As we continue our focus on the audits that are increasingly common in the Home Health world, we recount examples of recent claim denials that have been encountered. Both of today’s examples describe denied services that prompt examination and discussion of the concept of “reasonable and necessary” as it pertains to real-time care delivery. The Social Security amendment established CMS’s obligation to provide coverage to Medicare beneficiaries for services that are “reasonable and necessary”. This requirement is pertinent when Home Health claims are reviewed by either Fiscal Intermediaries - FIs (currently) or Recovery Audit Contractors – RACs (in the near future).
Partial denials of Medicare homecare claims are examined to determine exactly how the point of denial was determined. When homecare services are deemed unskilled, the reasonable and necessary theme comes into play as the primary unmet qualification requirement. This fact becomes particularly relevant when this occurs after the care delivery has been initiated. Rather than employing the concept to determine Start of Care eligibility, the partial denials referenced care that initially responded to clinical deficits by establishing appropriate care plans. Then, at some point during the well-planned episode, the care delivered failed to continue to meet the “reasonable and necessary” standard. This is where the FI denied service coverage and did not provide payment for the subsequent care. This point of denial allows us to ask what happened, and why, as a means of determining how care modifications would have prevented the delivery of un-covered service.
Our first example entails a 72 y/o client who was admitted to the Medicare Home Health agency status post hospital discharge for a CABG x 3 procedure. The client lived with their spouse in their own home. Skilled nursing was the only discipline in the episode; their initial Plan of Care provided wound care and vitals/medication management. The frequency was 2 x 2, and 1 x 2. The nurse provided excellent care that addressed the client’s good response to her visits, which included ongoing education based services with caregiver involvement. On the third visit, the nurse noted that the surgical wound had closed, described independent med management, un-remarkable labs and vitals. The remaining three visits continued to include care focused on these issues. The agency received a denial for the last three visits. When the Fiscal Intermediary determined that the care requirement had already been met, they denied the remaining three visits as not “reasonable and necessary”.
Our second example concerns a physical therapy program that was provided to a patient that was not admitted to a facility prior to Start of Care. This particular client (with mild dementia) was referred by the primary physician in response to declining ambulation and resultant weakness. The PT-only episode provided therapeutic exercise, gait training, and home exercise programming through a 3 x 3, 2 x 1 frequency/duration order. The notes demonstrated exercises every visit, but made no mention of caregiver follow-through or skilled progression on a per visit basis. The gait training included less than impressive description of gait quality, and therefore the skilled intervention in this area was somewhat cloudy. The patient did not receive gait training on visits 5 or 6 secondary to patient refusal because of their complaint that they were “too weak” that day. Though the therapist completed their program in terms of 11 visits, visits 5 and 6 and all subsequent visits were denied.
To this author, the intent of the FI in declining parts of these claims is obvious; the care initially programmed to address clinical needs, for some specific reason, failed to remain “reasonable and necessary”. In the case of the CABG patient, is it hard to see that the FI felt the un-remarkable clinical course of the post-surgical care with good healing noted on the third visit rendered the remaining care “un-necessary”? Do all Medicare CABG patients receive homecare upon hospital discharge? Unless ALL patients receive such care in 100% of the cases, it is understandable that both CMS and the FI would seek to determine when the program would no longer be necessary to assure outcomes.
In the therapy case, the reasoning seems clear; if CMS is paying for a program to be delivered with the goal of achieving safe ambulation, why would they continue to provide coverage if the gait training portion of the care was unable to be provided FOR ANY REASON? This sort of value-based reimbursement philosophy could prompt many changes in care delivery, most of them desired. Many questions come to mind. Would the client have declined to participate in the gait training if they knew their care could be compromised by the refusal? Would the therapist have so readily accepted the client’s reluctance to perform the gait training on visits 5 or 6 if they knew their program would not be sustainable as a result?
With better understanding of these coverage requirements, and how they will change in the future, both of the examples described may have had better outcomes, or at least expected outcomes. In the future, both agencies and clinicians may have better insight as to how their care programs might be viewed by CMS, and choose to modify care to fit these views.