On Monday’s broadcast of Monitor Mondays, we heard from William Dombi, the vice president of law for the National Association for Home Care and Hospice, regarding the Centers for Medicare & Medicaid Services (CMS) Pre-Claim Review Demonstration for Home Health Services, which began in Illinois on Aug. 3, 2016 – as well as how and why CMS is pulling back on it.

CMS has held open door forum calls and produced written materials for providers to try to ease the burden and to try to provide clarity. And while the supplied information was helpful, a question buried on the Frequently Asked Questions web page caught my eye.

The question was this: What should home health agencies do if the certifying physician will not provide documentation? CMS’s response was the creation of an informational letter directed towards physicians that will be available for download.  Home health agencies can give the letter to physicians, thus reminding them of their responsibility to provide the documentation.

If the physician still will not provide the documentation, home health agencies should notify their Medicare Administrative Contractor (MAC) or CMS. Physicians who show patterns of non-compliance with this requirement, including those physicians whose records are inadequate or incomplete, may be subject to increased reviews, such as through provider-specific probe reviews.

This is potentially a groundbreaking development. Is CMS actually offering to target physicians who are reported to them for non-cooperation? The Medicare Administrative Contractors already have the authority to deny physician payment for the review and signing of the plan of care, which is billed with G0180, if the home care agency payment for the episode of care is denied – but that is simply a claim edit. That actually makes sense; if a doctor certified a plan of care on a patient who was not eligible for the service, their payment should be recouped.

But that is already a standing policy, and CMS is suggesting a much broader audit. Yet what records will CMS or the MAC review? Will they only review the office and hospital visits associated with a particular patient? Or will they audit a sample of the physician’s claims, office visits, hospital visits, surgeries, and procedures, perhaps just try to scare the physician into cooperating?

From the statutory side, can CMS even deny the payment of an office or hospital visit that meets all the federal evaluation and management documentation and coding requirements for the billed level of service solely because the documentation does not properly spell out the homebound and skilled needs requirements? Furthermore, will CMS or the MAC actually want proof that the physician was non-cooperative, or can any agency report any physician and trigger an audit?

The home care agencies have been struggling for years with repeated changes in CMS policies regarding documentation of homebound status and skilled needs, as I have outlined on a previous RACmonitor article. I can now admit that my optimism was unfounded; in the two years since I wrote that article, the agencies have faced hurdle after hurdle to get paid for providing medically necessary services to patients. This statement from CMS may indicate to those agencies that CMS now “has their back” and will help them get the necessary documentation.

But only time will tell; perhaps this will be like transmittal 541 and just be another idle threat that rarely gets used. And unless physicians actually know a colleague who has been audited, their behavior is unlikely to change.

About the Author

Ronald Hirsch, MD, FACP, CHCQM is vice president of the Regulations and Education Group at Accretive Physician Advisory Services at Accretive Health. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians.

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