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Home Health Certifying Provider Change

NAHC

The MACs have issued [the following] article titled, “Home Health Certifying Provider Change.” The article outlines CMS' policy regarding the requirements for a certifying practitioner to authorize a change in provider at recertification, regardless of the reason for the change. We have some concerns and questions regarding the instructions and are seeking clarification from CMS. We will keep the membership updated as we learn more.   

[Article Posted on CGS’ website]

Home Health certifying physician or nonphysician practitioner (NPP) changes can occur anytime for a variety of reasons. Some examples may include practitioner retirement or vacation and patient choice.

Regardless of the circumstance, if the recertifying physician or NPP is different from the certifying physician or NPP, home health agencies (HHAs) are required to document in the medical record indicating they have ensured a different physician or NPP has been authorized to care for (including recertifying and signing the plan of care) the original certifying physician's or NPP's patients in their absence.

For example, if "Dr. A" signed the initial certification and "Dr. B" signed the recertification, the HHA should ensure and document that this has been authorized by "Dr. A"; however, there does not need to be written or signed documentation from the physician or NPP.

There is no designated format or form that must be used to show the change in provider. Documentation can be anything from the HHA that shows the HHA has confirmed the change(s) in certifying physician or NPP. HHAs are encouraged to include any documentation that support attempts to contact the original practitioner when changes occur.

Reviewers will confirm that all elements of the certification are included in the documentation sent for the recertification claim review. If the submitted certification documentation (submitted with the recertification documentation) does not support home health eligibility, the claim associated with the recertification period will not be paid.

 

Without Proper Post-Acute Care Relationships, MA Plans Are Leaving Money on The Table

Home Health Care News / By Andrew Donlan

Health plans generally do not have great visibility into their members’ care after an acute health event. Even when they do, many aren’t confident in the post-acute care provider that’s serving their member.

These findings come from a new survey of health plans conducted by the post-acute care technology company WellSky.

Specifically, the survey found that:

  • Only 37% of respondents (health plans) manage members in a post-acute setting after discharge from acute care. The majority attempt to manage care internally rather than partnering with vendors or other post-acute networks.

  • Just 33% of respondents reported that “the majority” of their members are discharged to “high-performing” post-acute care facilities.

  • 43% of respondents expressed “moderate confidence” that their members receive the appropriate level of care post-discharge.

The health plan respondents – which were Medicare Advantage (MA) plans – ranged from those with 115,000 members to those with over seven million members.

“These findings reinforce what we continue to hear from payers regarding how important it is for MA plans to have greater visibility and proactive influence into their members’ discharges to ensure they are being sent to not only the right level of care, but to high-performing post-acute providers for a member’s specific conditions,” Andy Eilert, president of payer and emerging markets at WellSky, said in a statement. “This will help plans achieve lower total cost, enhanced quality of care and improved member outcomes.”

This is noteworthy information for home health providers, who are trying to negotiate on higher ground with MA plans. Quality home health care can reduce the Medical Loss Ratio for health plans. If those plans don’t have much visibility into where their members are getting post-acute care – in other words, lacking solid partnerships – or are having members use subpar providers, that leaves room for opportunity.

Home health providers that can establish relationships with MA plans, where they can take a certain number of patients in a given market, can negotiate for better rates or a better payment setup than they currently have.

That, in turn, can help bridge the gap between MA’s rates for home health services and traditional Medicare’s rates…

Read Full Article

 

Unfulfilled MA Referrals for Home Healthcare Can Lead to ‘Grave Consequences,’ Study Finds

McKnight’s Home Care / By Adam Healy
 
Medicare Advantage patients who are referred to but never receive home health services experience higher mortality rates and lower readmissions compared to those who received such services, according to a new study published in the American Journal of Managed Care.
 
The researchers examined 2,876 acute hospital discharges occurring between January 2021 and October 2022 that included home health referrals. Of these, 2,115 referrals led to the patients receiving home healthcare. The remaining 761 referrals did not lead to home health visits. On average, those who received the recommended home healthcare experienced better outcomes compared to those who did not.
 
“Those members who receive home health services may benefit from additional attention and assistance from healthcare workers, who may in turn advocate for members and escalate situations that could be life-threatening,” the researchers wrote. “Members who are referred to home health but who do not receive services do not receive the same attention and care as their counterparts, and this could have grave consequences.”
 
Unfulfilled home health referrals were associated with lower chances of survival among MA patients at 30, 90 and 180 days. Patients who received home health care had an average mortality rate of 2% at 30 days. That compares to 3% among those whose home health referral was not fulfilled. At 180 days, home health patients had a 11% mortality rate, compared to 14% in the other cohort.
 
However, patients receiving home health care also experienced higher per-member per-month care costs, at an average of $787. Additionally, members who received home health had higher readmission rates, on average, compared to those who did not.
 
Unfulfilled home health referrals can occur for a variety of reasons, according to the researchers. One common reason is that members who do not understand home care services, or who might be uncomfortable with letting clinicians into their homes, may refuse home health. For these patients, the researchers recommended better education, including discussions during hospital stays about what to expect from home health providers after acute care discharge.
 
Also, some home health providers may have trouble contacting or locating referred clients, the study noted, which can lead to unfulfilled referrals. In this situation, case managers can play an important role in connecting home health providers with their referred patients, according to the researchers.

 

New Episode Alert: Dive into Episode 6 of 'Home on the Go'

SEASON 1 EPISODE 6 - OUT NOW!

Billy Campbell from VNS Health Home Care and Fahima Chowdhury from NYU Physical Therapy join this episode to discuss their unique perspectives as a Clinical Instructor (CI) and Physical therapy student. As the CI, Billy talks about the rewarding nature of working with students in the home health setting, as well as some of the unique challenges that come along with this added responsibility. As a soon-to-be entry-level PT graduate, Fahima discusses how her impressions of home health have changed over the course of her experience, as well as the growth in both confidence and competence she has experienced throughout her 8-week affiliation.

The audience can expect to walk away with a positive and inspirational view of the CI-student relationship in the home health setting.   

Click Here to Listen Now! 

 

All The Payment Factors Included In The 2025 Home Health Proposed Rule

Home Health Care News | By Joyce Famakinwa
 
Providers examining the 2025 home health proposed payment rule may be experiencing some déjà vu, according to William A. Dombi, the president of the National Association for Home Care & Hospice’s (NAHC).
 
“Much of what we see in the rule is just, on the payment side of it in particular, an update from ‘23 and ‘24,” he said during a recent webinar hosted by NAHC. 
 
On June 26, the U.S. Centers for Medicare & Medicaid Services (CMS) unveiled its home health proposed payment rule for 2025. 
 
The proposal includes a payment decrease in the aggregate by 1.7%, or by about $280 million.
 
“That needs qualification,” Dombi said. “That’s $280 million, not to what it would otherwise have been, but rather, in contrast to what it’s expected to be for 2024.”
 
Providers examining the proposed rule will also see a 2.5% net inflation rate update.
 
“The 2.5% is a creature of the annual inflation update of 3%, minus the productivity adjustment of 0.5, netting out at 2.5%,” Dombi said. “This is in the same range that we saw for proposed rules affecting inpatient hospital services, skilled nursing facility care and hospice services that were issued by and large in April of this year, and are moving towards final visitation sometime probably in the neighborhood of the end of July. This number of 2.5% will be updated in the final rule, using more recent data than they use for this calculation.” 
 
Dombi pointed out that CMS has refused to increase the inflation updates, for all sectors, 
based on what wasn’t accounted for each year. 
 
The proposed payment rule also comes with a $100 million reduction in the spending tied to a change in the outlier formula. The change will decrease the frequency of episodes 
qualifying for outlier payment, Dombi noted.
 
“The outlier fixed dollar loss ratio is the element of the outlier formula that’s going to be leading to a decrease in the number of outlier episodes,” he said. “When the FDL goes up, it means you have fewer and fewer episodes that will qualify because you’ve got to be above the normal PDGM episodic rate, in terms of cost, at a higher level, before you trigger outlier payments.” 
 
Additionally, CMS proposed a permanent prospective adjustment to the 2025 home health payment rate of -4.067%.
 
The budget neutrality adjustment is a combination of what was left over when CMS took the almost 5.8% projected, permanent adjustment and cut it in half to 2.89%. 
 
“Kicking the can down the road doesn’t kick the can into a trash can, it just postpones the application of that, so now we see CMS taking that 2.89% leftover from last year and adding to an additional 1.125%,” Dombi said. “They don’t add up together to 4.067 because of the compounding effects of these kinds of things.” 

Submit a Formal Comment on the Proposed Rule https://www.federalregister.gov/documents/2024/07/03/2024-14254/medicare-program-calendar-year-cy-2025-home-health-prospective-payment-system-hh-pps-rate-update-hh
 
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