduling (3 x 2 or 2 x 3). Yet it is quite common for this Home Health patient to be programmed for significantly higher visit totals, usually in the 10-14 range.
The point is not to suggest that therapists should receive the entire therapy portion of the Home Health payment. It is also not our intent to delineate any specific visit total as correct without individualization to each unique patient. But it does raise the question from the perspective of the payer (in this case, CMS); how much does this care cost, and should a level of quality, or skilled services be mandatory for payment?
These ideas will be pertinent as we address more audit/denial reports in the articles to come. Consider the concepts above as you determine how to respond to specific audits or denials you may experience. Be objective about denied care; could you have done anything different? As a participant in a value-based industry, your answers will help you identify a new care model.