Arnie Cisneros’ How to Produce Audit-Free Home Care Programs

Today, I joined in a seminar with Arnie Cisneros, a 30-year physical therapist and HHA consultant. Arnie is renowned for his experience, knowledge, and development of key programs in the ADR and super-audit-scrutiny era. My notes are a bit spastic, but you can get the point. We can fill in the blanks where necessary. I enjoyed hearing that Arnie and his team are on the same page as our office with implementing major changes to survive in the new home care age.

Medicare has increased private audit contractors and scrutiny to a massively new level. Arnie talked about how during the 80s Medicare looked to shift patients from hospital stays to home care, then during the 90s from skilled nursing facilities to home care. But today the problem is home care, which is no longer so much cheaper than acute care or skilled nursing facilities. Medicare/CMS now wants to decreased the number of HHA providers.

ZPICs will audit ALL patients who receive 4 certification periods in 2 years. (There are 6 total periods a year, 12 cert periods in 2 years.) So, if your HHA does 4 cert periods for one patient in 2 years, you WILL be reviewed by an audit contractor. As we saw in the recent MedPAC report, Medicare is also trying to audit all non-post-acute home care certifications and to charge a copay for home health services that aren’t following a hospital stay.

The key concerns for audit/denial risk are: clinical expectations; objective findings (PT or nurse findings backed up by evidence); refusals / missed visits (you tell Medicare you prescribe 9 visits, and if you only make 5 visits, you should expect to be denied even the 5 visits, when you proposed 9); delay in care delivery (takes too long for SOC); appropriate care/documentation; discharge concerns (discharges must be skilled visits); improper med management; lack of objective OASIS ADL deficits for therapy (you must make the case for therapy in oasis); incomplete visit care delivery; early goal achievement (success can breed denials!); poor potential programs; orthopedic protocols (probably not covered); plateau in progress; contradictory documentation; lack of post-SNF clinical needs; lack of OT focus; reasonable & necessary; previous episodes; unnecessary programming.

KEY: Frequent flyers as we know them are going away.

In order to be successful in home care, you cannot just do what the doctor orders, what the SOC nurse orders, what the PT orders: you must do UR–utilization review. Whatever the OASIS data says is what your patient is. We must make our nurses and therapists make the case in OASIS for everything they do.

SURCH: Service Utilization Review for Care in the Home

Protocal: SOC date; age of patient; primary diagnosis of patient–focus M1000, M1100, M1240, M1400, M1610, M2020, M2030, M2040 (all Skilled Nursing (unless Therapy is involved))–Rehab Functions: M1810-1860 (all OT, OT/PT, PT).

Therapy and nursing focus in OASIS needs to show proper prior level of functionality and show a progression.

Another KEY: Clinical Control and Content & Staff Management. Must argue each patient case as a stand alone entity. Must argue from OASIS. Must have proper controls. Contant review utilization (utilization projections has about a 1 week shelf-life), in-episode care delivery (nurses round 2x a day in hospital–has to be more than what we’re doing in home care).

Focus for being paid is moving patients forward. Giving it the college try won’t cut it. We need to focus on outcomes–service + OUTCOME. Documentation needs to show compliance, caregiver involvement, and progression on a regulation basis. The service and the fact that we care only gets us in the door. We must identify success in objective clinical terms on a per-case basis. Finally, we have to focus on care completion after discharge.

Our HH managers need to get their fingers in the care plans and make these things happen. Arnie suggests a commonsense approach: What if you weren’t being paid and the patient was your aunt?

1. Correct OASIS data;

2. Nurse in the office figure out what Medicare wants based on OASIS data (QA or UR nurse);

3. Nurse figures out how field SN, HHA, PT, OT, etc., make this happen;

4. Realize that this process is good for 1 week and must be redone weekly.

This may result in plans that the nurse or therapist disagree with so they need to be moved in your direction. You may need to say, we will get together individually on a weekly basis and look at your charts/notes and see the 2nd and 3rd notes and make sure this is a real plan that will get your agency paid.

You can’t always use your full certification period every time–nursing home don’t; hospitals don’t. This is new to home care.

The auditors take a close look at the 485 and think this is how you get a full care plan and figure out how treatment will occur. This is a critical place they look to.

You need to pull reports on all SOCs. You have a lot of cultural changes to make in your therapists and clinicians.