How to Survive Audits by Documenting Medical Necessity in Home Healthcare - Part 1

Additional documentation requests (ADR) are the norm today – everyone in home health gets them. Perhaps the best defense of documentation requests from payers (specifically Medicare) might be a stout offense that boasts an aggressive strategy of documenting every procedure at the point of care and providing specific details of the patient health plan. But even when taking an aggressive approach to defending services provided — with detailed documentation — of the patient experience, there still may be some instances when home health administrators must take action.

To do so, however, it may be worthwhile to understand exactly what some of the top reason for denial of payment are throughout the first quarter of 2017.

For CGS-processed claims, they list their top denials as: skilled nursing services were not medically necessary; physician’s certification was invalid since the required face-to-face (F2F) encounter was missing/incomplete/untimely; requested documentation was not received/or not received timely; documentation did not show that therapy services were reasonable or necessary; and initial certification was missing/incomplete/invalid, therefore, the re-certification episode is denied.

For PGBA-processed claims, they list their top denials as: requested records were not submitted; F2F encounter requirements were not met; Health Insurance Prospective Payment System (HIPPS) code change because of partial denial of therapy; no plan of care or certification; info provided does not support the medical necessity for therapy services; and unable to determine medical necessity of HIPPS code billed as appropriate, OASIS not submitted.

For NGS-processed claims, they list their top denials as: documentation submitted does not support homebound status; medical necessity not supported as OASIS not submitted; skilled observation was not needed from the start of care; skilled nursing services were not medically necessary; requested documentation not received/received untimely.

There are still many, many other reasons for denial of claims. Some of these include:

• OASIS data might conflict with what was billed.
• Skilled nurse visits are not covered because documentation indicated more visits were provided than were reasonable and necessary.
• Physician’s plan of care or certification present and is signed but not dated: Documentation submitted did not include the physicians signed certification or recertification. Electronic signatures ensure compliance with this standard.
• No plan of care or certification (POC) – no POC established and approved by a physician; all pages must be included; care plans are omitted from ADRs and/or the wrong plan of care may be submitted because agencies are working against a deadline. If not signed and dated, then it’s not a valid note.
• Unable to determine medical necessity HIPPS code billed as appropriate OASIS not submitted: Home health administrator did not submit the OASIS for the HIPPS code billed on claim.
• F2F encounter requirements not met: These charts can be scrutinized – documentation not submitted with ADR; homebound status not adequate; reason for skilled services not adequate; clinical data not found in patients acute/post-acute records.
• Information provided does not support medical necessity for this service: Clinical documentation submitted for review did not support the medical necessity of the skilled services billed – nothing listed during the therapy visits do not support the documentation.
• Auto deny – requested records not submitted: Medical records were not received in response to an ADR in the required time frame; therefore, unable to determine medical necessity – there’s no reason for this if services are provided.

Home health administrators must review claims and must have a process in place to review end of episodes so they are clean for billing. This doesn’t mean you must quality assets (QA) 100 percent of the charts you process, but establish some sort of protocol that ensures members of your QA team review end of episodes before they are billed. In the case of responding to ADRs, they should be sent with a signed receipt request so you are able to track the documents so that you can see when the documents arrived at the claims processor and who signed for them.

Administrators also should ensure that education is provided to staff during orientation, and annually on the coverage guidelines for clinicians, so they understand what is expected to re-certify a patient for care.

Also, it’s important to understand that your caregivers should not be allowed to turn in late paperwork. Notes that are completed long after the visit are rarely accurate and these notes are reviewed in the event of an audit. Each visit note for all disciplines must stand alone and provide needed.

When it comes to documentation, the only way to go forward is transparently and the best way to do that is to be as educated as possible on best practices.  Join us next time for part II of our blog series medical documentation where we’ll discuss specific areas of focus to ensure that your documentation is as thorough as possible to help ease the pain an audit can bring.

Entire blog post originally posted on DeVero, a Netsmart Solution’s blog onJuly 31, 2017.