Skilled home health agencies have taken on a lot of change in the last several years. We had changes to the Conditions of Participation and initiated Emergency Preparedness programs. We have been preparing for the clinical and operational changes coming in January with PDGM. Some have already begun the Review Choice Demonstration (RCD). It may be a big sigh of relief if you are not in the RCD states, but it is still important to understand the background and what the future may look like for your agency.
Pre-Claim Review (PCR):
The PCR process was a 3-year demonstration that began in Illinois in 2016. It was also scheduled to roll out in Florida, Texas, Michigan, and Massachusetts. It was stopped in Spring of 2017 after huge amounts of backlash from the industry. The goal of CMS was to prevent improper billing from agencies by reviewing all the necessary data needed in order to file a claim. Reality is, auditing done in ADRs and PCR showed CMS that a significant number of agencies didn’t meet the threshold of documentation required to bill for a claim. Enter the updated pre-claim in the form of the Review Choice Demonstration.
Review Choice Demonstration (RCD):
The RCD process has begun. Now, the states affected look a little different. Illinois and Ohio have already started the process. CMS has allowed some time for Texas, North Carolina, and Florida to settle into PDGM before beginning the RCD. Now, this process allows agencies a choice how they wish to be audited. Agencies choose between:
- Pre-Claim Review,
- Post-payment review, or
- Minimal post-payment review with a 25% reduction in payments
The process will allow, after a 6-month review period those agencies with a high approval rate to receive relief from all claims being reviewed as part of the RCD. Agencies will then be subjected only to minimal claim review. Those who do not achieve high approval ratings from the submissions will have to continue the process. Now, what does this mean for the rest of the states not currently in RCD? Get your ducks in a row now because there is no reason to believe the process will not reach all states in some form.
Getting Your Ducks In A Row:
Who currently does your auditing of charts? Is there someone designated in your office or branches to compile and review your ADRs prior to them being sent? If there isn’t, there should be. Look at someone in your agency that can have objective eyes when reading documentation. Look at a few of your long-term clients that may leave you vulnerable:
- How about your long-term wound patients: This patient has been on service for a year and a half with a chronic venous wound. The wound varies in size and sometimes is very close to healing. You know that if you are not present in this home, the patient will not comply with prevention measures or keep his dressings on the wound. The only reason this patient has remained out of the hospital or SNF is because of the care your agency has provided. Now, does the documentation consistently show this dynamic? Does the face-to-face check all the boxes that cover you for this care? If CMS pulls month 11-12, do you have what it takes to get the claim paid? If you don’t, then you can guarantee the next ADR pulled will be months 13-14. You can end up with multiple cert periods denied.
Who checks your face-to-face documentation? This is still a huge reason for denials in the auditing process. This tells CMS that agencies are not checking to confirm all the documentation is present. Make sure those responsible for documentation are not just looking for the face-to-face, but are able to interpret the data within the document. It is recommended someone clinical is ultimately responsible to see and determine that the face-to-face has all the required documentation in full. Homebound status is often vague and the primary reason for homecare is often not the primary reason for the face-to-face visit.
Kenyon Homecare Consulting Can Help With Your Audits:
At Kenyon Homecare Consulting, we have senior associates who are well-versed in clinical documentation requirements and can assist with ADRs or other Medicare auditing. We can educate staff of the requirements in a meaningful and relevant way. We can assess your documentation process to evaluate where deficits may exist and help you improve. If you are drowning in audits or need assistance in training on the process, then call us at 206-721-5091 or contact us online.