Effective October 14, 2020, CMS added 11 new services to its list of approved telehealth codes, which include cardiac and pulmonary rehabilitation. This handy list contains all the telehealth services, the dates on which they were approved and whether they can be provided telephonically. In light of CMS’s resumption of payments audits, we suggest providers review this list and make sure their billing codes are correct.
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President Trump signed an Executive Order on October 3, 2020 aimed at protecting and improving the Medicare program. The Order outlines steps to improve fiscal sustainability of the Medicare program and plans to increase choices, flexibility and value. Below is a summary of the actions requested to be carried out by the Secretary of the Department of Health and Human Services.
By January 1, 2021, the Secretary will propose regulatory changes to combat fraud, waste and abuse in the Medicare program.
Within 180 days of the Order, the Secretary will:
Within one year of the Order, the Secretary will:
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In a previous post, we announced that CMS would be resuming program integrity audits in August. This recent article explained some additional details of their “short-lived hiatus.”
Despite the continuing public health emergency (PHE), CMS did resume on August 3rd pre-payment and post-payment audits in its quest for integrity of the Medicare program. Providers may be targeted for review based on high utilization of particular billing codes or some other “abnormality” found during a review of CMS’s analytics. It’s important to understand that during the PHE when audits were suspended, CMS was still busily focused on data mining its claims for aberrations. One area in the cross-hairs is telehealth (TH) claims. Medicare is specifically looking for fraudulent TH charges, including “providers who bill for more visits per day than are humanly possible.”
Keep in mind, as we discussed in this FAQ document, the requirements for TH visits (documented consent, proper billing codes) and that some Medicare services require audio/video and not just telephonic services. The author of this article explains that given all the changes that occurred early in the PHE, claims paid during the first 60 days may be subject to different rules and may be more likely to contain errors, and be ripe for auditing.
What should you do if you’re selected for an audit? First, don’t panic 😊 but do be timely in your response. If responding to a documentation request would create a hardship for your practice (e.g., reduced staffing), discuss this with the auditor. Also, CMS will be taking into consideration any waivers or flexibilities offered during the PHE; we suggest providers go back through email notifications and CMS guidance to be clear on the internal changes you made as a result of those communications. Finally, as the article says, avoid prematurely returning any overpayments until you confirm the audit findings.
Remember that targeted probe-and-educate (TPE) reviews are meant to help you improve your documentation, coding and billing, so try to keep an open mind that TPE reviews could turn out to be a good exercise. (Like 2020 couldn’t get any worse.)
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For 2021 coding, which begins on October 1, 2020, Chronic Kidney Disease Stage 3 (N18.3) was changed to
Most lab-based diagnoses require two consecutive laboratory findings, spaced a few months apart, for confirmation of the condition. In the absence of clear guidance on the 2021 ICD-10-CM coding of Chronic Kidney Disease Stage 3, we suggest having two consecutive lab values in the CKD 3 range (GFR 30-59). When the provider is ready to assign a code upon receiving the second result, we recommend using the most recent GFR to assign the code.
Feel free to request our FREE Bulletin on coding CKD 3.
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It was just a matter of time before more players entered the healthcare space, which has been front & center for some time, but it’s interesting to see a retail giant take steps to become an insurer. Beginning next year, Walmart will offer a Medicare Advantage plan in partnership with Clover Health, according to a recent article in Healthcare Finance News.
The new LiveHealthy: Clover powered, Walmart Enhanced PPO will be available in eight Georgia counties, and offer care through its Walmart Health centers and network of 31 hospitals and 8,000 providers. The author explained that Walmart has been taking preparatory steps for this venture by remodeling stores to feature private consultation rooms in the pharmacy and opening a brick and mortar location that offers primary care, dental, counseling, lab, X-ray, audiology and more. The retailer plans to operate 22 facilities by the end of 2021.
LiveHealthy members will enjoy zero-dollar monthly premiums, free primary care visits, lab tests, preventive dental exams and annual physicals.
This is definitely one partnership to watch next year!
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CMS announced significant positive changes for 2021 Medicare Advantage (MA) plans, two of which are quite impactful for the home health industry. Supplemental MA benefits will be offered by more plans in 2021. This article covers the two broad categories of benefits:
All in all, this is big news, especially when coupled with the all-time high enrollment expected for 2021: 26 million, compared to 24 million in 2020. This is a good time for all agencies to begin crafting a plan to solicit contracts with MA plans in your area.
The article states the number of MA plans offering in-home care services will be finalized sometime in October, so be sure to check our blogs for any update.
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CMS announced numerous significant changes for Medicare Advantage (MA) plans that will positively impact members in 2021:
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On October 5, 2020, the Department of Health & Human Services announced that healthcare providers will be able to apply for a Phase 3 General Distribution allocation from the Provider Relief Fund. This allocation is available to providers who were ineligible from applying for earlier payments as well as providers who have already received Provider Relief Fund payments. HHS also expanded the eligible group of behavioral health providers, who are confronting increased mental health and substance use issues.
Because providers continue to struggle financially from COVID-related issues, the new distribution will include an additional two percent of annual revenue plus an added payment to compensate for revenue losses and added Coronavirus-related expenses.
Providers who began practicing between January and March of this year are now eligible to apply, and seem to be the first to be compensated.
The application window is from October 5 through November 6, 2020 and HHS is urging everyone to apply early.
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An interesting whitepaper from NavCare shed some light on the importance to the bottom line and patient outcomes of virtual visits and associated technology. In 2020, the perfect storm hit home care: the phasing in of the Patient-Driven Groupings Model (PDGM) and the COVID-19 pandemic. Declining patient visits and census due mostly to patients’ fear of exposure to COVID, scarcity of personal protective equipment (PPE), staff reluctance to conduct in-home visits and just the general effects on patient care (hospitals, physician practices, etc.) have profoundly threatened the very survival of home care agencies.
Although virtual visits cannot replace face-to-face (F2F) visits, a few changes due to COVID can be leveraged into positives for the industry.
Virtual visits for PCP F2F Encounters
In the past, home health agencies have had difficulty obtaining the required F2F visit from the patient’s primary physician. Without the documented visit, agencies could not bill Medicare. Virtual visits have lowered this burden. The article uses an example of a nurse setting up the patient’s virtual F2F visit and then attending the visit so as to dialogue with the clinician and receive his or her specific orders for home care. This delivers a win-win for everyone: the patient doesn’t need to leave his/her home; the nurse can dialogue directly with the clinician while expediting the agency’s billing; and the clinician can see the patient’s living environment, address any issues with the nurse in “real time,” and know that he or she has truly partnered with the agency on behalf of the patient.
Relaxed Homebound Requirement
Because of the pandemic, CMS has added to the homebound definition: patient feels at risk for contracting the virus that causes COVID. As the author states, “This essentially opens the door for any patient to be considered homebound.” For patients who may be postponing needed care, or whose families live far away and cannot travel during the pandemic, this development is a true game-changer: a professional can more readily evaluate mom or dad and coordinate needed care in the home.
Efficient Augmented Care
Virtual visits from certain home health agency professionals can supplement F2F visits in important ways that also happen to be cost-effective for the agency. Virtual technology can be employed to monitor a patient’s vital signs and virtual patient “check-ins” can allow a nurse, for example, to more frequently follow-up with the patient about his or her care. Therapists can also assess, for example, whether the patient is properly performing in-home exercises, which would normally require more frequent visits to the home. Virtual-ness, according to the author, makes the visit more efficient in staff travel costs and time, and also cuts down some of the chit-chat that occurs during a F2F visit, thereby expediting the encounter.
Improved Patient Satisfaction
Sometimes patients don’t want multiple home visits from all the professionals involved in their care, as is the case with my parents. COVID has exacerbated those feelings as primarily the elderly also fear exposure. Being able to touch base virtually to check on the patient’s progress toward his or her goals can still be accomplished with less hassle to the patient.
The article concluded that virtual visits represent a valuable tool in the home health bag and the author expects they will remain a key component in home health’s future.
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An article in Healthcare Finance News recounted a recently uncovered employee’s theft of patient information at a New York hospital over a period of two years. The breach of patient addresses, dates of birth and social security numbers was detected using technology that monitors improper access to electronic patient records. The employee had received “significant privacy and security training” but allegedly chose to violate policy and pilfer the information, and sadly, this hospital is not the first and probably won’t be the last to experience this type of electronic assault.
The author stated that HHS reported an increase in cybersecurity breaches in hospital and provider networks as hackers likely took advantage of COVID-related distractions. In addition, there was a 50% increase in breaches between February and May when compared to the same time last year.
Any provider type or size can be targeted by an unscrupulous individual on the payroll or from outside the organization, and should take immediate steps to increase security monitoring of all systems storing patient information.
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