Moving forward with our examinations of the audits recently seen in the homecare industry, we delve further into our assessment of “reasonable and necessary” and how the term has evolved under the increased inspection of the past six months. Practices that all clinicians have regularly engaged in now require re-examination for validity in the current and future Home Health model. As Fiscal Intermediaries pave the way for the Recovery Audit Contractors, most agencies and clinicians seem to feel that the “business as usual” approach to care delivery will suffice for success in the future. Cursory reviews of audits of even the most basic episodes reveal that this is far from the case. Today we will mine the model of “reasonable and necessary” even further, using multiple audit/denial examples to address and further define the concept that guides our care.
Our first example demonstrates the need for an objective clinical decline as a trigger for covered services. Start of Care OASIS findings reveal independent prior/current transfers and ambulation (0-0 M00 690/700), and no other diagnosis specific decline was identified. When the start of care nurse added orders for PT Eval and Treat on the careplan (documented as in response to patient request), the therapist made a single eval visit with no additional services provided. The visit was denied due to “care not reasonable and necessary”. The fiscal intermediary seems to restrict the addition of services to objective findings. As reasonable as this seems, it is also necessary to acknowledge that, in many cases, programs result from scenarios such as these. Programs that may or may not survive audit scrutiny due to the lack of qualifying care.
Other cases cite examples of care defined as complete by the auditor prior to the point that the actual visits ceased. These were seen in all different types of clinical programs and included both therapy and nursing care. Most prominent were episodes where the clinician themselves, albeit inadvertently, identified the end of care. Their documentation outlined the lack of further expected progress, but visits continued. Quotes such as “DC next week if patient maintains gains”, and “DC next visit with goals met if no changes”, illustrate the dilemma the auditor confronts. Where skilled care clearly led to acceptable and desired clinical outcomes, can they approve additional care after the goals are clearly realized?
Last are the episodes where the OASIS was either not completed or performed on the initial visit. Though this unusual but not rare practice often transpires for what are considered appropriate reasons, the audit and denial of programs where this occurred raises concern. Were the audit results of these cases (all complete denials) related solely on the lack of an OASIS-based plan of care after the initial visit? If so, the message seems to be that to initiate care without completing the OASIS presumes that a program is necessary and will occur. This represents one of many areas that should be keenly observed as audits evolve and become the domain of the Recovery Audit Contractors.
As clinicians understand the objective principles involved, they become increasingly able to avoid the subjective disappointment consistently encountered in response to successful care programs being questioned. They react by recognizing where previous practices (delayed OASIS, referrals without objective findings) may no longer be acceptable. This prompts increased attention to the relevant clinical questions and appropriate care responses required in all programs. Armed with this insight, all clinicians can recognize that it’s “Care”, not “Visits”, that defines skill. Linking this knowledge to the “reasonable and necessary” concept allows them to identify instances where they might complete programs when necessary as a means of assuring the compliance required by audits.
The Home Health provider is far from powerless as answers to the basic questions identified here emerge. Sincere participation in responses to denied care helps in numerous ways. By establishing a premise that throughout the agency, audits are taken seriously and objectively, frontline nursing and therapy staff will be able to modify future results. The eventual goal is to provide care that is not only clinically sound, but also results in a billable episode that survives in the audit era.