Appeals:
DOC CERT WINDOW FOR EXPEDITED REVIEW TOO WIDE
Published on Mon Aug 08, 2005
New leeway could increase HHAs' burden.
While you have less than a day to respond to an expedited review, your patients have 60 days to obtain the physician certification required for that review - and that unfairness is rankling overworked HHAs.
"If a physician certification has not been obtained by the beneficiary when making the request for review, the [Quality Improvement Organization] will allow 60 days for the beneficiary to receive the physician certification and proceed with the review process as requested," the Centers for Medicare & Medicaid Services says in one of the 40 new questions-and-answers it recently posted about the notices. After 60 days, the QIO won't proceed with the review.
This 60-day leeway "seems to undercut the entire process of expedited review," protests Burtons-ville, MD-based health care attorney Elizabeth Hogue. Patients who obtain certs weeks after home care services end will be distorting the issue of whether cutting off those services is a potential cause of harm, Hogue notes.
"Certifications should clearly relate to patients' conditions at the time of discontinuation of services," Hogue insists. The certs should not address the time of a later cert, "which may be provided weeks after discontinuation of services, when patients' clinical conditions may have radically changed," Hogue points out.
And another Q&A notes that patients can obtain a cert from any physician, not just their attending physician, Hogue observes. The 60-day timeframe gives them time to go doctor shopping, including asking physician relatives for a cert.
Good news: The Q&A specifying that QIO physicians will not furnish the certs remains unchanged. CMS seems to recognize that QIO physician certs would present a conflict of interest, Hogue notes. HHAs Out Resources Regardless of Review Status Even if the patient never secures a physician cert, the HHA is still out the time and resources spent responding to a review request, says Joe Hafkenschiel with the California Association for Health Services at Home. "Records are requested from the provider with a very rapid turnaround before the physician has certified significant health risk," Hafkenschiel criticizes. If no cert materializes, "the provider has gone to a lot of work for absolutely no benefit."
Adding to the confusion is the fact that the expedited review notice form does not spell out to the beneficiary that she is responsible for securing the cert, Hafkenschiel complains. "CMS says the notice has been approved for three years and will not be changed before then," he laments.
Requiring a same-day response to expedited reviews is unreasonable, Hafkenschiel charges. But requiring it in cases where the review will never proceed just makes no sense.
"Perhaps the saddest part ... is that there are very few, if any, situations where a home health discharge poses an emergency," Hafkenschiel tells Eli. "Agencies [...]
