New Timeframe for Response to ADRs

On November 18th CMS issued MLM Matters Number MM8583 concerning new timeframe for response to Additional Documentation Requests (ADRs).  This article is based on Change Request (CR) 8583, which instructs MACs and Zone Program Integrity Contractors (ZPICs) to produce pre-payment review Additional Documentation Requests (ADRs) that state that providers and suppliers have 45 days to respond to an ADR issued by a MAC or a ZPIC. Failure to respond within 45 days of a prepayment review ADR will result in denial of the claim(s) related to the ADR. Make sure your billing staffs are aware of these changes.

LINK for More Information 

CMS Issues Correction To Remittance Message For Late Filing Of Hospice Election

On November 6th CMS issued Change Request CR 8923.  CR8877 established an exception process where, in certain exceptional circumstances, a hospice can request the MAC to waive the consequences of filing the NOE late. The hospice files the associated claim with occurrence span code 77 used to identify the non-covered, provider liable days. The hospice also reports a KX modifier with the Q HCPCS code reported on the earliest dated level of care line on the claim. The KX modifier prompts the MAC to request the documentation supporting the request for an exception. Based on that documentation, the MAC shall determine if a circumstance encountered by a hospice qualifies for an exception.

If the MAC approves the request for an exception, the MAC processes the claim and removes the submitted provider liable days, which will allow payment for the days associated with the late-filed NOE. If the MAC finds that the documentation does not support allowing an exceptional circumstance, the MAC shall process the claim as submitted. Due to a system limitation, the provider liable days on these claims currently receive remittance advice remark code N211 (Alert: You may not appeal this decision) in error. The exception requests decisions are appealable. The purpose of CR8923 is to correct this error.

The provider liable days on these claims will receive the following remittance advice codes:

* Group Code CO;

* Remittance Advice Remarks Code 96; and

* Claim Adjustment Reason Code MA54

LINK CHANGE REQUEST 

Are You Missing The Private Duty Boat?

Do you own or have relationships with a Private Duty Home Health Company.  Many home health agencies and hospices have private duty home health agencies, but others do not.  To include private duty as part of your services may or may not be beneficial.  I have some clients who have private duty as part of their circle of care and have benefited financially and have obtained many cross referrals.  I have other clients who work with many different private duty companies, because they enjoy multiple referral sources.  There is not a right or wrong answer. Each home health or hospice needs determine if adding private duty would help or harm their business.  That study would include the number of private duty companies in your area, the amount of referrals you receive from these companies, the potential market for private duty services in your area, other Medicaid Waiver programs in your state that allow Non-Medicare home health agencies to provide services. Regardless of your decision, you are missing the boat if you do not either own a private duty agency or you are working with several private duty agencies.  There is a large possibility of cross referrals between private duty and Medicare Certified Home Health.  There are also possible cross referrals between private duty and Medicare Certified Hospice. We have a special new seminar in Las Vegas onFebruary 2nd to 4th at the Monte Carlo Hotel just for Private Duty.  The goal is to provide a comprehensive seminar to cover the hot topics that impact their Private Duty Agencies, using nationally known expert speakers.  Our clients are constantly asking how they can develop better relations with other referral resources.  Private duty agencies can and should be a good referral source for Medicare Certified Home Health & Hospice companies.  I believe the answer to developing better relations would be to recommend our new seminar to private duty agencies in your area.  It will show them you understand they are having similar problems in their industry.  It would also show it is not just about receiving their referrals, but your interest in helping them succeed in their business. If you are interested in starting you own private duty agency attending the seminar would be a good starting point.  It will provide information on the latest issues impacting private duty agencies. We can also help by extending the first cut off price to your referring private duty agencies to November 23rd.  That will save the $100 per registrant, just have them let us know about the November 23rd date.  They do not need to tell us who gave them the information, we will just extend the deadline to November 23rd. For more information about the Private Duty Seminar or for any of the Las Vegas Seminars please utilize the links below.       **********************************************

Dixon Healthcare Solutions, Inc. Next Destination Seminars  Exploring Trends & Routes for Success

Four Great Seminars presented by  Dixon Healthcare Solutions, Inc. Home Health Agencies - January 28-30, 2015 Physicians Practices - January 28-30, 2015 Hospices - February 2-4, 2015 Private Duty - February 2-4, 2015 **** Brochures Home Health Brochure Physician Practice Brochure Hospice Brochure Private Duty Brochure **** Location is the Monte Carlo in Fabulous  Las Vegas, NV **** Registrations Forms Home Health Physician Practices Hospice Private Duty It is important to register early, because the rates go up as the date gets closer and their is limited seating. **** The speakers include: Richard Dixon, J-non Griffin Robert Liles Richard Martin Cheri Martin Robert Floyd Donna Floyd Adam Bird (Physician Practice Only) **** Program Outlines Home Health Physician Practice Hospice Private Duty The program is great for each and we hope to see you in Las Vegas at the Monte Carlo

More on Final 2015 PPS Rules & Rates

We have sent out several emails concerning the Final 2015 PPS Rules & Rates. On November 3rd we sent an email on the Final Home Health Rates for 2015. On November 4th we sent an email concerning changes in case mix weights. On November 5th we sent an email explaining the changes regarding the elimination of the Face-To-Face Narrative.

Other changes include changes in wage index classifications based on a 50/50 blend in new CBSA designations.  Many home health agencies will lose their rural add-on as a result of the changes in the new CBSA designations. 

CMS has made changes to the therapy reassessment timeframes for the 13th and 19th visit to every 30 days for each therapy discipline.  They have added a penalty for late submission of OASIS Assessments.  Failure to meet the new threshold for the period of July 1, 2015 toJune 30, 2016 will result in a 2% rate reduction in future year.  CMS has provided new information for coverage of insulin injections.

We will discuss the above and more at our "Final 2015 Home Health PPS Rules & Rates" Webinar onNovember 20th 2014 from 3:00 PM to 4:30 PM EST.

LINK TO FINAL RULE

 

Webinar - Final 2015 Home Health PPS Rules & Rates

Registration Form For Webinar

CMS Whines "O Did I Do That!"

Our friends at CMS issued a strange request on November 5th and published it in the Federal Register.  This request was for information and solicits suggestions for addressing substantial growth in the number of hearings being filed with Office of Medicare Hearings and Appeals, and the backlog of pending cases.  The number of appeals has completely overwhelmed the system.

I wonder who caused this.  Do you think CMS may have created their own problem?  Most of our readers are well aware of the "Bounty Hunters" Recovery Audit Contractors (RACs) and Zone Program Integrity Contractors (ZPICs) who have created havoc in the health care industry with unbelievable claim denials.  I guess if we got paid to deny claims we could probably find millions ($$$$$$$$$) of reasons, but that does not mean the denials are correct. 

Basically CMS broke the system and now they want help fixing the system.  I have a couple of suggestions.  First I would reverse all Home Health Face-To-Face denials due to problems in the physician narrative.  CMS has already eliminated beginning in January of 2015, why not make it retroactive. Next they should require a RAC or ZPIC contractors to pay a penalty of 10 times the amount of claims they have denied that are reversed on appeal.  Of that penalty 5 times the amount should go to CMS and the other 5 times should go to the effective providers, suppliers or physicians.  That will probably make them much more careful with their arbitrary denials.

I along with 99.5% of the healthcare industry want the bad actors forced out of business, but CMS has let these RACs and ZPICs run wild without any control.  Maybe we should all send letters as comments based on the arbitrary denials to the proposal.  Some of the Medicare beneficiaries or their family members should send similar letters for services that were arbitrarily denied.  The clock is ticking, comments should be submitted by December 5, 2014. You can obtain the address for comments by downloading the link below.

I wonder what CMS would do if they had a million comments from providers, suppliers, physicians, and beneficiaries on this notice.  They would probably place another request in the Federal Register requesting help in responding to comments on their previous request.  

LINK

  

We Are All Swimming Up Stream

Do you feel like your industry is the only one swimming upstream against the battle over unfair government rules, regulations, oversight and audits?  You are not alone.  The entire healthcare industry has been on your team in the last few years.  The healthcare industry goal is to provide excellent care to patients, produce excellent outcomes, and make a small profit.  The government wants you to provide the above, but they want to pay less, add mountains of new rules, increase the burden of new regulations, constantly insinuate Medicare and Medicaid Fraud, keep you payment updates at much less than inflations, and send bounty hunter auditors to deny previously paid claims that probably should be allowed. Our company has one simple goal which is to keep our clients in business.  One of our best methods of doing this is to provide information to our clients and friends about new rules, regulations, trends, payments, and other information that impacts the Home Health, Hospice, and Private Duty industries.  We do this by providing newsletters and by providing comprehensive seminars, on the hot topics in the various industry, with nationally known experts.  I have been in the healthcare industry for over 30 years and the consulting industry for over 20 years.  I learned long ago that you cannot provide all services to all industries.  To be successful you must specialize and surround yourself with experts in other fields to provide information and services to your clients. Another group that all of our clients work with are physicians.  We have researched the physician industry and found that they are facing the same issues that impact Home Health, Hospice, and Private Duty.  The government is reducing their payments, adding mountains of new rules, increasing the regulatory burden, and sending the same bounty hunter auditors to deny previously paid claims. This year we are adding a new seminar in Las Vegas onJanuary 28th to 30th at the Monte Carlo Hotel just for physician practices.  The goal is to provide a comprehensive seminar to cover the hot topics that impact their practices, using nationally known expert speakers.  Most of our clients are constantly asking how they can develop better relations with their referring physicians without breaking any of the federal or state laws.  I believe the answer would be to recommend our new seminar.  It will show them you understand they are having similar problems in their industry.  It would also show it is not just about receiving their referrals, but your interest in helping them to run a successful practice. We can also help by extending the first cut off price to your referring physicians to November 24th.  That will save the physician's $100 per registrant, just have then let us know about the November 24th date.  They do not need to tell us who gave them the information, we will just extend the deadline to November 24th.  For more information about the Physicians Practice Seminar or for any of the Las Vegas Seminars please utilize the links below.   **********************************************

Dixon Healthcare Solutions, Inc. Next Destination Seminars  Exploring Trends & Routes for Success

Four Great Seminars presented by  Dixon Healthcare Solutions, Inc. Home Health Agencies - January 28-30, 2015 Physicians Practices - January 28-30, 2015 Hospices - February 2-4, 2015 Private Duty - February 2-4, 2015 **** Brochures Home Health Brochure Physician Practice Brochure Hospice Brochure Private Duty Brochure **** Location is the Monte Carlo in Fabulous  Las Vegas, NV **** Registrations Forms Home Health Physician Practices Hospice Private Duty It is important to register early, because the rates go up as the date gets closer and their is limited seating. **** The speakers include: Richard Dixon, J-non Griffin Robert Liles Richard Martin Cheri Martin Robert Floyd Donna Floyd Adam Bird (Physician Practice Only) **** Program Outlines Home Health Physician Practice Hospice Private Duty The program is great for each and we hope to see you in Las Vegas at the Monte Carlo ***********************************

Final Rules Eliminate Face-To-Face Narrative Beginning January 1, 2015

CMS has finalized it proposal to eliminate the face-to-face encounter narrative as part of the certification of patient eligibility for the Medicare home health benefit, effective for episodes beginning on or after January 1, 2015.  The certifying physician will still be required to certify that a face-to-face patient encounter, which is related to the primary reason the patient requires home health services, occurred no more than 90 days prior to the home health start of care date or within 30 days of the start of the home health care and was performed by a physician or allowed non-physician practitioner.    For instances where the physician is ordering skilled nursing visits for management and evaluation of the patient's care plan, the physician will still be required to include a brief narrative that describes the clinical justification of the need as part of the certification/re-certification of eligibility. In determining whether the patient is or was eligible to receive services under the Medicare home health benefit at the start of care, CMS will require documentation in the certifying physician's medical records and/or the acute/post-acute facility's medical records (if the patient was directly admitted to home health) to be used as the basis for certification of home health eligibility.  CMS will require the documentation to be provided upon request to the home health agency, review entities, and/or CMS. Home health agencies should obtain as much documentation from the certifying physician's medical records and/or the acute/post-acute facility's medical records (if the patient was directly admitted to home health) as they deem necessary to assure themselves that the Medicare home health patient eligibility criteria have been met and must be able to provide it to CMS or its review entities upon request. CMS will remind certifying physicians and acute/post-acute care facilities of their responsibility to provide the medical record documentation that supports the certification of patient eligibility for the Medicare home health benefit.  Certifying physicians who show patterns of non-compliance with this requirement, including those physician whose records are inadequate or incomplete for this purpose, may be subject to increased reviews, such as provider-specific probe reviews. CMS is also finalizing the proposal that physician claims for certification/recertification of eligibility for home health services (G0180 and G0179) will not be covered If the home health claim itself is non-covered because the certification/recertification of eligibility was not complete or because there was insufficient documentation to support that the patient was eligible for the Medicare home health benefit. This final rule does not eliminate the physician narrative for episodes beginning before January 1, 2015 and the thousands of home health denials based on the physician narrative. This will be discussed in our November 20, 2015Webinar titled "Final 2015 Home Health PPS Rules & Rates".  It will also be discussed at our "Exploring Routes & Trends for Success" Comprehensive Home Health Seminar in Las Vegas on January 28-30, 2015 at the Monte Carlo Hotel & Casino. Temporary Link to Final 2015 Home Health PPS Rules & Rates The final rule will be published in the Federal Register on November 6th.  We will provide a new link at that time. Webinar Information  Registration Form We are having another seminar at the same time in the meeting room next door for physicians in Las Vegas.  CMS is also working to decrease physician payments, negatively impact their practices, discourage home health and other referrals, and deny their claims.  You may want to encourage your referring physicians to attend our "Exploring Routes & Trends for Success" Comprehensive Physician Practice Seminar.  We believe it would help them better manage their practice and could improve relations with your home health company.  Information regarding the Physician Practice Seminar is listed below.   **********************************************

Dixon Healthcare Solutions, Inc. Next Destination Seminars  Exploring Trends & Routes for Success

Four Great Seminars presented by  Dixon Healthcare Solutions, Inc. Home Health Agencies - January 28-30, 2015 Physicians Practices - January 28-30, 2015 Hospices - February 2-4, 2015 Private Duty - February 2-4, 2015 **** Brochures Home Health Brochure Physician Practice Brochure Hospice Brochure Private Duty Brochure **** Location is the Monte Carlo in Fabulous  Las Vegas, NV **** Registrations Forms Home Health Physician Practices Hospice Private Duty It is important to register early, because the rates go up as the date gets closer and their is limited seating. **** The speakers include: Richard Dixon, J-non Griffin Robert Liles Richard Martin Cheri Martin Robert Floyd Donna Floyd Adam Bird (Physician Practice Only) **** Program Outlines Home Health Physician Practice Hospice Private Duty The program is great for each and we hope to see you in Las Vegas at the Monte Carlo

CMS Changes Case Mix Weights Again in Final 2015 PPS Rules & Rates

Every case mix weight has changed in the CMS Proposed PPS Rules for 2015.  They have adjusted the rates to include the latest paid claims available as of 12/31/2013.  They have also reweighted some of the impact of therapy.  We encourage you to review all of the new case mix weights to determine the potential impact on you individual home health agency.  We have listed a sample below for your review.

 

Code	Therapy Utilization	C, F & S	2015 Case Mix Weight	2014 Case Mix Weight	Increase / (Decrease)	% Increase /(Decrease)
10111	1st and 2nd Episodes, 0 to 5 Therapy Visits	C1F1S1	0.5985	0.6080	(0.0095)	(1.56%)
10112	1st and 2nd Episodes, 6 Therapy Visits	C1F1S2	0.7242	0.7273	(0.0031)	(0.43%)
10113	1st and 2nd Episodes, 7 to 9 Therapy Visits	C1F1S3	0.8499	0.8468	0.0031	0.37%
10114	1st and 2nd Episodes, 10 Therapy Visits	C1F1S4	0.9756	0.9661	0.0095	0.98%
10115	1st and 2nd Episodes, 11 to 13 Therapy Visits	C1F1S5	1.1013	1.0856	0.0157	1.45%
21111	1st and 2nd Episodes, 14 to 15 Therapy Visits	C1F1S1	1.2270	1.2049	0.0221	1.83%
21112	1st and 2nd Episodes, 16 to 17 Therapy Visits	C1F1S2	1.4220	1.3615	0.0605	4.44%
21113	1st and 2nd Episodes, 18 to 19 Therapy Visits	C1F1S3	1.6171	1.5180	0.0991	6.53%
40111	All Episodes, 20+ Therapy Visits	C1F1S1	1.8122	1.6745	0.1377	8.22%

We will have much more on the Final 2015 Home Health PPS Payment Rules and Rates in future email alerts.  We have scheduled a Home Health Webinar titled "Final 2015 Home Health PPS Rules & Rates" for November 20, 2014 from 3:00 pm to 4:30 pm EDT.  The webinar will be held Live, but will be available later on demand because it will be recorded.  

Temporary Link to Final 2015 Home Health PPS Rules & Rates

The final rule will be published in the Federal Register on November 6th.  We will provide a new link at that time.

Webinar Information 

Registration Form