Currently, Centers for Medicare & Medicaid Services (CMS) has a backlog of more than 25,000 appeals for home health care services that have been denied. In many of these cases, the agency claims that it does not have enough information to make a determination, which only contributes to the backlog.
In an effort to reduce the backlog and speed up the review of home health care claim appeals, Senator Kenny Marchant (R-TX), with co-sponsor Representative Earl Blumenauer (D-OR), introduced H.R. 2663, the Home Health Documentation and Program Improvement Act of 2017, in late May. The bill seeks to amend title XVIII of the Social Security Act, which would allow CMS to use additional documentation in their consideration of appeals, making the process faster and more accurate. The legislation is proposed to begin January 1, 2018.
Although GovTrack, an independent organization that tracks legislation, gives the bill a mere 7 percent chance of actually being passed, it is still worth paying attention because it’s likely to spur more discussion about how to reduce the time it takes to process appeals and ultimately get patients the care they need.
The Basics of H.R. 2663
In the most basic terms, passage of H.R. 2663 would accomplish two things:
- 1. Allow the inclusion of a home health medical record with the supporting documentation that a patient is eligible for home health services. Currently, only a physician’s record is acceptable.
- 2. Allow home health agencies to accept a percentage of the billed amount if they agree to forgo the administrative claims process. The actual percentage of payment would be determined by the Secretary of Health and Human Services should the legislation become law, using the percentage used under CMS hospital appeals settlement that began October 31, 2014.
Both statutes would theoretically speed up the review of appeals, reducing the backlog. However, CMS claims that the backlog is due to several factors, not just the number of claims. The agency notes that changes in a correspondence system and staffing challenges have also slowed down appeal reviews, but the Government Accounting Office identified additional issues. Chief among them is the fact that CMS uses several different data systems to manage claims denial and appeal information at different levels, which are not compatible with each other. This results in missing information, duplication of efforts, and confusion for beneficiaries — in addition to significant delays in processing time.
Therefore, while allowing CMS to use all pertinent information in the review of appeals and to make settlements with HHAs can reduce some of the backlog, without more systematic changes to streamline processing and create more consistency in the data management.
The Need for Appeal Reform
Anyone who has attempted to navigate the CMS appeal process can attest to the labyrinthine process — and the fact that it can often take as long as four to five times longer than the 90 days within which the agency promises a resolution. In fact, the average appeal time is now nearly 475 days, during which time patients often have to forgo care, pay out of pocket, or continue to receive care in hopes that their HHA will be paid upon the appeal being granted.
Two of the most common reasons that home health claims are denied are that the patient doesn’t meet the definition of “homebound,” and that home care would not measurably improve a patient’s condition. Often, words like “stable,” “chronic,” or “no restorative potential” are used in these types of denials. Under the current rules, in order for a patient to appeal such a denial, he or she would need a written statement from their physician noting the extreme difficulty inherent in leaving the house, or that the care could help slow the chronic diseases progression as well as reduce the likelihood of or provide treatment for concurrent conditions. Should H.R. 2336 pass, a home health agency could provide evidence from the patient’s record to support these claims, but for now, the only recourse for the patient is the physician’s statement.
Home health agencies can help with this process by maintaining the lines of communication with providers, and using software to manage patient records and share pertinent information with other providers. You can also help your patients by notifying them of their rights to appeal and providing information about the process of making an appeal.
H.R. 2663 is currently being considered by the House Ways and Means Committee. Stay tuned to this space for more information about its progress and what any changes could mean for your agency. In the meantime, to learn more about software solutions that can help you more efficiently manage patient records and reduce the chances of claims being denied, check out Complia Health’s extensive product offerings.