WASHINGTON, D.C. (January 10, 2019)—Home health agencies face a potentially serious claim denial issue related to new Plan of Care requirements, the National Association for Home Care & Hospice reported in its Jan. 9 bulletin. 

Effective January 13, 2018, the Plan of Care (POC) Condition of Participation under 42 CFR 484.60 also became a Condition for Payment under the home health benefit, 42 CFR 409.43. This means that all the elements must be in the POC or Medicare payment will be denied.

While this generally does not present any concerns, one of the new POC requirements has created problems for many HHAs that may not have modified their POCs sufficiently to meet the new POC requirements. A compliant POC for payment purposes must now include “information related to any advance directives,” NAHC advises.

Recent audits as part of the Comprehensive Error Rate Testing (CERT) program have uncovered significant noncompliance with this new requirement, according to NAHC. At the same time, MAC audits have approved claims that involve POCs that do not include full information on a patient’s advance directives. While these are inconsistent decisions, it is prudent to take steps to address concerns raised by the CERT audits.

NAHC is advocating to the Centers for Medicare & Medicaid Services (CMS) that a broad-scale, efficient remedy needs to be implemented given the apparent widespread oversight by HHAs. These HHAs do appear to have obtained all the needed advance directive information. It is just that the information did not fully find its way to the POC. At this point, CMS has not agreed to any remedial measures other than potentially hundreds of thousands of individual claim corrections.

In the absence of a systemic fix, the noncompliance puts HHAs at risk of further audits and the likelihood of a high volume of retroactive claim denials. However, there is still an opportunity to correct these POC deficiencies. Still, that opportunity will be shrinking as claim corrections must be filed prior to the close of the one-year window for claim submissions that will begin to close on Jan. 13, 2019.

What Should You Do?

1. Review Jan. 13, 2018, and later POCs to determine if they are compliant. For example, a POC will not be compliant on the advance directives requirement if the only entry references whether or not the patient has a Do Not Resuscitate (DNR) order, as there are more types of advance directives than just DNRs.

2.  If you find non-compliance, review the patient record to determine if the needed information is available. For example, the OASIS info should include advance directive detail.

3. For non-compliant claims, secure a signed POC addendum from the certifying physician, that includes the required information for the POC.

4. Submit corrected claims to your MAC. One of the MACs is accepting these corrections without a need to cancel the original claim and submitting a rebilling as there is no reimbursement effect. NAHC expects the other MACs will do the same. The corrected submissions can be done sequentially over the next 12 months so that the administrative burden is spread out consistent with the one-year window on claim submissions. It is advisable to get the MAC’s take on how to handle corrections before proceeding.

The correction process is a huge burden for HHAs, physicians and Medicare itself, according to NAHC. Since there is no effect on payment rates, NAHC strongly believes that it is in everyone’s interest that sensible remedial actions take place instead of massive claim corrections. Nevertheless, HHAs must protect themselves from the risk of retroactive claim denials based on insufficient advance directives information on the POC before corrective opportunities close with the one-year window. At present, the burdensome approach outlined above is the only option.

Visit nahc.org for more information.