Understanding Audit Activity

            The new year has brought stories regarding unprecedented levels of audit activity throughout various parts of the country, including regions not normally associated with utilization concerns. Pre-payment reviews from Palmetto, requesting ADR charts as part of sample probes, have been reported recently in Indiana, Ohio, and Florida; and other Medicare Administrative Contractors (MACs) are expected to follow suit. These audits focus on payment errors and excessive length of stay patterns when compared to other homecare Providers. In addition, there are reports of further scrutiny expected from Program Safeguard Contractors (PSCs) and Recovery Audit Contractors (RACs) charged with protecting the integrity of the Medicare program, including the Home Health benefit. It appears that recent regulatory activity in the Home Health industry has combined with PPS refinements to create a level of covered care that differs from what many patients currently receive.

Most Providers feel threatened by the inquiries, and some report payroll difficulties as a result of the suspended payments. The industry feels assaulted and un-appreciated; the historical value of Home Health, as an alternative to costly or archaic in-patient care, seems to have been lost in the shuffle. The recent programming burdens, including face to face requirements, have affected census levels, and the payment cuts and therapy changes only contribute to the stress in our agencies. Home Health owners and administrators are genuinely perplexed; doesn’t Medicare recognize what we do, our value, our patients’ needs, and the day to day difficulties of providing homecare coverage? How do we make sense of all this?

The first step is to understand some of the basic issues involving recent healthcare reform results across the care continuum, and how they relate to Home Health care. Prior to the installation of the acuity-based PPS model, providers of all types produced relatively self-managed care programs that were clinician-driven in form and content. Newly introduced PPS fee schedules, based on clinical acuity factors, prompted production of efficient episodes; patients improved quicker as a result of the focused, driven care. Hospitals and Skilled Nursing Facilities experienced significant decreases in length of stay results (77% and 35% respectively) by focusing care in response to the payment changes of DRGs or RUGs, which are their versions of HHRGs. It’s important to note that the impetus for these changes was the reduction in payment mandated by the PPS model and the DRG/RUG reimbursement cuts, not unlike the current changes to our case-mix and therapy coverage. Though the establishment and evolution of the Home Health benefit supported these reform efforts, it seems logical that Medicare would expect to refine care in the home via identical protocols.

The goals of the Home Health reforms and audits are the same goals Medicare sought from other Providers; efficient care based on best practices and adherence to PPS-based care philosophies. The current Home Health industry is rife with concerns regarding program integrity; gaming, abuses (see Senate Finance Committee Report on Home Health 10/11), utilization and payment questions, and lack of patient contributions, to name a few. The issues could not be clearer; Medicare has the same clinical designs for homecare delivery that it has for all services: UR-managed care programs, designed around best practices, devoid of any type of bias from clinicians or referral sources. Standard Home Health practices that deviate from this approach are not hard to identify in our industry today. One-size fits all certification period orders and visit based protocols ignore specifics regarding patient acuity or response to treatment. Concerns regarding PEPs dictate episode lengths, referral or patient expectations often define care episodes, and productivity levels fail to rise to those produced by Medicare Providers outside of homecare.

A few words about the subjective response of the industry to the above realities; All Providers feel indicted when they receive this type of scrutiny and regulatory pressure. Hospitals certainly felt this way when DRGs were introduced in 1984: dire predictions of patients discharged early to bus stops and city parks failed to come true. Regarding homecare, of course we think we are efficient and don’t need the regulatory reforms that other Providers require. And of course we believe our caring clinicians have the best interest of the patient and the Home Health benefit in mind at all times, un-affected by the normal issues that compromise outcomes across the Medicare landscape. And lastly, of course we feel that our care is contemporary in content and value despite our inability to affect hospitalizations in a statistically relevant manner.

These types of responses are commonly heard from all Providers when Medicare reforms or regulations alter the status quo. The difference between Home Health and the rest of the care continuum is that we are the last to experience the changes these cost and quality controls prompt, and our attitudes have been reinforced over the years we spent as the solution to other Medicare problems. There is no grand plan to wreck Home Health via audit scrutiny or regulatory changes. The only goal is to assure that contemporary care of all types is delivered to all beneficiaries, regardless of the care environment involved. Home Health Providers who plan to continue their care missions in the future would be well served to seek solutions to the program concerns sought by the audit activity. By identifying the differences between the care currently delivered and the care desired by CMS that is the focus of the audits, agencies and clinicians can determine where they need to change care production and delivery. When they complete the process of adopting the new care management protocols required for success in these areas, they are then able to determine their role in the Home Health industry of the future.

The most progressive of Providers consider the recent homecare challenges as an opportunity to distinguish themselves from their competition; where do you stand on this issue?

Arnie Cisneros, P.T., President of Home Health Strategic Management, is the most progressive speaker in homecare today. He provides coaching and consulting services to providers on a national basis (see www.homehealthstrategicmanagement.com) regarding S.U.R.C.H. and other clinical management protocols for quality outcomes.