QIRT Alerts!

April 5, 2017

Time is on My Side: Getting Ready for the CoP Challenge

Filed under: home health — Quality In Real Time Blog @ 9:40 am

On Friday, CMS announced a delay in the new Home Health Conditions of Participation (CoP) until January 2018. That should come as no surprise to anyone since, as of today, we have no interpretive guidelines and surveyors have not been trained regarding the new Rule.  Just like in that Rolling Stones song “Time is on My Side”, CMS has given us the gift of time and we need to take full advantage of it.

This delay is welcomed by all who have actually read the entire 374-page document released by CMS in January of this year. It is important that every single agency in the US take full advantage of this reprieve as a time of preparation. It will take at least 6 months to prepare.

We all remember ICD-10 and the back and forth with CMS with delays and resets.  Compared to these new CoPs, ICD-10 preparation was much simpler. This new rule changes everything. It is more than a paradigm shift in policy and procedure. Experts call it a ‘sea change’ that is unprecedented. Compared to changes in conditions we’ve all experienced in the past (i.e. OASIS), this is revolutionary and will shake our industry as nothing else has.

Be sure, every person in your agency will be affected.  From the receptionist to your Board of Directors, this rule will change the culture in our industry and change the way we do business. It will no longer be ‘business as usual’.

Not so long ago, we had ICD-9 to ICD-10 transitioning challenges. Much of what we planned for that transition can clearly be used in our strategy in the shift to the 2017 CoPs. For instance, GAP analyses, extended training of ALL staff, budgeting, job description changes, etc. will all be necessary when taking this journey from where we have been comfortable with for decades.

The July 13, 2017 enforcement date originally proposed by CMS would have been almost impossible to achieve. We have been given the gift of time. We need to manage this time well and plan our course. Even six months will be a short time frame to achieve everything we need to do.

The January deadline is unlikely to change. Understanding of the Rule and implementing the associated staff training, policy and procedure revisions, and hiring need to begin right away. This is a radical shift from the way we currently function.

You will be able to meet this deadline – but you may need help. It will be important for you to watch for the multiple training sessions QIRT has scheduled.  We will be offering education and tools to help you through the process.

Arlene Maxim, RN

April 4, 2017

Pre-Claim Review (PCR) – Be Careful What You Wish For

Filed under: home health — Quality In Real Time Blog @ 12:44 pm

That was close, Florida.

Literally hours before implementation, Florida home care agencies received the news they were hoping for.  A long-awaited hold has been placed on pre-claim reviews (PCRs) in Florida and a pause has occurred in the state of Illinois. After months of laboring with a poorly prepared Palmetto in Illinois, agencies in that state can now take a deep breath and go back to original billing policies and procedures.

However, is this really a good thing? Like that old saying, “Be careful what you wish for”, this pause/hold could be an effort to take PCR in a different direction – perhaps a nationwide implementation. While the impetus behind PCR was an effort to detect fraud, it appears that discovering fraudulent activity was not accomplished. What became evident, however, is the lack of understanding many providers have regarding patient eligibility and admission/recertification processes. In particular, face-to-face requirements and medical necessity are not being met.

Many experts in the home health agree that this pause/hold could trigger an expansion of this program to states nationwide.

Documentation related to medical necessity and homebound status has been a challenge for agencies and physicians for decades. While we have only been dealing with face-to-face for six years now, it has been a struggle to gather the necessary documents indicating patients’ homebound status and need for services. CMS recognizes this.

MACs and other oversight agencies promoting PCR are lobbying CMS hard to keep it going. Agencies and a number of legislators seem to want it either re-designed in its current form or dismantled altogether. It is important that agencies take this time to re-train staff on documentation practices related to medical necessity and determining patient eligibility.

The CMS announcement indicated a 30-day pause. So, for now, we will wait.

-Arlene Maxim, RN

VP QIRT Program Development

March 31, 2017

Home Health PCR Suspension Announced Today!             

Filed under: home health — Quality In Real Time Blog @ 7:31 pm

Late Friday afternoon, CMS announced that effective April 1, 2017, PCR will be paused for Illinois at least for 30 days. In addition, PCR will not begin on April 1, 2017, in Florida, as previously planned.  This news follows a meeting with the new CMS Administrator, Seema Verma and several providers from both Illinois and Florida. Agencies are to stay tuned to QIRT Regulatory experts and their MAC for further development.

CMS Proposes Delay in the HHCoPs

Filed under: home health — Quality In Real Time Blog @ 6:30 pm

Our industry received a slight delay in the implementation of the Home Health Conditions of Participation. This proposed delay is to be effective January of 2018.  Providers should use this time to begin training on the new CoPs and to begin setting your agency up for compliance. Take this opportunity to attend QIRT’s two-day event on the new regulations to be held in Las Vegas at the beautiful Mandalay Bay, June 12-13, 2017.  Our regulatory experts are here to be your partner in success!

December 21, 2016

Probe and Educate Strategy Continues

Filed under: home health — Quality In Real Time Blog @ 2:25 pm

CMS Announces a Continuation of the Home Health Probe and Educate Medical Review Strategy

In the December 16, 2016 MLN Release (SE1635), CMS announced that Medicare Administrative Contractors (MACs), in conjunction with CMS, have initiated Round 2 of the Probe and Educate Strategy for home health providers. This will be effective on or after December 15, 2016. The original Probe and Educate Strategy was constructed following a significant change in the CY 2015 Home Health PPS Final Rule. For providers, the specific change surrounding the F2F included the removal of the narrative requirement for the certification of the patient for home health. The final rule included the new expectations for how the certifying physician, or NPP, could incorporate the reasons for home health into the accompanying medical record from either the physician or the facility. Lastly, it outlined allowances for the physician to use portions from the home health medical record in the certification.

The first round of the probe involved select agencies experiencing five additional document requests (ADRs). The feedback from the ADRs offered details on agency deficiencies, along with an offer to provide additional education. With this second round, the anticipated strategy conclusion is one year from the date it is initiated. CMS is directing home heath MACs to select a sample of five claims for pre-payment review from each HHA within their jurisdiction, excluding those providers who had five claims reviewed in Round 1, with zero or one claim in error.

Whether or not your agency is included in this probe, QIRT has the solution to relieve ADR anxiety. Our expanded internal audit team is well versed in pre-claim audits. Let our team partner with your agency to provide a full audit of your claim-related data. Audits are conducted using the compliance measures CMS expects to be used when reviewing for medical necessity and full face-to-face compliance. Our team will audit the record and then partner with your team to educate on specific deficiencies. The QIRT compliance team can also prepare your already selected ADRs and submit to your MAC on your behalf. Call QIRT today for a discussion on how we can help!

Stefanie Woodrow


November 29, 2016

PCR Update: Palmetto Moving Forward Texas and Florida to Begin Testing eService Portal Now

Filed under: home health — Quality In Real Time Blog @ 4:16 pm

Last week, Palmetto announced that Texas and Florida providers could begin testing the Pre-Claim Review (PCR) eService Portal for submissions of PCR claims. This is the first indication that CMS intends to move forward with pre-claim review in the remainder of the five states previously identified. As of November 28, 2016, National Government Services (NGS) has nothing on their website to indicate how and when they plan to move forward with a plan for PCR.

Conventional thinking may lead agencies to believe that the lack of any information by NGS means there is nothing planned for Michigan and Massachusetts. QIRT experts would disagree. We believe NGS does not have the experience of the ramifications resulting from the rollout of the PCR process in Michigan and will not be prepared when CMS requires the process to begin.

On the other hand, we believe Palmetto has learned its lesson. It is more likely Palmetto is preparing agencies in Texas and Florida for entry into the PCR world in a more orderly fashion by allowing them to test the electronic system before another ‘mess’ occurs.

QIRT experts guess the remaining two Palmetto states (Florida and Texas) will soon receive the 30-day notice and will begin on January 1, 2017. The next following expectation is that NGS will come on board and begin the reviews soon after that date, perhaps in February or March.

As you have probably heard, the PCR process is reported to be improving. Affirmations have increased into the 80% range now. However, the number of provisional affirmations has still not caught up with the RAPs that have been submitted in Illinois. That bulk of RAP recoveries will take place on non-affirmed claims during the first week of December. Many agencies have yet to submit final claims. We will need to wait to experience the results of that fall-out.

The Michigan Association is working hard to keep agencies updated on the latest with PCR. We will notify you of any updates we receive on NGS’s plans to move PCR forward in Michigan.


Arlene Maxim


November 15, 2016

Pre-Claim Reviews: Curse or Cure?

Filed under: home health — Quality In Real Time Blog @ 9:00 am

Pre-claim reviews (PCR) have caused quite a panic in the home care industry recently. QIRT consultants have been hearing terms such as “a big mess, chaos, etc.” used to describe this new process. PCR is, indeed, a change in the way agencies should be looking at the documentation showing actual beneficiary eligibility and unique care provided. The rules have not changed. However, the way the industry approaches these requirements must change if agencies want to survive in the PCR world.

So: is PCR a curse or a cure for our industry?

The curse of PCR can be measured in multiple ways. There is a large number of industry complaints about the “mess” agencies find themselves in since the onset of PCR. Added to this complaint are the number of delayed affirmations and complete non-affirmations, multiple inconsistent directions from the Medicare Administrative Contractor (MAC), …the list goes on.

But what if the MACs are right? What if it is the industry itself that has actually caused the curse?

As consultants, QIRT staff members have the unique opportunity of reviewing home care documentation from hundreds of agencies across our great nation. Unfortunately, many home care agencies actually create their own problems at times, ultimately leading to their own demise. With an increase in the number of fraud and abuse cases identified, one must wonder if the industry is being subjected to unfair reviews or if, in reality, PCRs are proving to be a wake-up call to enforce a predetermined, long-established process.

In completing reviews on records that have been subpoenaed by state and federal governments, I have found there is a noteworthy disconnect. This disconnect exists between CMS’s rules in determining beneficiary eligibility and the unwritten, self-imposed (or occasionally self-created) rules that many agencies actually follow. Although most agencies strive for compliance with CMS rules, old and hazardous habits are cause for alarm in the industry.

It is interesting to note that during FY 2013, 17.3% of all payments made to home health care were considered improper. These improper payments cost the Medicare program $3 billion. In FY 2014, the number of improper payments increased to 51.4%, carrying a $9 billion cost to Medicare. The largest percentage of the totals in each of these years was a direct result of the fact that documentation submitted for review did not support the claim. The documentation we are speaking of in this case is that related to the physician’s face-to-face and that of the clinician’s provision of care to frail, elderly, and vulnerable patients.

As the MACs review the records agencies submit seeking provisional affirmation, they are uncovering alarming findings. Findings include, but are not limited to:

  • G-codes are misrepresented (or simply not understood) by the agency.
  • Physician information supplied for face-to-face is inadequate and inconsistent.
  • Documentation by clinicians is woefully inadequate.

For years agencies have been told that documentation is the key to success. Documentation in the clinical record that clearly supports the use of the Medicare benefit as it was intended is missing. We need a documentation revolution. The lack of agency training and understanding of the home care benefit and the requirements for documentation with a high degree of specificity has taken its toll.

As experts in the industry, it is QIRT’s opinion that PCR may just be the reveille needed. These reviews may be the cure to what is actually causing the harm to our industry.

In the recent past, CMS has used other techniques to initiate corrective action within our industry with little (or not enough) success. PCR may be the answer. Medicare’s decision to stop the game of pay-and-chase has begun in Illinois and is headed to four more states very soon. Reviewing documentation related to eligibility and services to be rendered will provide CMS with data in real time, prior to paying claims. PCR promises to provide the Medicare program with a significant amount of data.

The homecare industry has never liked change. But change is here, and change can be our friend. If agencies heed the warnings from the issues being identified today, they may encounter the necessary cure and experience a better tomorrow.

Arlene Maxim

November 3, 2016

Summary of the Final Rule for HH PPS Rate CY2017

Filed under: home health — Quality In Real Time Blog @ 10:47 am
The end of October ushered in the release of the Centers for Medicare & Medicaid Services (CMS) Final Rule for the CY2017 Home Health Payment (CMS-1648). On the surface, it appears payment will increase for 2017 since the base rate increases in 2017 to $2989.97 from the 2016 base rate of $2965.12.

On the surface, this report sounds exciting, but realize that although the base rate has gone up in 2017, this increase will not translate to more money per episode. CMS had to increase the base rate to help offset the reductions created by adjustments to the case mix categories.

What does this really mean for home health agencies? It is estimated that the HH PPS pay rate will actually decrease by 0.7% in 2017.
Remember, you can always contact the QIRT team if you have any concerns. We are proud to support home care agency success.  – QIRT Education Team

October 20, 2016

The Future of Home Health Reimbursement

Filed under: home health — Quality In Real Time Blog @ 9:37 am

For many years, home health care experts have heard the rumblings…we have seen the signs. As an industry, we have known that eventually we would see another drastic change to the established reimbursement model. Even so, there are many who will not make preparations to move toward a methodology change until there is an effective date. But what if I told you that agencies currently have access to the information needed in order to prepare now for what is to come? All that we have to do is to look to the current CMS initiatives to know what course to take.

As a result of the Affordable Care Act (ACA) and prior initiatives, Congress established the CMS Innovation Center with one goal in mind. The center was established for the purpose of testing “innovative payment and service delivery models to reduce program expenditures …while preserving or enhancing the quality of care” for those individuals who receive Medicare, Medicaid, or Children’s Health Insurance Program (CHIP) benefits. In short, the Innovation Center is continually testing payment and service delivery models that deliver quality, efficiencies, and compliance. Because this goal is intact regardless of the initiatives or demonstrations, agencies can establish an operational infrastructure that will allow them to adapt to any reimbursement environment.

There are several things that home health care agencies can do now in order to be equipped to manage the future changes within the industry.

Agencies should:

  1. Establish an internal committee that constantly oversees agency operations and performance (multi-professional, multi-disciplinary).
  2. Conduct an operational assessment to evaluate processes, procedures, workflow, departmental flow, and compliance measures (must have interdepartmental comprehensive tool for accuracy).
  3. Review and revise necessary components of agency operations (based on the assessment findings).
  4. Adjust education plans to address the revisions. Education must be customized to applicable departments and roles within.
  5. Monitor and review the result of the education, as well as implement a compliance audit plan to produce measurable results.
  6. Revise compliance audit plan as needed. Multiple revisions of the new plan may be necessary in order to gain the most effective outcome.

The steps are simple. However, it is imperative that agencies have the proper tools and expertise to conduct a thorough analysis and the subsequent necessary revisions that come as a result. These steps will not be effective without the proper tools and/or resources. When completed properly, this exercise will lead to a radical culture change within your organization that will yield improved quality, streamlined efficiencies, and additions to your bottom line. QIRT (Quality in Real Time) has established a complete tool kit and complied a team of experts with the knowledge to carry out this process for your agency. Call or email us today to schedule your consultation.

Stefanie Woodrow, RN

Director of Education

October 4, 2016

Face-To-Face: When Will We Learn?

Filed under: home health — Quality In Real Time Blog @ 9:29 am

Following a recent conference call with industry leaders, it became clear that the home health care industry often fails to take advantage of changes in policy or in the many educational opportunities offered. The latest subject continuing to cause confusion has to do with face-to-face compliance.

In 2011, CMS issued a face-to-face rule that would significantly impede the home health care industry. The combination of the lack of clarity within the rule itself coupled with the industry having little to no control has initiated crippling financial consequences. Increased audits verifying specific compliance with the rule caused denial rates of 80-90% and stifled the growth of many agencies.

Never before had the homecare industry been at the mercy of physicians for the reimbursement of homecare services. CMS was charged with the responsibility of educating physicians on the elements required to complete the face-to-face form. However, the education provided was nearly non-existent and often proved to be ineffective. Most physicians (indeed most professionals) do not care for additional paperwork and this rule required a considerable amount of increased documentation with specificity.

As a result, a number of individual agencies and state and national organizations worked with CMS to change the rule. The initial direction for the 2015 change was confusing for agencies and physicians. QIRT experts’ experience in the field has shown us that most agencies still have not unraveled the requirements of the newest face-to-face rule. Many agencies continue to use the original face-to-face form created 5 years ago, even though the Medicare Administrative Contractors (MACs) have been very clear that the face-to-face form is not what they are looking for.

In 2015, the rule changed. Another five-record review by the MACs in 2015 found compliance with the new rule to be unchanged. In point of fact, the percentage of denials increased. It got worse. Why? Because homecare agencies did not follow the new rule.

Despite the warnings, attempted education, and written instruction by CMS and the MACs, agencies continued to ignore the direction, continued to use the same face-to-face form, ignored the requirement to secure the physician progress note, and more. Today, in the pre-claim review state of Illinois, most of the non-affirmations received from the reviewers are the result of a “lack of information in the physician file.”

Just what is the 2015 Face-to-Face Rule?

The information needed for face-to-face has actually not changed much from the 2011 rule. Agencies still need to show documentation of medical necessity and the two criteria for homebound status. What has changed is that it is now acceptable for the agency to provide the necessary information along with the physician’s information, as a supplement (not replacement) to his/her progress note.

So…it is actually fairly simple. If the agency provides specific items, such as OASIS responses related to skilled need and homebound status (M1800s), therapy evaluations, a medical update written by agency staff, etc., CMS will allow these items to be added to the physician progress note in response to a medical review request, including pre-claim reviews. It is important to understand that the agency documentation supplied must include the physician signature indicating he/she has reviewed and agrees with the supplemental assessment information.

With the 2015 rule, agencies now have the opportunity to support the information on the physician progress note with agency information. Why are agencies not doing this? Hopefully the simple steps outlined above will encourage agencies to review current practices and begin to provide the necessary information, resulting less denials and more accurate and timely reimbursement.


Arlene Maxim

VP Program Development

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