In today's changing regulatory environment, home health care agencies juggle multiple priorities: increase the quality of care and patient satisfaction, keep meticulous documentation, control costs, manage alternate payment systems, and monitor changing compliance requirements. That last item is often the most difficult: who has the time to read the Federal Register each day? Yet, staying on top of regulatory and compliance changes is central to your agency's success.
CMS Is Focused on Cost Cutting & Fraud Prevention
The Medicare Part A Trust Fund is under financial strain. The 2016 annual report from the Board of Trustees warned that it could be depleted by 2028. In response, the Office of Inspector General (OIG) at the Department of Health and Human Services (HHS) outlined key components of the challenge facing HHS as it works to ensure the program's integrity and fiscal health.
- Reducing improper payments
- Preventing, detecting, and responding to fraud
- Fostering prudent payment policies
Home health agencies and hospices were subject to particular scrutiny, the report noted "improper payments across a number of risk areas, such as insufficient documentation, medical necessity, and homebound determinations."
The 2017 annual report, issued in November, had good news for both CMS and home health agencies. The improper payment rate dropped to 9.6%, saving an estimated $4.9 billion. The report also notes that fraud isn't the only driver of overpayments:
Improper payments are not always indicative of fraud, nor do they necessarily represent expenses that should not have occurred. For example, instances where there is insufficient or no documentation to support the payment as proper are cited as improper payments under current Office of Management and Budget guidance. The majority of Medicare FFS improper payments are due to documentation errors where CMS could not determine whether the billed items or services were actually provided, were billed at the appropriate level, and/or were medically necessary.
Expanded documentation requirements are one way of addressing these challenges. This means that home health agencies must pay close attention to all regulatory and documentation details. The document flow is so interconnected that a single mistake can cascade through the system and trigger numerous red flags to payers and auditors.
Alternate Payment Models & Non-Medicare Payers
The "we've always done it this way, and it worked fine" attitude is a recipe for failure.
Even though Medicare paused the pre-claim review process in early 2017, the program hasn't been formally scrapped. It's important to watch for new developments. With Medicare, agencies are still dealing with a single payer with relatively predictable rules and regulations. However, with Medicare Advantage Plan Providers (MAPPs), payment levels, documentation requirements, and information sharing methods vary between providers and between states. The larger the HHA, the bigger the problem. It's crucial to have an IT system that supports compliance and documentation requirements.
Alternate payment models (APMs) are another CMS strategy to increase quality and reduce costs. They come with their own sets of rules, regulations, and documentation requirements. Because APMs expect that the entire care team - from primary care physician to home health nurses - will function as an interconnected unit, success depends on the ease and speed of communication. Data has to be shared across the spectrum of care, often across a plethora of data platforms.
By 2022 (or earlier), agencies will be subject to Value Based Purchasing (VBP), which is another CMS initiative to control costs and increase quality. Agencies compete with each other for top scores, with performance measurements based on operations, reporting, and quality of care. How the scores calculated? Mainly through documentation, of course! Be digilent: erroneous or incomplete documentation lowers an agency's score.
Keep Your Agency Up to Date & Plan for Increased Scrutiny
Understand that every health care actor is facing additional scrutiny and regulatory requirements. You may not be able to avoid an audit (CMS conducts a wide variety of random audits, like CERT audits), but you can be ready for one.
- Avoid coding mistakes: Multiple mistakes bring increased scrutiny and delay payments.
- Document workflows: Care takes place away from the office and is customized to individual patient needs. Be sure caregivers document all care.
- Review documents for completion: Defensible documentation is your first line of defense. Have all necessary signatures, document examination findings, care plans, etc.
- Perform internal audits: Identify and correct problems before regulators find them.
An established, well-documented compliance program reassures auditors that your agency is making good-faith efforts and expending resources to ensure accuracy.
HCHB's robust software and training solutions help remove uncertainty about regulatory compliance. We work regulators to understand and implement new requirements, so that our clients are free to focus on their core business of providing quality health care. Talk to our experts about how Homecare Homebase can help your agency with data collection, retention, reporting, staff scheduling, and more.