A new medical review concern has recently surfaced in the home health industry through the Review Choice Demonstration, specifically within the Pre-Claim Review phase.
Only a few states within Palmetto GBA’s jurisdiction currently have home health agencies taking part in the Review Choice Demonstration. Even if your state isn’t among them, we encourage you to keep reading.
The Review Choice Demonstration offers multiple participation options, with Pre-Claim Review being the most widely used. This option requires agencies to submit documentation such as a signed plan of care and face-to-face encounter details to receive affirmation for services that will be delivered, billed, and reimbursed under the Medicare program.
In recent weeks, non-affirmations have started appearing in the Pre-Claim Review process due to situations involving patients in Assisted Living Facilities. The issue arises when a home health agency’s documentation does not clearly state that the patient is not receiving the same services from the Assisted Living Facility that the agency is providing.
Medicare has long allowed home health agencies to serve patients living in Assisted Living Facilities. What’s new, however, is that medical reviewers are now closely paying attention to the documentation related to these cases.
This is not a new concept in Medicare policy. The Medicare Benefit Policy Manual clearly states that a patient may live in an Assisted Living Facility, provided they meet the homebound requirement. For coverage purposes, if the individual resides in a facility that is not primarily engaged in providing diagnostic or therapeutic services, medical treatment, rehabilitation, or skilled nursing care, they remain eligible to receive home health services.
The manual specifies that if it is determined that the services furnished by the home health agency are duplicative of services furnished by an ALF, when provision of such care is required of the facility under the state license requirements for ALFs, claims for such services should be denied under the Social Security Act. It excludes services that are not necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member from Medicare coverage.
This does not change the fact that home health agencies are still permitted to provide care to patients residing in Assisted Living Facilities. However, medical reviewers are now taking a closer look at these cases. While non-affirmations have recently appeared under Pre-Claim Review with Palmetto GBA, it’s likely that this increased scrutiny will extend to Targeted Probe and Educate reviews within Palmetto GBA and eventually spread to other Medicare Administrative Contractors and contracted review entities such as UPICs and RAs.
It’s essential to begin clearly documenting in your records when a patient resides in an Assisted Living Facility. Your documentation should specify the services your home health agency provides and confirm that these are not the same as those the Assisted Living Facility is responsible for delivering.
In most states, this issue will likely apply mainly to Skilled Nursing and Home Health Aide services, since Assisted Living Facilities typically don’t offer therapy. However, that doesn’t rule out the possibility of a denial or non-affirmation related to therapy services, which could require an appeal. To avoid complications, it’s best to include this documentation upfront.
If you have any questions about documentation for medical review or need support with any type of review process, HPS stands ready to assist. Please feel free to reach out to us.
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