S.U.R.C.H. for Answers Before Program Safeguard Contractors Review Your Care

By Arnie Cisneros

Home health reforms identified by the 2012 PPS Final Rule will affect ALL home care agencies throughout the coming year. The case-mix payment cuts will combine with the market basket reductions to create reduced income levels when compared to 2011 reimbursement for the same services. Certainly the removal of two hypertension codes from the case-mix system will create an additional decrease in revenue that will be felt by most providers; based on their previous use of these codes, some agencies will feel the effects more than others. Therapy payment reform changes will also be agency-specific as providers who deliver higher volume therapy coverage, or fail to manage their rehab staff and programs, will experience decreased payments (in 2012) when compared to last year. In addition, further reform proposals for 2013 and beyond propose additional payment reductions, co-payments, and capitated rehab reimbursement unrelated to visit volumes.

As CMS and MedPAC continue their refinement of the home health benefit, and how we deliver services to qualified enrollees, certain areas of the country will be disproportionately affected. This will occur via audit reviews primarily focused on states with higher historical numbers of home health providers and over-utilization patterns, and Florida providers; this means you (also TX, CA and MI agencies). In addition, recent audit activity is reported in various corners of the country not usually associated with home health programming concerns; LA, MS, IN, OH and IL, to name a few.

Until recently, most of this ADR activity was the work of fiscal intermediaries, but the emergence of Program Safeguard Contractors (PSCs) charged with protecting the integrity of the Medicare system also looms large for many providers. Recent reports reveal that Florida-based home care agencies are in the sights of the PSCs, evidenced by stories of pre-payment audit requests for up to 50 patient charts. Agencies receiving these types of ADR requests feel indicted despite their intent to deliver quality home health services to Medicare beneficiaries. Accountants and attorneys can help providers defend themselves in these instances, but they can only minimize the damage from the current audit.

Though they can be prompted by a multitude of factors, the primary focus of these audits is clinical over-utilization based on the current definition of “reasonable and necessary”. Experienced providers struggle with this concept; that CMS has designs for home care services that differs from what has occurred to date in the PPS era. Any response to this type of audit scrutiny should be derived from the knowledge that how Medicare will cover, manage, and pay for home health is CHANGING. Care production and delivery practices established and developed by providers under PPS, in many instances, have outlived their usefulness. Audit results state this fact in no uncertain terms: the care programs of the past will not be the care programs of the future.

This should prompt many Sunshine State agencies to ponder the question, “Are we currently developing care programs that will represent the denials of the future?” Virtually ALL providers who emerge from this type of ADR scrutiny do so with modified or altered care content, so surviving the audit is just the first step. Actual evolution of care must occur to remain viable in the future, and that involves a wholesale re-wiring of how your agency personnel view home care. Many signs point to a more efficient, focused, and shorter home health episode model in the future; co-payments for non post-acute episodes, therapy payment regression, bundling plans that will focus care goals on a 30-day intervention, etc. Futuristic care model proposals describe plans to integrate the home health episode further into the care continuum, and that will require many of us to adopt the care and quality control practices commonplace outside of the home care world.

First and foremost of these controls is “Utilization Review” or “UR”, which is the process of monitoring healthcare services for cost-effectiveness. This approach is standard operating procedure across the rest of the care continuum, and is the primary clinical management tool for PPS delivery in other care environments. Acute hospitals employ this approach for DRG management, and have decreased length of stay results by 77% while improving clinical outcomes.  SNFs were given a UR program by CMS called the Minimal Data Set (MDS) when PPS was installed in nursing homes, and this is employed to manage qualified nursing and therapy coverage.

Progressive home health providers have installed UR quality assurance procedures into care production and management practices with outstanding results. S.U.R.C.H. – Service Utilization Review for Care in the Home, is based on the UR processes described above, and has been installed by agencies across the country seeking a new direction for their care. Decreased episode costs (and visit totals), elevated clinical outcomes, and improved after-cost profit margins are obtained; all while producing PPS-compliant care that will meet the CMS requirements of today and tomorrow.

UR programs that mirror the types of clinical and quality controls used by CMS outside of home care are certainly the order of the day for home health providers. Whether employing S.U.R.C.H., or an internally developed UR program, home health providers seeking life after ADRs must retrieve care production and management from front-line clinical staff and return it to the office where it belongs. Administrative, management, and clinical and supervisory staff must defer to UR-based care protocols if they expect to remain on the care pathway of the future. Don’t find yourselves behind the curve on this important home health issue.

Upcoming Education Workshops!

Join Arnie Cisneros in April for a one-day seminar that will break down the changes and present strategies for success in the home health landscape of the future. Case studies will provide analysis on how care plans can promote desired results on management, financial and clinical levels. Interactive programming exercises will help management, supervisory, and both nursing and therapy staff clinicians develop the care plans required in 2012 and beyond.

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

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