Medicare Compliance & Reimbursement

HHAs need to know what's required under the new mandate.

Relationships between Medicare+Choice organizations and home health agencies are getting a lot less friendly - and they weren't that friendly to begin with - thanks to new fast-track appeals requirements.

As required by a settlement in the Grijalva lawsuit, the Centers for Medicare & Medicaid Services began requiring new notices of termination of coverage for M+CO enrollees Jan. 1 to facilitate speedy appeals decisions. And the requirements for the fast-track appeals process are translating into extra costs and headaches for HHAs that contract with the Medicare managed care plans.

New York HHAs feel "beaten down" by the new regulation, said Patrick Canole of the Home Care Association of New York State in the Jan. 22 CMS Open Door Forum reviewing the Grijalva requirements. While skilled nursing facilities and comprehensive outpatient rehabilitation facilities have patients in-house or coming to them for visits, HHAs "have to go out and actually visit the patients" to deliver the first of the two termination of coverage notices required in the new process, Canole protested.

The new reg has translated into adjustments to the visit schedule - often meaning an additional visit by someone who can explain the notice, Canole said in the forum.

"I don't think that the process really takes into account how home care works, as usual," criticizes Burtonsville, MD-based home care attorney Elizabeth Hogue. "The process may be burdensome to agencies in a variety of ways, including requiring them to make extra, costly visits to patients."

HHAs are also struggling under the requirement to furnish documentation supporting the termination decision to the independent review entity (IRE) - generally a Quality Improvement Organization (QIO) - in time for the decision deadline of four days from the initial notice, Canole reported. Because the appeals process deadline continues over the weekend, agencies either have to hire a clinical or medical records staffer to work over the weekend or arrange for current workers to be on call when they normally wouldn't be, he complained.

"It's another unfunded mandate," Canole told the CMS staffers in the forum.

The Grijalva requirements caught many HHAs unaware, says William Dombi, vice president for law with the National Association for Home Care and Hospice's Center for Health Care Law. And it was far from a pleasant surprise.

Even CMS has acknowledged that HHAs have gotten the short end of the stick from the regulation. "The home health situation definitely poses the most difficult challenges, I think, in this process," one CMS staffer said in the forum.

Managed care plans are running into just as many problems figuring out the home health notice process as HHAs. "We are full steam ahead on SNFs but stuck on the home health side," says Linda [...]