Healthcare Provider Solutions

The vice just gets tighter and tighter and the heat gets hotter!  Agencies are struggling to keep their heads above water and to keep up with the massive amounts of audits and then more fuel is added to the fire! Beginning December 15, 2016 (December 27 in FLORIDA) the 2nd Round of Probe and Educate ADR reviews begins.  Agencies that received 0-1 denials/partial denials on the 1st Round of reviews will be exempted from the 2nd Round.  It has been confirmed that this will be based on your initial denial rates.  So if you had 3 denials and then got 2 of them reversed, you will still be subject to the 2nd Round based on the 3 denials.  The MACs will again be requesting 5 charts to be reviewed and if the agencies receive any denials they will receive a phone call from the reviewer to discuss the problem.

As of now, the Pre-Claim Review Demonstration is set to begin in Florida on April 1, 2017.  Postponement of the implementation, earlier this year, brought hope of its possible demise, but so far that has not proven to be the case.   Agencies in the state of Florida will begin submitting under the PCR Demonstration in April unless there is another change.  The Medicare MAC has said that the 2nd Round of Probe and Educate reviews will help agencies prepare for PCR.

Value Based Purchasing (VBP) is still going strong in 9 states.  The 2017 Home Health Regulation brought changes to the Pilot, but many of those changes, expected.  There were 3 process measures and 1 outcome measure eliminated due to lack of data collected in 2015 to be used for those measures in comparing with 2016 performance.  They also have clarified that each state would need at least 8 agencies that qualify for the small cohort category to have a small vs. large cohort calculation.  The reporting will now require a 15 day time limit for requesting recalculation of your scores vs. 30 days.  Lastly, the new item regarding the reporting of Influenza Vaccination of your agency staff will be changed to annual reporting, Effective April 2017. The claims processing edit, to ensure that OASIS has been transmitted prior to claims being billed, will go into effect April 3, 2017. OASIS is a requirement of payment. Full implementation of CR 7760 has arrived and will begin in April 2017.

OASIS-C2 Implementation is effective January 1, 2017.  Not only is there a significant number of documentation changes, OASIS-C2 WILL impact reimbursement.

As if that were not enough already!  Palmetto GBA also has a probe edit that is currently active for any HIPPS code that has a CH or BG in the Clinical/Function domains of the HIPPS code.  The CH represents the highest level of clinical acuity and highest level of functional acuity that can be represented in the HIPPS code from the OASIS documentation.  There are 11 possible combinations of HIPPS codes that have a CH in them and they have set the limit for ADRs in this edit at 10 per HIPPS code, so potentially this edit could create 110 per agency.  The content of the probe edit does say 100 maximum.  Do keep in mind that agencies in the 5 states that are subject to Pre-Claim Review are not affected by this probe.  The BG edit is similar, except that the BG is the middle clinical acuity and middle functional acuity.