Issue One: Looking at Statistical Data
Every time an OASIS is submitted to the state, portions of it may be parsed out to state, regional, and Federal groups such as the HEAT, MAC review groups, and Federal special projects in the DOJ and FBI. That means that when a review letter arrives, it may already be too late. Since we are aware that Predictive Analytics are employed, correct complete data must be submitted.
In home health care, predictive models are being used to exploit patterns found in historical and transactional data to identify risks and opportunities. The present Models capture relationships among many factors to allow assessment of risk or potential risk associated with a particular set of conditions. The relationships should guide clinicians in their care plan decisions as well as care delivery. There are thousands upon thousands of potential OASIS and coding combinations. Because of the patient profiles and patterns retained over the years, comparisons can be made readily. Add HHRGs and service information to the OASIS and diagnostic data and CMS can gather very significant data regarding your agency’s care delivery and outcomes. MANY analytic filters are utilized to screen the data. The initial round of filters are termed MUEs (Medically Unbelievable Edits). These edits are the first predictors of fraud and can alert the Z-PICs of agencies that should be monitored. Auditors may monitor an agency for years, gathering data, analyzing data and patterns, andreviewing payments. The agency profile is completed.
This data and these pre-probe edits allow Z-PICs to have plenty of time to analyze data and monitor agency behaviors so that when they send a letter, they have already completed their initial audit and arrived at a solid conclusion.
Since experts state that 75-85% of all agencies are acutely unaware of business operations data and do not have necessary compliance rules built into or a part of their billing practices to protect them from wrongful claim submission, agencies are at risk. Who is auditing your clinical records and care, the ICD-9 coding, and the claim submission? Who is monitoring your data? Do you have clinical and operational benchmarks? In 2009, billing errors were found to have doubled. Be proactive now, because if your compliance rules and program are weak, you could be hearing from the Z-PICs soon.
Issue Two: Look at Clinical Data
CMS has proposed strong regulations establishing hefty intermediate sanctions to be imposed on home health agencies not in compliance with CoPs. Agencies must read the survey regulations carefully, implement precise policies and procedures, and audit utilization of those policies and procedures to be certain they meet processes as intended by the agency compliance program.
Proposed provisions include:
Monetary sanctions of $8500.00-$10,000.00 for condition level deficiencies that place a patient in immediate jeopardy.
Fines of $8500.00 per day for repeat deficiencies
Fines of $2500.00-$5000.00 per day for other deficiencies not placing a patient in jeopardy.
The monetary sanctions can be applied for the number of days the agency is out of compliance and they can be increased or decreased after the application of the penalty. The sanctions may be per day or per instance. They could not be applied simultaneously for the same deficiency. Please go to the CMS website to review the proposed rule.
Monetary sanctions are not the only sanctions that CMS may impose. CMS can chooses to terminate a provider agreement. If an agency is unable or unwilling to correct deficiencies. Additional alternative or additional sanctions include suspension of payments for new admissions and new episodes of care, temporary management of care, mandated directed inservices and training, as well as the emporary management of deficient agencies including making personnel changes and providing necessary interventions to assist the agency back into compliance.
The proposed rules would place much more pressure on a home health agency requiring excellent documentation of care following a careplan that is consistent with the needs identified in the patient clinical assessment. If outcomes are not achieved because needs were not appropriately identified, visits were missed, or care was not appropriately delivered, or a patient was placed in danger, an agency could face sanctions.
Agencies are expected to audit care, audit data, audit employee performance and be attuned to levels of care delivered to the patients of the agency. Agencies must clearly accept responsibility for care delivery and the outcomes derived from that care. It is clear from the proposed rule that
If the proposed survey sanctions are passed, agencies must be concerned they have excellent processes in place such as a “built-in, self regulating quality assessment and performance improvement system to provide proper care, prevent poor outcomes, control patient injury, enhance quality, promote safety, and avoid risks to patients on a sustainable basis that indicates the ability to meet theCoPs and to ensure patient health and safety ( Fed Register Vol 77 #135, Friday, 7/13/2012 Proposed Rules, p 41582 col 3). or the financial consequences could be devastating.