Watch out for tough commercial payer audits
Learn from a Michigan agency’s nightmare
Here is the kind of year that gives home care quality managers nightmares. Genesys Home Health and Hospice in Flint, MI, underwent a state Medicaid audit in the spring and was preparing for a fall survey by the Joint Commission on Accreditation of Healthcare Organizations. Then, Blue Cross Blue Shield of Michigan called to say its auditors would visit in July.
Genesys makes 110,000 visits a year; 10% are to Blue Cross patients. Blue Cross gave the agency two weeks notice before the week-long audit and requested a list of 95 charts from the past year to review, says Nancy Griffiths, RN, quality improvement medical records manager.
Four Blue Cross auditors combed through the charts to determine if each represented reasonable, necessary, and skilled care. They used the same criteria as Medicare.
"Each day we had a little exit interview, and they told us what they had found in the charts," Griffiths says. "At that point, we’d get out the medical record to look for any details that were missing." The auditors were particularly interested in the long-term cases, Griffiths notes.
The secrets are in the details
The experience showed managers that they needed to pay closer attention to homebound documentation, stressing with staff that each note has to show reasonable and necessary care.
"Our education coordinator did some research and came up with a sheet of phrases you could use to define homebound status," Griffiths explains. "She got those through team meetings and inservices, and passed them out to every discipline."
The Blue Cross audit was stressful and resulted in Blue Cross challenging payment for some cases. The agency is appealing. However, the audit did help prepare the agency for the Joint Commission survey and helped it earn accreditation with commendation.
Blue Cross Blue Shield of Michigan, serving 4.5 million members, made a decision last year to improve the clinical criteria program, including the audit and preapproval process, says Thomas J. Ruane, MD, associate medical director in Detroit.
Blue Cross has published a home care manual and Ruane is leading an effort to update the payer’s home health care criteria.
"We’re going to move from our own in-house written criteria to criteria provided by InterQual, a national provider of clinical utilization management criteria, located in Marlboro, MA," Ruane says. "We’re going to get that criteria out to all of the home care agencies through the Michigan Home Health Association in Lansing."
As Genesys Home Health’s experience illustrates, quality managers should be aware that an agency may be audited by private payers in addition to Medicare and Medicaid audits. While statistics are unavailable showing if private payer audits are rising, it’s possible more agencies will face them as the home care industry increasingly turns to private payer business to supplement the declining revenues from Medicare under the interim payment system.
In any event, it’s a good idea for agencies to prepare for such audits, experts say. "I think people just get lax and think if they didn’t get audited or surveyed before, then everything they’re doing is all right," says Penny Rhein, RNC, clinical operations chair for the Michigan Home Health Association. Rhein is also vice president of United Home Health Services in Canton, MI.
An insurance company might not have conducted regular audits because it was short-staffed. In other cases, a payer is purchased by another corporation and the new corporation believes in conducting regular audits. Whatever the reason, home care agencies that have been going about their business the same way for years might suddenly find themselves in the same position as Genesys.
Another explanation is that the commercial home care market, while still small, is growing. Ruane says Blue Cross in Michigan probably covers only about 5% of the state’s home care patients, while Medicare may be covering more than 90%. However the company’s cost for home care is rising.
"Even though we’re not a major player by Medicare standards, the amount of money we have been paying has increased substantially and audits have occurred," Ruane explains. "And in audits, we’ve found situations where the home health care was inappropriate."
As a result, Blue Cross is putting some effort into being clear and consistent in its criteria for home care, he adds.
Follow Medicare COP with all cases
Rhein says home care agencies might have some trouble if they are handling their commercial cases differently from the way they handle Medicare cases because the commercial payers might expect them to follow the Medicare Conditions of Participation on all cases.
Michigan Blue Cross auditors, for example, use the homebound definition as Medicare describes it, and auditors look at charts to see if there are instances where the care was inappropriate, Ruane says.
"When it’s uncertain whether home care would be covered, we want to have home care agencies contact us and discuss these issues and figure out whether any kind of case management program would be appropriate for the patient," he explains. "This way, the agency wouldn’t end up two years later with $15,000 in charges that we don’t think are appropriate."
Commercial payer audits could serve as a wake-up call to home care agencies. For instance, agencies that have not been routinely audited in the past may be making mistakes that have never been caught, Rhein says. "Sometimes a good outcome of audits is that it checks your system and validates whether you’re doing the procedure correctly."
However, there’s no easy way to get through a 95-chart audit, she notes. "The advice I would give everyone is that you really need to know what your rules are and reference and review those on an annual basis to see what your own internal audit would find."
Sources
• Nancy Griffiths, RN, QI Medical Records Manager, Genesys Home Health and Hospice Inc., 3933 Beecher Road, Flint, MI 48532. Telephone: (810) 762-4600.
• Penny Rhein, RNC, Vice President, United Home Health Services Inc., 2200 Canton Center, Suite 250, Canton, MI 48187. Telephone: (734) 981-8820.
• Thomas J. Ruane, MD, Associate Medical Director, Blue Cross Blue Shield of Michigan, 600 Lafayette E., Mailcode 0740, Detroit, MI 48226. Telephone: (313) 225-8207.
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