November 07 2017 | 0 Comments | 107 reads Average Rating: 4

Getting Home Health Payments Just Right: 4 Steps to Success

by Nicole Cormier and Leslie Strader in Payment Integrity

As the population ages and the healthcare industry moves toward value-based care models, the need for home health services is rising rapidly.

The flipside: As the home health market grows so too does fraud, waste and abuse in the sector. The upshot: Payers must audit providers as they deliver home health services to hold them responsible for appropriate care and billing. The conundrum: Payers need to do this in a fair way, ensuring that they will not cause abrasion and prompt providers to return to more costly sites of care delivery.

The task at hand for payers is to ensure that providers are delivering home health that:

Is medically necessary. Payers should not reimburse providers to come out and do something that anyone could do. There has to be a skill involved. As such, providers need to paint a complete picture of the care that is being delivered in the home to substantiate medical necessity and prove that the patient requires the services for a skilled professional.

Is intended to make the patient self-reliant. The ultimate goal of the home care services should be to bring the patient to a point where he can care for himself.

Is provided to patients who are truly homebound. Patients who receive home care must be homebound. Patients must require a person to push them in a wheelchair to get out of the house or physical assistance to walk because they can’t ambulate more than a few steps by themselves.

Is delivered on an intermittent basis. Care providers should deliver services on a periodic basis to make sure that the patient is adhering to the care plan. For example, when working with a chronic obstructive pulmonary disease (COPD) patient, the provider would not provide ongoing observation and care but would check oxygen levels and ensure that the patient is adhering to the prescribed medication regimen. If there are any problems, the care provider would then report those to the physician and the physician would adjust the care plan.

How can payers ensure that providers are delivering care that meet these criteria? Here’s a four step process that can help to create a successful audit program:

#1: Understand how you pay your claims. To start, payers need to understand how they pay their claims before determining if they are paying them incorrectly.

#2: Take a sample from all providers. Payers need to monitor all providers. As such, payers can determine if providers are sending out the right staff member to perform the assessment; documenting correctly; and admitting the right patients.

#3: Provide feedback. If problems are identified, payers should not just correct them. Instead, they need to provide feedback to providers. This feedback can show providers the right way to do things. As such, payers can better position themselves as a partner and will be less likely to cause abrasion.

#4: Never completely stop auditing providers. Even when providers seemingly fall in line, payers should not stop auditing them completely. Guidelines change every year and payers need to ensure that providers stay in step with these changes. In addition, personnel at provider organizations also changes. So, payers need to ensure that new staff members are towing the line as well.

These are just a few examples of how payers can work to get home services payments right.

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Author
Nicole Cormier
Senior Manager, Home Health

Nicole has worked in healthcare for almost 30 years and over 20 years as a nurse.

Read full profile and other posts |

Author
Leslie Strader
Project Manager

Leslie manages the entire product lifecycle from strategic planning to tactical activities for SCIO’s Reimbursement Optimization platform, SCIOMine.

Read full profile and other posts |

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