— National Training Program Monthly Update Webinar
— May 2019 Hospice Compare refresh of quality data is now available; now includes additional information on hospice characteristics to complement existing quality and patient experience metrics.
— Final rule removes redundancy, reduces administrative burden on PACE providers. (more…)

The following is a statement from the Office of Inspector General of the Department of Health and Human Services regarding a dispute between OIG and EHS Home Health Care Service, Inc. of Oakbrook, Illinois over a finding of overpayments.
(more…)

By Tim Rowan, Editor and Publisher of Home Care Technology Report

Let’s call him Jerry. The 79-year-old Medicare beneficiary was discharged from a hospital stay after a bout with pneumonia and an exacerbation of congestive heart failure. He also suffered from acute kidney injury, diabetes, and advanced Alzheimer’s disease. In other words, Jerry was a typical home health patient.

EHS Home Health Care provided extensive care for this fragile patient and submitted claims to its Medicare Administrative Contractor, National Government Services, Inc., which routinely paid the claims without any questions. Subsequently, EHS came under ZPIC scrutiny and was eventually selected by the HHS Office of Inspector General as part of a series of reviews of HHAs. According to the OIG explanation, “Using computer matching, data mining, and data analysis techniques, we identified HHAs at risk for noncompliance with Medicare billing requirements.”

As reported in our news item elsewhere in this week’s issue, OIG demanded 100 EHS patient records and identified overpayments amounting to $55,303 for services provided in calendar years 2014 and 2015. OIG did not stop there, however. It determined that these 100 samples could be extrapolated to $7.5 million in assumed overpayments during those years.

We spoke with former CMS employee and current Medicare appeals consultant Michael McGowan for help understanding what is happening here and why. What we learned is there is a pattern of behavior that permeates CMS’s MAC/ZPIC/OIG system, a pattern that, in recent years, has led to bankruptcy for home health agencies more often than not.

Automatic Denial Policy

In Jerry’s case, and in the overwhelming majority of the denials adding up to the final audit finding of $55,303, patients were found by OIG medical reviewers to not meet the Medicare homebound requirement. No, these investigators did not visit Jerry in person. They examined physician Face-to-Face documents and found them to insufficiently justify homebound status. CMS has admitted that the rate of claim denials has skyrocketed since its Face-to-Face rule – far more restrictive than Congressional intent as found in the language of the Affordable Care Act – was implemented in 2011.

OIG reviewers determined Jerry was not homebound because he lived in a residence without barriers and was able to walk with a walker or cane.

EHS hits back

Faced with bankruptcy, EHS decided not to go quietly into that good night. In a 12-page comment, EHS’s law firm countered every OIG accusation and refused to comply with all four OIG recommended operational cures. Instead, they described errors in every example OIG gave to justify both the initial fine and the $7.5 million assumption. There were several examples in the OIG accusation but, regarding the patient we are calling Jerry, the attorneys said: (emphasis added)

“OIG’s reviewers repeatedly failed to view the medical record as a whole and appeared to allow individual clinical factors to drive the conclusion that a particular beneficiary was not “homebound.” In doing so, OIG’s reviewers applied —and appeared to rely exclusively or primarily on—criteria for evaluating homebound status simply not contained in the Medicare regulations and often ignored “longitudinal clinical information” that supported the level of care rendered by EHS. For example:

OIG reviewers found this 79-year-old beneficiary was not homebound because (i) on several infrequent occasions of short duration, the beneficiary attended medical appointments for his spouse, and (ii) the beneficiary ambulated 200 feet without an assistive device, suggesting that leaving the home did not present a considerable or taxing effort.

Determining homebound status based on these factors alone is wholly incongruous with the Medicare regulation and manual guidance. In fact, the Medicare manual is clear that a beneficiary is not disqualified as being homebound for leaving the home, even for non-medical purposes, if the trips are infrequent and of short duration. In addition, nothing in the Medicare rules suggests it is permissible to discount homebound status based on technical measurements such as the number of feet a patient can ambulate.

Had the OIG reviewers considered the complete record, they would have seen a 79-year-old beneficiary who, just prior to receiving home health services, was hospitalized with pneumonia and an exacerbation of congestive heart failure. The patient also had multiple co-morbidities, including but not limited to, acute kidney injury, diabetes, and advanced Alzheimer’s disease. The Alzheimer’s disease itself, without his precipitating acute conditions, severely restricted the beneficiary’s cognitive function relative to orientation, memory, attention, problem-solving, and judgment.

The combination of the acute medical incidents and his chronic conditions made it not only impossible for the individual to leave the home without his spouse’s assistance, but also made it impossible for his spouse to leave him home alone while she attended appointments outside the home. …When considered in its entirety, the medical record supports a finding of homebound status under the Medicare standards.

Why do they try so hard to deny?

We know this orientation toward “deny if you can, pay if you must” exists. It took some digging to find out why. This is how our Medicare appeals consultant explained it to us.

CMS awards lucrative contracts to a multitude of collection agencies to take a second look at healthcare claims after they are paid by MACs, searching for evidence of fraud, waste, and abuse that threatens the lifespan of the Medicare Trust Fund. Some of these contracts amount to as much as $85 million per year for each of six Unified Program Integrity Contractors (UPIC). CMS justifies the expense citing historical data that UPICs, formerly known as ZPICs, return an average of $7 for every dollar paid them. According to the DC law firm Liles & Parker:

ZPICs have traditionally asserted that, unlike their Recovery Audit Contractor (RAC) counterparts, they are not “bounty hunters.”  They base this argument on the fact that, unlike RACs, ZPICs are not paid on a contingency basis. Instead, ZPICs are directly compensated by CMS on a contractual basis.

Nevertheless, common sense tells us that if ZPICs are unsuccessful at identifying alleged overpayments, the chances of a ZPIC’s government contract being renewed are likely to be diminished. Additionally, experience has shown us that, despite the fact that ZPICs are expected to adhere to applicable Medicare coverage guidelines, a ZPIC’s interpretation and application of these coverage requirements may greatly differ from your understanding of the same provisions. In recent years, ZPICs have been aggressively pursuing a wide variety of enforcement actions.

McGowan agrees, “Nearly every time CMS bids out a ZPIC/UPIC contract and selects a winner, one or more losing bidders challenge the award in court. These are coveted, highly contested contracts. If they don’t perform, if they don’t hit that 7-to-1 payback, they could be replaced, costing hundreds of jobs and slashing corporate profits.”

CMS harmed as much as HHAs

This, however, while a life or death problem for HHAs, is not the worst consequence of the environment CMS has allowed to develop, McGowan emphasizes. “When a contractor, or in the EHS case the OIG behaving the same way, extrapolates from a reasonable overpayment for which it has evidence to an assumed overpayment 135 times higher, for which it has no evidence other than math, there is no way the HHA defendant can meet that demand. Instead, most HHAs declare bankruptcy and close their doors.” He described three consequences when this happens:

• Tens, if not hundreds, of employees lose their jobs and the owners lose any equity they have built in their business.
• The UPIC/ZPIC is able to report the assumed overpayment amount, in our example $7.5 million, on its “win” column, even when it does not collect from a bankrupt HHA.
• CMS receives nothing.

“Obviously, CMS cannot allow this situation to continue,” McGowan opines. “What good does it do to force an agency to close? Why not take the $55,000, investigate sufficiently to determine the cause is sloppy documentation and not criminal fraud, and help the HHA develop an improvement plan? Better yet, why not create a Face-to-Face document instructional program for referring physicians, since they seem to be the bulk of the problem? The investigating contractor and attorneys on both sides are the only winners here. All the entities involved in providing or paying for actual patient care are the losers.”

There is one additional flaw in this method to curb fraud, waste, and abuse. Note that the OIG investigation covered claims from 2014 and 2015. Considering the rate of home health staff turnover, not to mention referring physicians who retire or relocate, how many people responsible for inadequate documentation would be touched by a correction plan that begins in 2019 or 2020? A rhetorical question but one worth asking.

Based on conversations with former colleagues, McGowan remains optimistic that CMS will not allow this situation to survive much longer. “Why would they?” is his own rhetorical question. “The HHA closes down, beneficiaries wind up with fewer care choices, and CMS, instead of reaping a $7 to $1 gain, gets nothing.”

One might reasonably add one more suggestion to McGowan’s recommendations, “Better yet, why not create a Medicare policy instructional program for OIG/UPIC/ZPIC medical reviewers?”

For further research, see 42 CFR § 405.371 – Suspension, offset, and recoupment of Medicare payments to providers and suppliers of services.

©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechreport.com

Dear Healthcare at Home Colleague,

Our lead news story this week concerns an investigative finding by the HHS Office of Inspector General that extrapolated a $55,000 overpayment into a $7.5 million repayment demand. You will want to read how the accused Illinois HHA is fighting back in court. Many agencies hit with unreasonable overpayment demands have chosen the Chapter 11 route and closed their doors. Click below on “OIG Uses Homebound Status and Skilled Care Need to Target Providers” to read the official OIG statement. (more…)

By Tim Rowan, Editor & Publisher of Home Care Technology Report

The CMS “Review Choice Demonstration (RCD)  for Home Health Services” will begin June 1, 2019 in Illinois.  The program is an improved version of the Pre-Claim Review demonstration that began in Illinois in 2016 but was aborted in April, 2017 before CMS pursued its original plan to expand the demonstration to four additional states.

by Darcey Trescone, RN, BSN

PDGM is still a topic of conversation as both vendors and providers continue to prepare for its launch January 1, 2020. We were able to catch up with a few of the vendors recently to learn more about their perspectives and preparations for PDGM.

PDGM Impact to the Industry

[The first of these two vendors-Mike Kramer, SVP Home Care and Hospice at Casamba told us: “The level of impact really depends on the particular home care provider. If the home care provider reacts appropriately to PDGM, the new requirements can help healthcare at home providers to          maintain and potentially improve reimbursement.. . ”

Kramer continues, “PDGM is certainly driven by diagnoses. Close attention needs to be paid to the coding aspect of what the providers are doing when assigning the primary diagnosis and all co-morbidities for the patient receiving services. This is going to require providers be in a position to defend the diagnosis coding and services they deliver within their clinical documentation.”

“Getting all the services to the patient’s and prioritizing the needs of that patient in the first couple of weeks of care is going to be important. We need to focus on the clinical needs and getting them stable, but we forget that there are other factors, beyond nursing, that are driving this patient to have problems. It’s going to require the whole home health multidisciplinary team to decrease hospitalizations,” added Melissa Cooper, Chief Clinical Officer at Thornberry Ltd.

Ms. Cooper continued with more company detail:

“Many are concerned about the financial aspect of PDGM, not really concentrating on how we are going to achieve goals in 30 days where we can. Thornberry is doing many things, one is further education on the multidisciplinary team aspect of PDGM thru emails, blogs and educational sessions. If we are really going to be successful and partner with the patient and care community to improve patient outcomes it will require nursing, therapy, social work and the home care aide. Ensuring that these disciplines are established if needed and visits planned earlier in the patient’s care is key. Additionally, we have launched a PDGM evaluator update to help our customers look at the data that is coming in now and model for them what that reimbursement will be in the PDGM world. We believe along with monitoring reimbursement, working with our customers to focus on their top diagnoses, care practices in place and the number of disciplines and visits to achieve positive outcomes for their patients they will drive success.”

Casamba’s Kramer added, “We have been doing webinars with our customers that review the PDGM regulations along with the existing and new features available in our product. Since the first of the year we have been working closely with the CMS technical specifications and our customers to ensure PDGM readiness. PDGM education is important and we will continue to do what we can to support the industry.”

“Much work needs to be done in a relatively short period of time to ensure clinicians are up to speed on the regulatory changes going forward,” said Billie Nutter, president of Casamba. “What’s encouraging is that our customers’ leadership believes they have a strong knowledge base to leverage and help prepare their staff. Using that understanding to educate practitioners will be critical during this transition to PDGM.”

Kramer continued, “PDGM will be a featured topic at our May user group. We will be sharing what trends we have seen across our customer base with the analysis we have done. We are all trying to improve patient outcomes and decrease hospitalizations. The most cost-effective environment to provide care is in the home, and that is where our patients and families would rather be. The good news is that when an episode has reimbursement for both 30-day billing periods, our customer’s reimbursements appear to be the same or better under PDGM based on our analysis.”

PDGM Innovations

Mike Kramer described more services Casamba is preparing:

“We have built our own PDGM grouper and this allowed us to provide our customers with a PDGM analytical review tool within Casamba. The tool provides a comparison of the actual PPS revenue and the projected PDGM revenue for each 30-day period from January 1, 2018 to present.

“Our goal was to show our customers in real time how their reimbursement would be affected under PDGM with the current patient population and care practices they have in place. The tool provides enough detail to help our customers identify adjustments in care practices and then monitor what projected PDGM reimbursements would be based on these modifications. This approach helps our customers gain insight into future outcomes and pinpoint specific clinical themes where behavioral process changes most impact positive patient outcomes.

“We have built in alerts to the user when a disqualified diagnosis is chosen and warnings around potential LUPA scenarios. Additionally, within our clinical documentation, there are a number of links between an order and what needs to be documented to support that order. In reverse, when documentation is completed the system provides a list of orders required for physician signature.”

Thornberry’s Cooper added,

“We have a couple of new tools. One that we are excited about is our Smart Goals. SMART Goals are Specific, Measurable, Attainable, Relevant and Time Based. They are goals which allow the clinician to define a time frame of achievement for the patient. The goals are assessed at each visit done by the clinician to make sure they are relevant and obtainable. The goal dates can be ended with a date of achievement, marked as ongoing or the date can be modified to allow more time for achievement. The clinician’s dashboard notifies them five days before the goals due date. There is also a companion supervisor’s report which allows supervisor’s to monitor all patient’s on census for over due goals. The road map for our goals leads us to qualifying diagnosis driven goals and interventions. With PDGM on the horizon it is important to have standardized protocols and interventions to achieve consistent goals. These goals are multi-disciplinary.”

“Our interactive dashboard in NDoc will give users a warning about patients nearing the end of the 30-day period and, based on the PDGM model, will highlight those patients that are potential LUPAs. This allows the customer to evaluate in advance if the patient is truly a LUPA case or if more services are needed. As well, we have delivered managerial oversight that shows the patient population on service, where they are in their cert period and who is not meeting goals. With built in drill downs by clinician and patient the manager can easily guide the care team.”

PDGM remains a highly relevant topic for providers and vendors both. These regulatory changes are continuing to feed thought leadership and innovation in home care technology.

©2019 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan’s Home Care Technology Report.homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. editor@homecaretechre

By Tim Rowan, Editor & Publisher of Home Care Technology Report

A recent Microsoft newsletter provided us with some news your IT Department already knows but that all Windows 10 users should hear.