By now, home health agencies are well aware of the new program under development by CMS to crack down on what they believe is a major problem with improper payments for their services. This is referred to as the “Pre-Claim Review Demonstration”.
This document describes these new regulations that were published in the Federal Register in June.
This effort is a drastic attempt by CMS to reduce the increasing improper payment rates associated directly with home health services. Essentially, developing a process to examine 100% of all claims submitted by Home Health Agencies (HHA) prior to their approval and final payment.
CMS’s Comprehensive Error Rate Testing (CERT) program annually estimates the percentage of payments that did not meet Medicare coverage, coding and billing rules. For 2015, they calculated the improper payment rate for home health claims at 59%. This compares to 51.4% in 2014 and 17.3% in 2013. CERT determined that a majority of errors that occurred in 2014 were due to the fact that the narrative documentation associated with face-to-face encounters did not support the patient’s homebound status and the need for skilled services. Now CMS no longer requires separate narrative documentation for the face-to-face, but they are still seeing many cases where the documentation provided by the HHA in the medical record does not support the home health benefit they are providing. These improper payments do not necessarily indicate fraud, it may simply be a lack of documentation, documentation errors, or a lack of understanding of Medicare rules. However, fraud is a substantial contributor to the problem.
Since October of 2014, timely filing of NOE/NOTRs (Notice of Election/Notice of Termination-Revocation) has been a leading issue for the hospice industry. As a software company that works on Medicare electronic transaction processing, when these regulations were announced, they caught our attention as a possible opportunity for a new product that might resolve some of the issues that CMS and the hospice industry dealt with regarding the efficiency of these transactions.
One of the most difficult tasks you deal with regarding developing new software solutions is understanding the actual issues involved with a process and what the problems really are for the entities involved. When these regulations were announced, it was clear that CMS felt that it was important to get these transactions submitted within five days. This told us two things. First, they were not being processed within this window a substantial portion of the time and second, that this delay presented problems for CMS and the industry.
Healthcare analytics can be used to identify successful treatments, control costs, and make processes more efficient. It can also be used to shed light on practices and industry relationships that might not be considered entirely healthy for the industry as a whole.
It is no secret that drug manufacturers make payments or provide services to physicians in an effort to strengthen their relationship with these providers. Providers have long argued that these practices in no way influence their decision on which drugs they prescribe to their patients.
ProPublica, (www.propublica.org) an internet news site, has used this public data to create a database on providers and how much they collect through these payments from drug and medical device manufacturers. They have made this database available through their site and you can look up the payments reported as paid to your physicians from these vendors.
As we discussed in my last article, the ACA has allowed CMS to explore new payment models that might more accurately reflect the value or cost of the services rendered by healthcare providers. For acute care facilities, we are experiencing the beginnings of value-based payments intended to blend outcome data with billed services to determine fair compensation.
For hospices, new payment models have been introduced this year that are an attempt to more accurately reflect the cost of treating these patients at various stages of care. The hospice payment changes are an attempt to match the “cost curve” where patient care costs more in the early days of treatment and the final days of life compared to the days in between. This study was used to document these “curved” resources and provide the basis for the current payment model:
Cost Curve Study
The Affordable Care Act includes many healthcare regulations unrelated to the distribution of insurance and expanding Medicaid. One important part of this legislation allows the federal government to explore new payment methodologies that they believe more accurately compensate providers for their services. For acute care facilities, the term used for these new payment models is “Value-Based” payments where data previously considered to be unrelated to the billed services is used to determine the compensation for providers.
For hospitals providing services covered by this model, post discharge data is used to determine the outcome of the service. This outcome will then have an impact on payments for these services. In this new model, discharging a patient is no longer the “end point” of a billed service. The service is expanded to include post discharge services and results. This is a revolutionary concept and as it applied to other services, it will have major impact on the hospital industry in many ways that are both intended and unintended by this model. Regardless of your point of view regarding the fairness of this payment model for this service and others like it, there will be problems with existing patient accounting systems in dealing with this new reimbursement model.
It has been a month since my last post. I normally don’t take so long, but sometimes life takes over and you don’t always have the free time to get your thoughts down on virtual paper. Although my writing has been lax, I have been reading quite a bit lately. Now it’s time to write again.
Around this time of year, we see the obligatory bests and worst lists of the ending year. Like most people, when I read these lists I often think of what is missing that makes these lists incomplete or rankings that seem irrational or unjust. There were several examples of these I saw regarding healthcare IT that examined the past year and what is coming in 2016.
Instead of discussing a list, I would like to point out a single completed objective that all of us should reflect on as we evaluate 2015 and look toward the future adoption of new technology in healthcare. During late 2015, we converted from the ICD9 to ICD10 diagnosis code set. This was over 90 days ago and the expected major disruptions associated with this change have never materialized. Like Y2K and Obamacare, we have once again proven that healthcare is an industry that can absorb change and adapt to new procedures. We have demonstrated again that we normally overestimate the negative impact of change and our ability to cope.
Healthcare providers collect an extensive amount of data regarding their patient’s medical history. Most providers understand the importance of maintaining accurate and complete health records. Collectively, this data tells a story of the medical history of the patient and can provide insight into new conditions or symptoms that might develop in the future. If you can combine the data from many patients into a database and examine it, new trends can be identified that can lead to new treatments, more efficient healthcare delivery, and better outcomes.
Provider organizations understand the value of this data. They would not think of discarding the medical record after a patient encounter or transferring the only existing copy of this data to a third party for processing, paying for a copy of the data if it was ever needed in the future or losing the data entirely if the third party goes out of business.
MEDTranDirect is a vendor of Medicare connectivity services, including access to the CMS HETS system (HIPAA Eligibility Transaction System) that provides real time eligibility data for healthcare organizations. The data processed through this system is intended to provide a complete picture of all beneficiary data necessary to determine if payment will be received when healthcare services are provided to Medicare patients.
Late last year, we found a problem in the HETS data where the hospice NOE (Notice of Election) data was only present part of the time when it was processed in the CWF (Common Working File). We documented this issue and reported it to HETS support. Their initial response was that this was not a claim and that is why it was not showing up. This did not make much sense since it did show up at least half of the time. We resubmitted the problem again in February of this year, their response at that time was that it did not show up because the data was not in the CWF and the problem was with the MACs processing the NOEs and not the HETS system. This conclusion was also not supported by the data we provided since we gave them screenshots of NOEs entered and accepted in DDE (Direct Data Entry), but were not present in HETS several days later.
The MACs (Medicare Administrative Contractors) audit claims submitted by providers within their jurisdictions. These organizations are mostly insurance companies who administer the contracts awarded by CMS to process claims submitted electronically by providers in a given geographic area. As part of this responsibility, these MACs are required to make sure that the claims submitted are complete and submitted in accordance with the rules developed by Medicare to assure that these claims are for services that are medically necessary and properly documented.
They work similar to the IRS, examining submitted claim data for outliers and patterns of suspicious behavior. Like the IRS, they perform this service as part of their contractual obligation to the government, not as a revenue generating activity.
MEDTranDirect provides connectivity between healthcare providers and all the Medicare contractors (MACs). Through this connection, providers can have access to the Direct Data Entry (DDE) or FISS system, the ability to send claim files and receive response files like the 835 and 277CA, and connection to the Medicare eligibility system (HETS).
The first two services have been available for almost thirty years. When they were introduced, access to these systems was achieved through a modem, phone line, and a remote terminal to the IBM mainframe computers running these services. Now, decades later, this technology is still prevalent among providers who are still using the same methods to access this information and conduct these transactions. Although many users have replaced the remote terminal with an emulator that can run under Windows on an existing PC, the technology connecting this emulator to the MAC systems still exists and is still supported by many MACs today.