Home health PPS focuses spotlight on quality issues
Home health agencies (HHAs) should brace for an uptake in federal investigations into fraud and abuse as agencies complete the transition to prospective payment under Medicare, warns Elizabeth Carder, a health care attorney with Epstein Becker in Washington, DC. Inevitably, she says, providers learn how to maximize their reimbursement under new Medicare payment methods while a minority go about finding ways to game the system. Just as inevitably, federal investigators find ways to crack down on these moves.
Bill Dombi, vice president of law at the National Association for Home Care in Washington, DC, agrees that the home health prospective payment system (PPS) presents both opportunity and risk. "There are paths you can take that will increase your risk, and there are paths you can take that will help manage those risks," says Dombi.
While overutilization has long been the boogeyman of home health, Dombi says that under the PPS the biggest concern is quality of care. Here is a rundown of some of the major potential trouble spots agencies should begin to plan for:
- Premature discharges. Dombi says the issue of premature discharges should be a priority concern for HHAs. "You make money by providing less care, and one way to provide less care is to discharge the patient earlier," he explains. But premature discharge carries a "high risk."
- Failure to provide a discipline of service. Dombi points out that while most home care patients are accustomed to face-to-face visits, HHAs now will be placing an ever-greater emphasis on training patients and family members to care for themselves. "You have to prepare for the risk that creates," he warns.
- Outcome Assessment and Information Set (OASIS) assessments. According to Dombi, OASIS assessments often will be used as the evidence prosecutors require to prove that HHAs have not managed risk properly. In fact, he says, this is the first place many prosecutors will look when preparing lawsuits based on inadequate quality of care. Dombi predicts they will want to see how much of a relationship it bears to reality and how well-coordinated the OASIS assessment is to the actual care received by their client.
- Internal and external benchmarks. Dombi says that as HHAs go through their strategic planning about how to transition to prospective payment, two important benchmarks will be productivity and patient outcomes. While many agencies once had a policy of 30 visits every 30 days, they may now have a policy of a maximum of three visits every 30 days. "That benchmark is evidence that is not going to be helpful," he warns.
Dombi adds that while patient records and documentation always have been the key factors in risk management, outcomes will become increasingly important. "People already are look at factors such as rehospitalizations, institutionalizations, and degree of rehabilitation," he says.
- Discharge policies. According to Dombi, discharge policies can turn out to be an agency’s best friend or worst enemy, depending on how they are developed. "You have to do it correctly or it will raise presumptions and you will be rebutting those presumptions rather than providing direct evidence that you have met the quality-of-care responsibilities," he asserts.
Dombi says agencies also must examine these strategies for any "smoking guns" such as incentive compensation. He recalls one agency that paid staff liaisons with hospitals based on the number of referrals they received. "They were not viewed by the auditors as liaisons," he asserts. "They were viewed as marketing staff."
Likewise, when compensation was based on a per-visit basis, some nurses would deliver more visits because it increased their income, notes Dombi. He advises agencies to avoid that kind of incentive unless they have adequate safeguards. "I am not saying that any of that kind of compensation incentive is a problem," he explains. "But it does create some dangers."
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