Public Policy HCA Public Policy No

Public Policy HCA Public Policy No.2-2014 TO: FROM: RE: HCA CHHA & LTHHCP PROVIDER MEMBERS PATRICK CONOLE, VICE PRESIDENT, FINANCE & MANAGEMENT UPDATES FROM NGS HOME HEALTH ADVISORY MEETING DATE: MARCH 7, 2014 National Government Services (NGS), New York s Medicare Administrative Contractor (MAC) for Jurisdiction 6 (J6), conducted a Home Health Advisory Meeting yesterday via conference call for the state associations in U.S. Centers for Medicare and Medicaid Services (CMS) Regions I, II, V, IX and X. HCA participated in the meeting and received important updates, posed questions and advocated on behalf of the membership. The following memorandum summarizes key updates provided by NGS staff at the meeting as well as information acquired by HCA on issues of particular importance to New York State, including: Comprehensive Error Rate Testing (CERT) data review Medicare home health utilization data and top diagnoses codes NGS Advisory group participants review of upcoming education sessions Remaining NGS Fiscal Year 2014 education sessions CERT Data Review Insufficient Face-Face (F2F) Documentation Continues to Keeps Error Rate High but Significantly Lower than Last Review NGS gave an update on CMS s CERT program, which was established to monitor the accuracy of Medicare fee-forservice payments made to Regional Home Health Intermediaries (RHHIs) by reviewing the medical records of providers. CERT contractors also review claims for compliance with Medicare coverage, coding and billing rules. According to NGS s Christa O Neil, the most current CERT error rate is 21% for home health claims in the Wisconsin Workload (which includes New York), based on 260 claims reviewed, with 55 denials, between April and September 2013. The 21% error rate was significantly lower than the previous CERT error rate of 62% for NGS s Wisconsin workload between September 2012 and March 2013. Ms. O Neil reported that the top home health denial reason (why contractors made improper payment) was due to insufficient documentation related to the face-to-face (F2F) physician encounter requirement by the provider. Ms. O Neill stated that some of these denials were because the physician s documentation did not clearly document the patient s need for skilled nursing or therapy services and did not explain the patient s homebound status. 1

Other denials were triggered because the F2F encounter forms contained a preprinted statement regarding the homebound status, which is not permitted. Because the F2F encounter represents the physician s assessment of why a person is homebound and in need of skilled services, a preprinted statement that merely reiterates or copies part of the CMS guidelines does not meet this assessment criterion. The prevalence of F2F issues in the CERT error reports is a symptom of the enormous paperwork burden and challenge for home care providers to coordinate with their referring physicians on F2F documentation, including the complex scenarios governing F2F, especially when multiple physicians are involved. Relief from F2F remains a major priority of HCA s federal advocacy efforts, and an issue we will continue to raise during our Federal Advocacy Program on March 25 and in our ongoing engagement with New York s Congressional Delegation. HCA told NGS that some of our provider members in New York have recently been contacted by a Medicare contractor called StrategicHealthSolutions who requested Medicare F2F encounter documentation on five to six patients. Other state association representations also confirmed that their members had been audited by StrategicHealthSolutions. NGS staff confirmed that StrategicHealthSolutions is a Zone Program Integrity Contractor (ZPIC) auditor not affiliated with the CERT program and is one of several auditing organizations operating in connection with the Medicare program. ZPIC audits generally stem from the Medicare Administrative Contractor receiving some beneficiary, provider and/or whistleblower complaint. According to NGS, CERT reviews are typically completed within three to four months of receiving the medical records, and NGS is notified by the CERT contractor of any disagreement with the Medicare intermediary s initial decision so that provider payment adjustments can be made. NGS recommends that providers adopt internal processes to recognize and respond to CERT requests, noting that when records are not returned to the CERT contractors, provider claims will be denied and/or recouped. NGS also recommends that agencies designate a clinician responsible for responding to any CERT inquiries. Providers can review several articles related to CERT at www.ngsmedicare.com. Please go to Hot Topics, then click on Comprehensive Error Rate Testing. The articles provide details of CERT errors, pertinent references from Medicare manuals, and, most importantly, information about how to prevent errors. Home Health Utilization Data and Top Diagnoses Codes Ms. O Neill reported that the updated home health utilization data and top diagnosis codes from July 1 through December 30, 2013 were not yet available but would be presented at our next advisory meeting. For the first half of 2013, however, the following are the top five Medicare diagnoses from Medicare claims data, as well as from other Medicare home health utilization data, during the period January 1 through June 30, 2013 in New York: Encounter Procedure/Aftercare V58 Orthopedic Aftercare V54 Heart Failure 428 Diabetes Mellitus 250 Chronic Ulcers or Skin 707 According to NGS data (January through June 2013), HHAs in New York made 22.44 visits per episode, which was significantly higher than all of the other states in Regions I, II, V, IX, and X of J6. NGS data also revealed that Medicare beneficiaries in New York averaged 1.52 episodes (per beneficiary), which was slightly higher than most other NGS states. 2

HHAs in New York experienced a low utilization payment adjustment in 12.21% of their Medicare cases, which was slightly above average in relation to the other NGS states. Finally, New York home health agencies (HHAs) experienced an outlier adjustment in 11.56% of their Medicare cases, which was significantly higher than all of the other 20 states in Regions I, II, V, IX, and X of J6. Ever since CMS implemented the outlier cap in 2010, HCA has maintained that the percentage of episodes resulting in outliers in New York exemplifies the inadequacy of the current 10% outlier revenue cap imposed by CMS. To get stronger evidence of the impact that this cap has on providers, HCA at our previous Advisory meeting asked NGS staff to analyze how many Medicare HHAs in New York had been subjected to the 10% outlier cap during this latest review. In response, NGS has confirmed that 104 HHAs in New York had been affected by the outlier cap. This represents more than 60% of New York s Medicare certified providers in the state, offering further rationale for a change in the outlier policy, as HCA has regularly called for when we ve submitted our annual comments to CMS on the Home Health Prospective Payment System (HHPPS) rule. Upcoming Clinical Education Session Material Ms. O Neill asked Advisory Group participants for feedback on the following upcoming education sessions and job aids which NGS is going to make available to providers in the near future. The purpose of this review is to brief HCA and other provider representatives on important education programs that are in the works before they go live. This preview gives the provider community an opportunity to let members know about education programming and resources on the horizon and to share some of the planned guidance in advance, including: Home Health Billing Basics for New Billers This webinar presentation is being updated to provide a detailed summary of the HHPPS and to educate new home health billers on basic billing of the Request for Anticipated Payment (RAP), partial episodic payments (PEPs), Low Utilization Payment Adjustments (LUPAs) and final episode claims. The webinar will also review HIPPS Coding, correct episodic sequencing, therapy thresholds, supply groups, consolidated billing, transfers, the discharge and readmission process, required billing fields on the RAP and final claim, and NGS resources to assist billers. NGS will be offering this webinar to providers this month and repeat it multiple times throughout the year. Home Health Billing Scenarios This draft webinar session is being designed to help providers and billers gain a better understanding of home health billing guidelines which will in turn hopefully reduce the amount of incorrect claims submitted to Medicare. During the session, NGS will review important home health billing requirements, consolidated billing guidelines and specific scenarios that correspond to the highest error rates for home health RAPs and final claims. Some of these specific scenarios include when beneficiaries use outpatient therapy during a home health episode, when beneficiaries have an inpatient visit or stay during a home health episode and when beneficiaries enroll in Medicare Advantage plans during a home health episode. Home Health Forms: Advance Beneficiary Notice of Noncoverage (ABN), Home Health Change of Care Notice (HHCCN) and Notice of Medicare Non-Coverage (NOMNC) Job Aid NGS constructed this job aid, which is in the form of a chart summarizing various scenarios, to assist providers in knowing when the new ABN, HHCCN or NOMNC form(s) must be given to a Medicare home health beneficiary. One such scenario includes when the physician writes an order to decrease services listed in the plan of care (POC) 3

but the beneficiary or patient wants to continue to receive higher amounts of services. In this case, the provider should issue the beneficiary an ABN as well the HHCCN form. Correcting and Avoiding Reason Code 31755 Job Aid NGS created this job aid to remind providers and their billers to ensure that the 0023 revenue line is on the final episode claim and that the line item date of service equals the date of the first billable visit in the episode. There must also be at least one revenue line that has a line item date of service that matches the date on the 0023 revenue line. The admission date, from date and 0023 revenue line date should all be equal on an initial home health episode RAP and claim. If the episode claim is for a subsequent episode, the admission date should equal the date the patient was admitted to home care, the from date should equal the date of the first day in the episode (day 61, 121, 181, etc.) and the 0023 revenue line date should equal the date of the first billable visit provided in that episode. An example of this process is given within the job aid. Home Health Therapy Reassessment Schedule/Calendar This following job aid provides a home health therapy reassessment schedule for calendar year 2014, showing HHAs when the therapy reassessment is due based on when the agency provided the first therapy visits. The job aid shows first therapy visit dates beginning January 1, and every day after in 2014, ending on December 31 along with when the subsequent reassessment visit is due. Again, NGS plans to make each of these job aids available in the coming weeks and HCA will notify the membership when they are posted to the NGS website. Remaining 2014 NGS Education Programs Ms. O Neill provided an update on the following upcoming and important home health education sessions in FY 2014: March 18, 2014 Home Health Billing Basics March 26, 2014 Revalidation of Provider Enrollment April 16, 2014 NGS Connex (This web-based application saves providers time in checking: beneficiary eligibility, claim status, claim submissions, financial data, provider demographics, and redeterminations and re-openings) May 1, 20143 J6 Virtual Part A & B and Home Health Conference May 13, 2014 How to Correct and Avoid the Top Home Health Claims Errors NGS requires providers to register for all education sessions through its website at www.ngsmedicare.com. Providers should then click on the J6 Home Health & Hospice Home Page and look for the Register for Training link under the Quick Links section on the left-hand side of the Home Health & Hospice page. NGS will be posting many more home health and hospice education sessions to the site and HCA will notify the membership via our ASAP newsletter when these educational sessions are scheduled. 4

Next Meeting NGS s next Home Health Advisory Meeting for state association representatives is scheduled for June 27 in Chicago and NGS will continue its policy of conducting at least three Home Health Advisory Meetings for state association representatives during FY 2015. HCA will provide a detailed Public Policy Memorandum to the membership after each of these meetings. HCA will also provide updates via our newsletter on any news related to NGS or Medicare payment matters, including future CMS instructions to MACs, as well as any news regarding F2F audits, the Medicare Provider Enrollment, Chain, and Ownership System (PECOS) claims edits, and the upcoming proposed rule for the Calendar Year 2015 HHPPS (in June or July) and HCA s advocacy in these areas. For further information, contact Patrick Conole at (518) 810-0661 or pconole@hcanys.org. 5