The difference between the Conditions and Participation and the Conditions of Payment is a crucial topic, and a critical issue regarding the distinction between the two needs to be addressed.
When discussing the Conditions of Participation, it’s well understood that compliance with CoPs is essential. Whether in home health or hospice, surveyors carefully review these conditions during their surveys.
Additionally, some Conditions of Participation also extend into the Conditions of Payment. For instance, in home health, payment for a claim under medical review requires signed physician’s orders, including a Plan of Care and any supplemental orders from the certifying physician overseeing the patient’s care. If these orders are not signed and dated before submitting the claim, payment may be held.
A Condition of Participation also requires having signed physician’s orders to treat a patient. The challenge arises when medical reviewers deny a claim under medical review based on a Condition of Participation that does not apply to the Conditions of Payment.
A key example is the 48-hour rule. When a home health patient is referred, the patient must be opened within 48 hours unless a physician has specifically ordered a Start of Care date. If the 48-hour requirement or the physician-ordered Start of Care date cannot be met, the physician must be contacted for an updated Start of Care date to maintain compliance.
That requirement is a Condition of Participation, not a Condition of Payment. Over the past year, some claims have been denied specifically due to the 48-hour rule, even though it is not a Condition of Payment.
To differentiate between Conditions of Participation and Conditions of Payment, it’s important to know where to look. If you’re trying to determine a Condition of Payment, refer to the Medicare Benefit Policy Manual and the Medicare Program Integrity Manual. Notably, neither of these manuals mention the 48-hour rule. Instead, this rule is found in the Conditions of Participation and the State Operations Manual, which surveyors use to review agencies based on the Conditions of Participation.
This is another key reason why agencies must understand that passing a survey with full compliance, and meeting all of the Conditions of Participation, does not automatically mean they meet all Conditions of Payment. It’s crucial to recognize the difference. If a claim is denied under Medical Review based solely on a Condition of Participation rather than a Condition of Payment, be sure to appeal the decision all the way to the ALJ.
Healthcare Provider Solutions can support you whether it be regarding Medical Review issues, distinguishing the difference between Conditions of Participation and Conditions of Payment, Mock Surveys, and more. We also provide chart reviews or guidance if you’re currently undergoing a medical review. If you require assistance in any of these areas, please reach out to us.
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