What are the reporting requirements for home health agencies (HHAs)?
The reporting of quality data by home health agencies (HHAs) is mandated by Section 1895 (b) (3) (B) (v) (II) of the Social Security Act (“the Act”). This statute requires that ‘‘each home health agency shall submit to the Secretary such data that the Secretary determines are appropriate for the measurement of health care quality.
Do HHAs have to report quality data to CMS?
The requirement that HHAs report quality data to CMS is contained in the Medicare regulations. Section 484.225 (i) of Part 42 of the Code of Federal Regulations (C.F.R.) provides that HHAs that meet the quality data reporting requirements are eligible to receive the full home health (HH) market basket percentage increase.
How can home health agencies best safeguard themselves from audits?
Additionally, home health improper payment rates decreased from 58.95% in 2015 to 17.61% in 2018. To best safeguard themselves from being audited, agencies should make sure to educate their staff on the latest regulations and do their best to operate within them, Long said.
What is the standard sample size for a medical billing audit?
The standard sample size ranges from 10 to 15 charts. When conducting an audit involving multiple physicians, the OIG recommends five to 10 charts per medical provider. The OIG also recommends using RAT-STATS to help with statistical sampling.
What is the system for home care patient data collection?
The Outcome and Assessment Information Set (OASIS) is a comprehensive assessment designed to collect information on nearly 100 items related to a home care recipient's demographic information, clinical status, functional status, and service needs (Centers for Medicare and Medicaid Services [CMS], 2009a).
What is Preclaim review?
Pre-claim review is a process through which a request for provisional affirmation of coverage is submitted for review before a final claim is submitted for payment. Pre-claim review helps make sure that applicable coverage, payment, and coding rules are met before the final claim is submitted.
What is PCR in home health?
The Centers for Medicare & Medicaid Services (CMS) has implemented a three year pre-claim review (PCR) demonstration for home health services to ensure that the Medicare home health benefit coverage criteria are met.
How do you write a visit frequency for home health?
0:0011:35How to Write a Home Health Frequency - YouTubeYouTubeStart of suggested clipEnd of suggested clipDr. Smith physical therapist here and today I'm going to teach you how to properly write a homeMoreDr. Smith physical therapist here and today I'm going to teach you how to properly write a home health frequency for patients on Medicare Part A services.
When did pre-claim review start?
The initial three-year pre-claim review demonstration begins in Illinois on August 1, 2016 and then will roll out to Florida, Texas, Michigan and Massachusetts.
What are pre claims submission activities?
Pre-claims submission activities are a process that involves tasks such as scheduling and registration, verifying eligibility, getting authorization for services, collecting copayments or coinsurance, documenting charges, coding, grouping, scrubbing and editing claims.
What does RCD mean in home health?
Review Choice Demonstration for Home Health ServicesThe Review Choice Demonstration for Home Health Services (RCD) provides flexibility and choice for Home Health Agencies (HHAs), as well as risk-based changes to reduce burden on providers demonstrating compliance with Medicare home health policies.
What is a UTN number for Medicare?
o A Unique Tracking Number (UTN) will be included on the decision notice from First Coast. The UTN must be submitted on the hospital claim to receive payment. Claims billed without a UTN will be denied. The UTN should be included on your booking sheet in order to schedule the surgery.
Do I need to keep self isolating if I have received a negative COVID-19 test result?
The self-isolation advice for people with coronavirus (COVID-19) has changed. It is now possible to end self-isolation after 5 full days if you have 2 negative LFD tests taken on consecutive days.
Which of the priority conditions will be determining factors on the frequency of home health visits?
Guidelines. The following guidelines are to be considered regarding the frequency of home visits: The physical needs psychological needs and educational needs of the individual and family. The acceptance of the family for the services to be rendered, their interest and the willingness to cooperate.
How Long Will Medicare pay for home health care?
Medicare pays your Medicare-certified home health agency one payment for the covered services you get during a 30-day period of care. You can have more than one 30-day period of care. Payment for each 30-day period is based on your condition and care needs.
Which of the following could be considered a patient's place of residence?
Place of Residence A patient's residence is wherever he or she makes his or her home. This may be his or her own dwelling, an apartment, a relative's home, a home for the aged, or some other type of institution.
What do you need to know about Medicare audits?
1. There are three major audit-worthy red flags for physical therapists. As you know, Medicare policy is a web of super-confusing rules and regulations.
How to avoid Medicare audits?
When it comes to avoiding audits, knowledge is power, so make it your mission to educate yourself and your staff on Medicare’s Local and National Coverage Policies. Seek out Medicare-related CEU courses, or sign up for Medicare compliance training through the PT Compliance Group or Gawenda Seminars (also be sure to check out the other educational resources these organizations provide). Additionally, you should have a compliance plan in place—headed up by your office’s designated compliance officer—to ensure that all staff members can recognize potential compliance issues and to develop processes and procedures for dealing with misconduct. The plan should:
How often are CERT audits conducted?
According to the CMS website, CERT audits are conducted annually using “a statistically valid random sample of claims.” Auditors review the selected claims to determine whether they “were paid properly under Medicare coverage, coding, and billing rules.”
What is RAC in Medicare?
Developed as part of the Medicare Modernization Act of 2003, the RAC program reclaims money by conducting retrospective reviews of fee-for-service (FFS) claims—a process known as “claw back.”. For this initiative, the country is divided into four regions.
What is chart audit?
What is a Chart Audit? A chart audit, could be initiated by Medicare and other third-party payers and documentation would be requested for many reasons (i.e., randomly; as a result of a CBR [Comparative Billing Report] where you fall outside of the “norm”; patient complaints about your billing; too many hours in a day, etc.).
How to ensure medical records are past muster?
You can be proactive by conducting an internal or external chart audit to ensure your documentation would “past muster” if Medicare or another third-party payer does request copies of your medical records.
Do you have to pay back Medicare after a chart audit?
Not every chart audit results in having to pay money back to Medicare or other third-party payers…. but, many do. In addition, to your, possibly, being flagged (Prepayment Review); whereby, documentation would be required prior to your being paid.
How many charts should be used for a medical audit?
The standard sample size ranges from 10 to 15 charts. When conducting an audit involving multiple physicians, the OIG recommends five to 10 charts per medical provider.
Why are chart audits necessary?
Chart auditing programs have become necessary in response to the increase in federal payer audits. Even commercial payers have geared up teams to conduct frequent and random on-site and off-site compliance audits of hospitals and medical practices.
How far back can RACs audit claims?
RACs may audit claims going back three years from the date of payer reimbursement.
Why is medical auditing important?
Medical auditing performed by the provider organization, or on its behalf, is crucial because it keeps coding and billing errors in check. Audits not only identify incorrect coding, but also prevent incorrect coding from being repeated.
What is CMS in healthcare?
Federal Scrutiny and Compliance Enforcement. Law requires the Centers for Medicare & Medicaid Services (CMS) — the largest payer for healthcare in the U.S. — to protect the taxpayer-sponsored Medicare Trust Fund.
What is the first step to ensuring your organization doesn't invite a MAC or RAC audit?
Remaining aware of federal audit targets based on claim errors trending across the U.S. is the first step to ensuring your organization doesn't invite a MAC or RAC audit. Several publications detail current targets and problem areas, directing medical coders toward vigilance and auditors toward proactivity. The two most definitive publications are the OIG Work Plan and the Comprehensive Error Rate Testing (CERT) report.
What is medical audit?
Medical auditing is a systematic assessment of performance within a healthcare organization. Almost any element of healthcare can be audited, but most audits look at components of payer reimbursement processes to evaluate compliance with payer guidelines and federal and state regulations. By identifying errors and devising remedial actions ...
When will home health agencies begin collecting data?
For example, if the COVID-19 PHE ends on April 30, 2021, home health agencies will be required to begin collecting data using the updated versions of the item sets beginning with patients discharged on January 1, 2023.
What percentage of Medicare FFS is paid by Medicare Advantage?
In 2019, of these quality episodes, 8.4 percent were paid (at least partially) by Medicaid, 31.2 percent by Medicare Advantage, and the remaining 60.4 percent by Medicare FFS.
How does CMS improve quality?
CMS's Quality Strategy vision for improving health delivery can be said in three words: better, smarter, healthier. CMS is focusing on: 1 Using incentives to improve care. 2 Tying payment to value through new payment models. 3 Changing how care is given through:#N#Better teamwork.#N#Better coordination across healthcare settings.#N#More attention to population health.#N#Putting the power of healthcare information to work
What is the Oasis data set?
The instrument/data collection tool used to collect and report assessment data by home health agencies is called the Outcome and Assessment Information Set (OASIS). Since 1999, CMS has required Medicare-certified home health agencies to collect and transmit OASIS data for all adult patients whose care is reimbursed by Medicare and Medicaid with the following exceptions: patients under the age of 18, patients receiving maternity services, patients receiving only chore or housekeeping services. OASIS data are used for multiple purposes including calculating several types of quality reports which are provided to home health agencies to help guide quality and performance improvement efforts.
What is the requirement for HHAs to report quality data to CMS?
Section 484.225 (i) of Part 42 of the Code of Federal Regulations (C.F.R.) provides that HHAs that meet the quality data reporting requirements are eligible to receive the full home health (HH) market basket percentage increase.
How often do you need to update OASIS?
The Home Health conditions of participation (CoPs) which are contained in 42 C.F.R., section 484.55 (d) require that HHAs must update and revise the comprehensive assessment (including the administration of the OASIS) no less frequently than: (1) The last 5 days of every 60 days beginning with the start of care date, unless there is a beneficiary elected transfer, significant change in condition, or discharge and return to the same HHA during the 60-day episode; (2) within 48 hours of the patient’s return to the home from a hospital admission of 24 hours or more for any reason other than diagnostic tests; and (3) at discharge.
What is OASIS reporting?
Outcome and Assessment Information Set (OASIS) reporting is mandated in the Medicare regulations at 42 C.F.R.§484.250 (a), which requires HHAs to submit OASIS assessments and Home Health Care Consumer Assessment of Healthcare Providers and Systems Survey (HH CAHPS) data to meet the quality reporting requirements of section 1895 (b) (3) (B) (v) of the Act.
What is a ROC assessment?
A Start of Care (SOC) or Resumption of Care (ROC) assessment that has a matching End of Care (EOC) assessment. EOC assessments are conducted at transfer to an inpatient facility (with or without discharge), death, or discharge from home health care. These two assessments (the SOC or ROC assessment and the EOC assessment) create a regular quality episode of care and both count as quality assessments.
What is non quality assessment?
SOC, ROC, and EOC assessments that do not meet any of these definition s are labeled as “Non-Quality” assessments. Compliance with the pay-for-reporting performance requirement can be measured through the use of an uncomplicated mathematical formula.
Do HHAs need to submit OASIS data?
HHAs do not need to submit OASIS data for those patients who are excluded from the OASIS submission requirements. As described in the December 23, 2005 Medicare and Medicaid Programs: Reporting Outcome and Assessment Information Set Data as Part of the Conditions of Participation for Home Health Agencies final rule (70 FR 76202), ...
What are the Interpretive Guidelines for Home Health Agencies?
Home Health Agencies. The Interpretive Guidelines serve to interpret and clarify the Conditions of Participation for home health agencies (HHAs). The Interpretive Guidelines merely define or explain the relevant statute and regulations and do not impose any requirements that are not otherwise set forth in statute or regulation.
What is HHA survey?
The HHA survey is conducted in accordance with the appropriate protocols and substantive requirements in the statute and regulations to determine whether a citation of non-compliance is appropriate. Deficiencies are based on a violation of the statute or regulations, which, in turn, is to be based on observations of the HHA’s performance or practices.
What is CMS's priority?
Reducing improper payments has been a priority for CMS in recent years, with the agency taking several measures to help curb fraudulent or sloppy claims submissions. Efforts, for example, include the 2016 Pre-Claim Review Demonstration and the upcoming Review Choice Demonstration.
How much did home health improper payments decrease in 2018?
Additionally, home health improper payment rates decreased from 58.95% in 2015 to 17.61% in 2018.
How much did OIG recover in 2018?
After ramping up its oversight in fiscal year 2018, OIG recovered an estimated $2.91 billion last year, thanks in part to tips to its hotline. Between April 1 and Sept. 30 last year, OIG received more than 60,000 tips, 8,096 of which were actionable, according to its semiannual report.
Why do UPIC employees show up at home health providers?
Other times, UPIC employees might show up at a home health provider’s door — announced or unannounced — to ensure the business is operational and request records.
What to do if a home health agency is uncomfortable?
If a home health agency is still uncomfortable, it can request a CMS contact to ensure the representative is legitimate.
Where was the Chicago audit held?
Long explained the audit process and touched on common investigation catalysts during the event, held in Itasca, Illinois, a suburb of Chicago.
Can a patient be ineligible for home health?
Per CMS’s criteria, that patient would be ineligible for the home health benefit. To receive home health services, patients must be confined to their home and require skilled care. They must also be under the care of a physician, with whom they’ve had a face-to-face encounter, and have a plan of care established.