Having spent the last three months reporting and interpreting the results of the audit/denial activity recently experienced by Home Health providers in targeted states (CA, TX, FL, MI), this would seem an opportune time to gather our notes and assess what we’ve learned. Since ALL agencies are facing similar scrutiny in the not too distant Recovery Audit Contractor (RAC) era, lessons evident from our analysis will be of value to each and every homecare provider. Decisions will be required in an ongoing manner regarding clinical programming and direction, clinical staff supervision and guidance, and identifying and maintaining skill for efficient care. These types of assessments and judgments will be required for programs that are efficient in both clinical and delivery content. These efficient programs are precisely the type of care described by MedPac in releases outlining reform goals. Providers must take note that reimbursement formulas of the future will also be determined by this value-based philosophy.

 

            It is easy to identify how some of the basic elements of the daily routine of a Home Health agency may change:

           

Intake/Admissions – The primary lesson from recent audit activity is that not all care covered in the recent past will be covered in the future. Average Case Mix will replace the near defunct census as the main determinant of agency health, and intake personnel may have to increase referral scrutiny; quite a change from the assertive marketing of any and all Medicare beneficiaries some agencies participate in today.

 

Start of Care Protocol – The use of the OASIS as a programming guide will become paramount. Agencies that struggle to adapt to the OASIS-C will find themselves behind the curve when it comes to producing the type of progressive care programs required for audit scrutiny. Will agencies and clinicians mistakenly presume that the OASIS-C can be integrated at the same pace the industry employed with the OASIS during the Interim Payment System phase (1999)? Will we elevate our use of the OASIS tool as a programming guide when required to produce efficient care plans derived from OASIS(C) data? Will we educate SOC clinicians regarding correct use of the OASIS, provide scripting to assure delivery, and shed the “only a therapist can answer the ADL/IADL questions correctly” mentality we often employ? Just how important will the answer to M0826 (and its predictability) prove to be when over-shadowed by the myriad of Start of Care concerns?

 

Quality Assurance/Utilization Review – Consistently identified as a necessary step to efficient (and caring) programming, a pre-RAP, utilization review of all Start of Care programs will be absolutely required. After the establishment of this protocol, QA staff enjoy the opportunity to help clinicians identify and deliver better care; many describe it as a clinical “scavenger hunt”. The days of hoping front-line clinicians will produce PPS-compliant programs are over, as are the days when providers would be paid for sub-standard programming. Auditor reports that any clinical extension order will potentially be seen as a “red flag” underscores the need to bring clinical control in-house.

 

Pro-active Case Conference structure – How can agencies assure that clinical field staff deliver skilled care and remain focused on clinical goals during the episode itself, especially when the lack of an effective audit experience in our industry has not required this in the past decade? In this area, the traditional multi-disciplinary case conference format leaves much to be desired. Considering the short duration of Home Health programs in the future, it would be difficult to schedule a case conference in a timely manner, particularly one that is able to affect meaningful care modifications. Weekly, individual rounds that help clinicians provide efficient, directed care while remaining focused on the clinical goals that relate to OBQI indicators (OBQI Case Conference) is the answer that agencies and clinicians will embrace to obtain clinical outcomes via best practices.

 

Clinical Staff Management – Concerns regarding productivity, use of office time, contract staff, missed visit coverage, and vacation coverage, will require examination on an individual agency basis. The prevailing notion, that the reimbursement structure of the industry will cover cost concerns in these areas, may not serve providers well in the future. Questions regarding the concept of reasonable and necessary are relevant here. How necessary is the care if it can be halted for up to eleven days due to the week-long vacation plans of the treating therapist? And what reasons for missed visits will be acceptable and won’t de-value the premise of your claim? Are MD visits causes for missed therapy frequencies? This scenario, the loss of scheduled therapy frequency due to an MD office visit scheduled the same day, seems to challenge the concept of “reasonable and necessary”.

Durable Medical Equipment – How will clinician involvement with equipment procurement change in the future? What will the RAC opinion be regarding care that is extended or present for reasons related to equipment? Will therapy programs for WC measurement, ADL equipment measurement and procurement, and other DME issues be considered skilled? Clearly the clinical input often utilized to identify the appropriate equipment required to improve function will continue to be relevant in the future, but how will auditors respond to the claim that therapy be involved in order to assure that the client receives the correct piece of DME, especially when the DME bond mechanism assures that equipment vendors provide CMS-compliant delivery? Would ten PT visits be covered in order to measure for a WC, assist the DME vendor with ordering said WC, and continuing a skilled program until the WC arrives? This question has yet to be answered, but it seems unlikely that RACs would not have an opinion about this sort of claim.

 

            So many areas of Home Health may be affected by the reforms that are undoubtedly coming to our industry. Certainly, the plans to derive funding for the proposed budget-neutral healthcare bill by focusing on cost savings attainable by re-wiring Medicare to address outcomes in lieu of care volumes will have effects on our services. It remains to be seen how progressive our providers can become in response to the care requirements of the future.