CMS has posted a Plan of Care (POC) Regulation Change.
With all the pending changes coming to home health for 2020 with Patient Driven Grouper Model (PDGM) and pending Review Choice Demonstration (RCD), it may be easy to overlook one earlier change affecting home health reviews and denials that just went into effect. Finalized in the Calendar Year (CY) 2019 Home Health PPS Final Rule (CMS-1689-FC) is some relief for home health agencies for their plan of care content.
Specifically, the regulation at 42 CFR 424.22(b)(2) has been revised to remove the requirement that the recertification statement must include an estimate of how much longer the services will be required. This change is effective January 1, 2019. It will need revision to IOM Publication 100-02, Medicare Benefit Policy Manual, Chapter 7, Section 30.5.2 to remove this recertification requirement.
CGS Administrators, the home health Medicare Administrative Contractor (MAC) for Jurisdiction 15, cited in their Targeted Probe and Educate (TPE) Top Denial Reasons July 1, 2018 – September 30, 2018 that “Recertification estimate missing/invalid” was the #4 reason for denial: it accounted for 9% of the denied claims. This denial reason was also incorporated into the Palmetto GBA, home health MAC Jurisdiction M, TPE results for October 1, 2017 – September 30, 2018, where it was part of 13% of denials for certification issues.
So for home health claims with recertification periods starting January 1, 2019, this requirement is no longer in effect and should give some small measure of relief to home health agencies undergoing Medical Reviews.
MedLearn Matters SE 1436 has been revised on November 5, 2018, to reflect this change.
QIRT Compliance and ADR services are considered the best in the industry.
Joe Osentoski, BAS, RN-BC, is based in QIRT’s Troy, Michigan office. Joe specializes in additional documentation request (ADR) response and appeals and has been a registered nurse for more than 25 years. Joe’s career has included clinical consulting in home health and hospice, with a specialty in clinical quality assurance and regulatory compliance. He also has extensive experience with multiple types of Medicare audits, probes, and reviews from all types of Medicare contractors: MACs, UPICs, RAC, SMRC, OIG, CERT, and Medicare Advantage, as well as private insurers. Joe has completed over 5,000 ADRs in home care and hospice, filed thousands of appeals, and represented agencies in hundreds of administrative law judge (ALJ) hearings.
Impressively, Joe has been lauded by retired US Administrative Law Judge Robert Soltis in his book, How to Handle Your Medicare Hearing: “Mr. Osentoski was one of the first non-attorney representatives to appear before me when I was an ALJ, and he stands head and shoulders above every other non-attorney representative. Mr. Osentoski…knows home health law, and prepares thoroughly. His credibility is beyond reproach.”
Joe is most recently the author of Home Health ADR & Appeals Answers, First Edition, available through DecisionHealth. He also is a contributor to Home Health Line and Eli’s Home Care Week. He holds a gerontological nursing certification from the American Nursing Credentialing Center.