Showing posts tagged with: CMS

Home Care and Home Health…What’s the difference?

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Frequently Asked Questions

Home Care and Home Health…What’s the difference?

Skilled care givers verus unksilled care providers. Which type are you looking for?

 
Home health care is an umbrella term that describes a wide range of health care services that can be provided in your home. Home health care can be divided into two additional descriptors “Home Care” and “Home Health” Home Care describes unskilled care provided by caregivers, usually referred to as home health aides, personal care givers, or homemakers. These individuals are trained in the intricacies of senior care. Home care aides can provide assistance with activities of daily living or provide companionship. Home care is classified as personal care or companion care and is not considered “skilled” care. Home Health is a phrase that describes clinical medical care provided by a Registered Nurse, Occupational Therapist, and Speech Therapist, Physical Therapist or other skilled medical professionals. Home Health is typically prescribed as part of an interdisciplinary, multi-setting approach to medical care following an acute illness, exacerbation of chronic illness or surgery. The fundamental difference between Home Care and Home Health is who pays for the service. Due to its unskilled nature Home Care is typically privately paid with some state programs providing assistance with the cost. Home Health is a service that is paid for by Medicare, Medicaid and private insurance. Agencies can find it difficult to meet the regulatory demands of the Centers for Medicare/Medicaid Services (CMS). CMS doesn’t recognize the patient as Jane Smith but instead views Jane Smith through a series of codes. These codes are diagnosis codes, OASIS items, G-codes from claims, and procedure codes. These codes are also used in different formulas that are important in measuring outcomes and re-hospitalizations. Select Data provides professional coding services to Home Health agencies and are industry experts in the language of CMS. We assist agencies with the accurate representation of their patient. To find out how Select Data can help you improve coding accuracy check out our OASIS review and coding services click here.
Check out our FREE 30-minute webinar for OASIS-C2 corrections and more. Select Connects with Clinicians webinar on December 14, 2016. Click here to read more.
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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New Changes for OASIS C2 Data Sets Revision

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Compliance, Events, Legislation, OASIS, OASIS-C2

New Changes for OASIS C2 Data Sets Revisions

New OASIS C2 Revisions: Thinking about finalizing your OASIS-C2 forms? Read this before you do.

 

November 8, 2016, new revisions to OASIS-C2 item set. Select Data’s very own Compliance Officer, Susan Carmichael, MS, RN, CHCQM, and VP of Services Integration, Pam Hernandez, found an issue with multiple OASIS answers in the latest release from CMS for the OASIS-C2 Guidance Manual 6-29-16. Carmichael notified the Centers for Medicare & Medicaid Services of these inconsistencies last month. A corrected version of the OASIS C-2 Item Set, correcting 2 minor typos on page 3 of the all-time points version, has been posted on the OASIS Item Set page. The document can be found in the Downloads section (CMS, 2016).

For a full review of these OASIS-C2 corrections and more, attend our free 30-minute Select Connects with Clinicians webinar on December 14, 2016. Click here to read more.

Sources

Centers for Medicare & Medicaid (2016). OASIS Data Sets. CMS.gov. Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/OASIS-Data-Sets.html
Select Data is committed to a strong compliance program that includes educating all personnel on mitigating HIPAA breaches. For more information about Select Data and their commitment to quality in Home Health and Hospice, call 1.800. 332.0555.

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New Quality Initiatives and Your Falls Risk Program: How Strong is Your Program?

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Clinical Practices

New Quality Initiatives and Your Falls Risk Program: How Strong is Your Program?

One of the key areas to review, that cannot be stressed enough, is a thorough medication review.

 

Falls Risk Mitigation

Tracking data related to patient falls is vital to your agency so you can identify gaps in risk assessments necessary to prevent falls.  Payor sources are looking at Home Health Compare standings and Star ratings. They know these are indicators in the challenging world of Value Based Purchasing.

Review your Falls Risk Program. Do you conduct a post review of any falls incident? Do the clinicians ask upon every visit if the patient has fallen or experienced any unsteadiness? Is there evidence of depression, muscle weakness, or problems ambulating?

Do you monitor which clinicians are involved with which patients who have fallen? Do you monitor what the follow up has been if a patient scores a 4+ on the Missouri Alliance for Home Care? Whatever tool your agency uses for Falls risk, be certain it is a standardized tool that is multifactorial and validated (CMS.gov, 2016).

One of the key areas to review, that cannot be stressed enough, is a thorough medication review.

How to improve your Medication Review

Once the number of medications has been recorded, has a decrease in that number of meds been explored with the physician? Is this documented in the clinical record? Recently, a hospitalist shared that upon reviewing a patient’s medications, he found four medications prescribed to handle symptoms the patient had experienced when taking three medications that had long since been discontinued.

If the patient is on psychotropic, diuretic, or cardiovascular drugs, have lower dosages been explored with the physician? Is the patient on more than one psychotropic drug? Have narcotics been prescribed for a patient on a psychotropic?

Have vitamins and supplements been discussed with the physician or pharmacist, as several herbals and vitamins are known to cause dizziness such as too much Vitamin A or too much or too little Vitamin D. Does the patient take a multi vitamin and Vitamin A supplement and eat several foods fortified with Vitamin A?

When was the patient’s  last vision exam? Is the patient due to see their vision specialist soon? When was the last time their eyeglasses were reviewed and or updated?

What are the best exercise routine and balance exercises needed specifically for each patient? Could a PT referral reduce the risk of falling? What are activities the patient enjoys? If a strength or balance program is incorporated, is progress being evaluated routinely? Is there a history of peripheral neuropathy? Perhaps from a prior diagnosis that is no longer considered active?

Does your agency have a home safety checklist that reviews room by room potential hazards? Assist the patient to see that reducing clutter, improving lighting in hallways and stairwells, and installing handrails and grab bars strategically can be a long term investment in maintaining their independence.

Sometimes, just a refocus on a subject with personnel can increase awareness. The National Council on Aging has an in depth training program on Falls risk education for home health aides. In a Value based Purchasing environment, you may well see the resurgence of home health aide service in the home. Assist them to see the patient through a Falls risk lens.

Let’s focus on Falls Risk.  CMS and other payors are focused. In a value based world, your care of each patient and their outcomes will be a key factor in your agency viability. Falls risk mitigation is good for everyone and can have a great moral, caring, and financial return on investment.

Sources

Centers for Medicare & Medicaid (2016).  Quality Measures. CMS.gov. Retrieved from: https://www.cms.gov/Medicare/Quality-Initiatives-Patient-Assessment-Instruments/HomeHealthQualityInits/HHQIQualityMeasures.html
For assistance with your revenue cycle, care planning, coding, and OASIS needs, CONTACT SELECT DATA at 1.800.332.0555. To download a copy of a sample Fall Risk Program PowerPoint click here.

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New Bundled Payment Projects

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Legislation, Payment Updates

 

New Bundled Payment Projects: Get Prepared Now or Risk being Passed Over by the Hospitals

Agencies should prepare NOW developing Cardiac and/or Orthopedic Best Practice programs if they are not already present. Conduct statistical analysis reflecting outcomes. Demonstrate your agency’s value and strengths to that acute care hospital. If you already have a program, run the analytics. Show the value of your Agency’s specific care.

 

On July 25, 2016, CMS released the proposed rule stating they intend to test new bundled payments to Hospitals for the following diagnoses: Myocardial Infarcts (MIs), Coronary Artery Bypasses (CABGs), and Surgical Hip/Femur fractures. This proposal is similar to the Comprehensive Care for Joint Replacement (CJR) model that began the Spring of 2016. That proposal made hospitals responsible for the first 90 days of cost following hospital discharge for that condition. CMS has been pleased with the results thus far.

The new models would run from July, 2017- 2021 and like the CJR model, the hospital providing the procedure would be held accountable for costs and quality of care from surgery through 90 days post acute care. Of course, the hospital will be able to choose the post acute providers.

Agencies should prepare NOW developing Cardiac and/or Orthopedic Best Practice programs if they are not already present. Conduct statistical analysis reflecting outcomes. Demonstrate your agency’s value and strengths to that acute care hospital. If you already have a program, run the analytics. Show the value of your Agency’s specific care.

How to Show YOUR AGENCY’s Value

Gather emergent and rehospitalization data such as number of patients cared for and the resulting rehospitalization admission rate. Be prepared to discuss what makes your Cardiac program successful and why your agency will be an excellent partner.

CMS will choose 98 markets by random selection. Those hospitals working with post acute care providers including physicians are expected, by CMS, to deliver care that is at a “quality adjusted target price, while meeting or exceeding quality standards, and would be paid the savings achieved.”

For the Surgical Hip/Femur Fracture Treatment, that model will be placed in 67 areas where the CJR is ongoing. This looks to be an add-on to the present project. This diagnosis is the eighth most common discharge diagnosis for Medicare fee for service patients in a hospital. CMS has noted that mortality rates associated with this diagnosis is 5%- 10% after 1 month and approximately 33% at a year.

Sources

Centers for Medicare & Medicaid (2016). Bundled Payments for Care Improvement (BPCI) Initiative: General Information. CMS.gov. Retrieved from: https://innovation.cms.gov/initiatives/bundled-payments/
For clinical record document review and coding services that can assist you with these models and more, CONTACT SELECT DATA at 1.800.332.0555

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RACs are Gearing Up to Audit Medicare Advantage, Part D, and MEDICAID

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Audits

And yet another RAC audit… Section 1902(a)(42)(B)(i) of the Social Security Act requires states to contract with Recovery Audit Contractors (RACs) to identify underpayments and to recoup overpayments as part of the state plan. The Patient Protection and Affordable Care Act required the states to have contracted with one or more RACs by December 31, 2010.  Scheduled to begin April 1, 2011, the Medicaid RACs will be a bit different because of the different focus that could be seen by each state. There will be a large list of Medicaid auditors approved by each state. In the September, 2010 Federal Register, CMS posted an “information collection request” about Medicaid RACs. They identified that contracts should be similar to those of the Medicare program. However, states may tailor the Medicaid RAC activities to the specific aspects of the Medicaid program in each state and collectively “propose targeted areas of susceptibility regarding improper payments.” Each state was required to amend their state plans reflecting the RAC program and attesting to a plan in place. This plan must also include Medicaid waiver contracts. The RAC Medicaid requirements remain separate from the Medicaid Integrity Program (MIC) audits, which will continue. The RAC audits are additional Medicaid audits that the law requires to ensure plans under Parts C and D  have claims examined for reinsurance payments to determine if the claims costs are in excess of allowable reinsurance costs.  RACs are also to look at prescription drug plans for high cost beneficiaries. New York State Medicaid Inspector General is leading the charge in attacking waste, fraud, and abuse, recently reminding home health agencies they “cannot bill for excluded providers or accept orders from excluded providers.” He has identified that many agencies were not appropriately verifying physicians approved for Medicaid payment. In addition, the pressure is on to be certain that diagnosis codes, hospital admission and discharge codes, and procedure codes are all in order in all areas of health care. Coding, once again is at the forefront of audit review for all areas of healthcare. Health care entities should review the annual OIG workplan, and besides the understood areas of risk; diagnoses coding, rehabilitation services, medical necessity, and adequate documentation, they might wish to add Medicaid Hospice services and being certain a process is in place to verify physician orders are not taken from Medicaid excluded physicians. How frequently is the exclusion list reviewed? Risk areas identified by corporate compliance necessitate a policy and procedure to be in place with a method of verifying compliance to reduce corporate risk. Mandated corporate compliance programs are to become a reality in all areas of health care within the next few years. However, more and more organizations realize they need a corporate compliance program in place now. In case of a RAC, MAC, MIC, and especially in case of a Z-PIC or HEAT audit, establishing the view that you are compliance oriented with a compliance plan in place sends a far stronger positive message than you are waiting until a plan is actually mandated. The OIG recently announced they will be reviewing “Medicaid Program Integrity Best Practices” in state Medicaid agencies especially in the areas of coding and payment risks. You may well have Best Practices in clinical areas but do you know that your billing practices follow Best Practices in Medicaid billing? You need to have this assurance. For additional information: http://www.cms.gov/ www.cms.gov/RAC/01-Overview.asp www.RACmonitor.com www.oig.hhs.gov Reminder: RAC facts RACs can review via automated review (no medical record from the agency required) or a complex review which entails a medical record request. The four present CMS approved RACs include: RAC B: CGI Federal http://racb.cgi.com racb@cgi.com RAC C: Connolly, Inc www.connollyhealthcare.com/RAC RACinfo@connollyhealthcare.com RAC D: HealthDataInsights http://racinfo.healthdatainsights.com racinfo@emailhdi.com

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