Health Plans Continue To Reduce Prior Authorization Burden For Home Health Providers

Home Health Care News| By Andrew Donlan
 
Yet another payer organization is removing certain prior authorization requirements for home health care services. 
 
Point32Health – the parent company of Harvard Pilgrim Health Care and Tufts Health Plan – announced Wednesday that it is removing prior authorization requirements for the first 30 days of home health care beginning on April 12. 
 
The changes will affect members in Point32Health’s commercial plans. 
 
“We continuously evaluate all our programs to ensure our members are receiving the highest quality of care and work closely with our provider partners to decrease their administrative burden wherever possible,” Dr. Hemant Hora, senior medical director at Point32Health, told Home Health Care News in an email. “We strive to offer a broad network of high-quality providers to our members. We welcome all home care providers interested in working with us to reach out.”
 
A nonprofit organization, Point32Health serves over 2 million members through a variety of health plans. 
 
Formerly, home health services required prior authorization after initial evaluations from Harvard Pilgrim and Tufts Health Plan plans. That will no longer be the case, though prior authorization will still be required after the initial 30 days for a continuation of services. 

Prior authorization requirements have long been one of the pain points for home health providers working with health plans outside of traditional Medicare. 
 
“Care delayed is care denied,” Intrepid USA CEO John Kunysz told Home Health Care News recently, regarding prior authorization woes in home health care. 
But there has been progress of late…

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What Home Health Providers Need To Know About The Medicare TPE Audit Process

Home Health Care News | By Joyce Famakinwa
 
There are decades-old home health providers that have not yet gone through the Medicare Targeted Probe and Educate (TPE) process. But all home health leaders should familiarize themselves with the review process and its potential outcomes, as well as its challenges.

That’s one key takeaway from a recent Home Health Care News webinar that was sponsored and presented by MatrixCare. 

Broadly, TPE is a medical review program that began for the home health and hospice settings in December 2017. The goal of the program is to weed out improper payments by zeroing-in on providers with high claims denial rates or unusual billing practices. 
The program was put on hold in March 2020, in accordance with the public health emergency. It was then reestablished in September 2021. 

TPE has three pillars. Target refers to errors or mistakes that are identified through data in comparison to providers or peers. 

Probe is the examination of 20 to 40 claims. The claim size is meant to be large enough to get a clear picture of the behavior without intending to be burdensome, Rachael Feeback, senior product manager at MatrixCare, noted during the presentation.

Education means helping providers reduce claim denials and appeals through one-on-one individualized education.

Some common claim errors include things like a missing signature of the certifying physician, documentation not meeting medical necessity and missing or incomplete certifications or recertification documents. 

When a provider becomes the subject of a TPE audit, they receive a letter explaining the process. Then a Medicare Administrative Contractor (MAC) reviews between 20 to 40 of their claims and supporting medical records. If the audit finds discrepancies, after education occurs, the provider has 45 days to fix these issues. After this, the process begins again.

“If you fail three rounds, you could be referred to the OIG or CMS, you could even be facing a UPIC or a SMRC audit,” Feeback said. “It’s really important that you have a good process here.”…

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MedPAC Recommends MA Program ‘Overhaul’ in Report to Congress

McKnight’s Home Care | By Adam Healy

In its March report to Congress, the Medicare Payment Advisory Commission recommended policymakers make sweeping changes to address serious, ongoing issues with the Medicare Advantage program. 
 
“A major overhaul of MA policies is urgently needed,” MedPAC’s experts wrote in their report.
 
The commission outlined several issues that have plagued MA beneficiaries and other stakeholders in recent years. These include limited information regarding the quality of MA plans, payment disparities between MA and traditional Medicare beneficiaries, a lack of transparency surrounding private plans’ use of supplemental benefits, and more. And as MA enrollment continues to grow, these problems may only get worse, according to MedPAC.
 
Quality bonus program flaws 
 
One of the most pressing concerns is beneficiaries’ access to MA plans’ quality information, according to the commission. While these plans currently use the MA quality bonus program to help consumers distinguish between plans, this may not be enough to promote informed consumer decision-making. Many of the program’s quality measures do not actually reflect beneficiaries’ real outcomes or experiences, MedPAC said, giving customers an imperfect or incomplete picture of their potential health plan. 
 
“To make informed choices about enrolling in an MA plan, beneficiaries need good information about the quality and access to care provided by MA plans in their local market,” the report said. “Congress should replace the current MA quality bonus program with a new MA value incentive program.”
 
Despite these issues, Medicare spends roughly 22% more per beneficiary for MA enrollees compared to those enrolled in traditional Medicare, according to MedPAC. A significant portion of this money helps fund nonmedical supplemental benefits, which include in-home supportive services, but there is little transparency surrounding utilization rates and health outcomes resulting from these benefits. And, still, providers contracted with MA plans often see only a fraction of the reimbursement that they would have otherwise received from traditional Medicare for their services…

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https://www.mcknightshomecare.com/medpac-recommends-ma-program-overhaul-in-report-to-congress/

Why Don't We Stick to Home Physiotherapy Exercises?

MedicalXpress | By Ben-Gurion, University of the Negev

The lack of persistence in home physiotherapy exercises is a well-known problem hindering the effectiveness of treatment. It is especially evident in vestibular rehabilitation (exercises to treat dizziness and balance problems).

Researchers from the Ben-Gurion University of the Negev analyzed the barriers to conducting regular home exercises and have published recommendations to overcome them in The Journal of Neurologic Physical Therapy.

Vestibular rehabilitation addresses abnormalities in the vestibular system, such as dizziness, gait instability, sensitivity to movement, and blurred vision. Treatment is especially effective when consistently practiced at home.

To find a solution to the lack of consistent practice at home, a research group from the Department of Physiotherapy at Ben-Gurion University approached 39 patients doing vestibular rehabilitation and experienced physiotherapists to identify barriers.

They found six barriers: motivation (lack of confidence in the effectiveness of the practice, boredom, and lack of internal drive); increased symptoms during the practice (temporary worsening of dizziness during or after the exercises); difficulties in time management (difficulty integrating practice into daily routine); lack of feedback and guidance (patients' limited understanding of how exercises should be done and their effect); psychosocial factors (what will the environment think?); and related medical deficiencies (such as neck pain and migraines).

The research team formulated recommendations for clinicians, which can significantly improve treatment outcomes and patients' quality of life. Thus, for example, to increase motivation—personal interaction and follow-up by a clinician would allow for greater attention to the exercises, availability, and feedback conversations on the performance of the exercises—including initiated phone calls, text messages to patients in between visits to the clinic, would nurture motivation for the practice. Investing time and money should also increase motivation. In terms of time management—personalizing the exercises to fit into the patient's daily routine.

For example, practice a little bit at a time throughout the day and/or write in a daily diary. Patient guidance—the exercise instructions should include an explanation of the importance of the exercises, the expected symptoms, and the expected recovery time. Documenting improvement by providing quantitative and visual feedback, such as charts and graphs, should encourage continued practice.

"Our study provided a broad perspective for data analysis by both patients and treating physicians," explained Prof. Shelly Levy-Tzedek, who led the research. "Identifying the common barriers to practice allowed us to build strategies that could improve adherence to home practices and, as a result, the effectiveness of treatment. This is a study that can be applied in any clinic and to any patient, and therefore an important guide for therapists."

More information: Liran Kalderon et al, Barriers and Facilitators of Vestibular Rehabilitation: Patients and Physiotherapists' Perspectives, Journal of Neurologic Physical Therapy (2024). DOI: 10.1097/NPT.0000000000000470