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Important Alert for All Home Health Operators Regarding Plan of Care and Condition of Payment

Posted on Saturday, January 12, 2019 5:24 PM

Starting January 13, 2018, the “Plan of Care” (POC) Condition of Payment under 42 CFR 484.60 also became a Condition for Payment under the home health benefit, 42 CFR 409.43.  If all elements are not in the POC, then Medicare will deny payment.  One of the new POC requirements has created problems for many HHA s that may not have modified their POCs sufficiently to meet the new POC requirements. A compliant POC for payment purposes must now include “information related to any advance directives.”

NAHC is advocating to CMS that a broad-scale, efficient remedy needs to be implemented given the apparent widespread oversight by HHAs. These HHAs do appear to have obtained all the needed advance directive information. It is just that the information did not fully find its way to the POC.  At this point, CMS has not agreed to any remedial measures other than potentially hundreds of thousands of individual claim corrections.

In the absence of a systemic fix, the noncompliance puts HHAs at risk of further audits and the likelihood of a high volume of retroactive claim denials. However, there is still an opportunity to correct these POC deficiencies. Still, that opportunity will be shrinking as claim corrections must be filed prior to the close of the one-year window for claim submissions that will begin to close on January 13, 2019. 

1. Review January 13, 2018 and later POCs to determine if they are compliant. For example, a POC will not be compliant on the Advance Directives requirement if the only entry references whether or not the patient has a Do Not Resuscitate (DNR) order as there are more types of Advance Directives than just DNRs.

2. If you find non-compliance, review the patient record to determine if the needed information is available. For example, the OASIS info should include Advance Directive detail.

3. For non-compliant claims, secure a signed POC addendum from the certifying physician that includes the required information for the POC.

4. Submit corrected claims to your MAC. One of the MACs is accepting these corrections without a need to cancel the original claim and submitting a rebilling as there is no reimbursement effect. We expect the other MACs will do the same. The corrected submissions can be done sequentially over the next twelve months so that the administrative burden is spread out consistent with the one-year window on claim submissions. It is advisable to get your MACs take on how to handle corrections before proceeding.

These are the updated responses we have from MACs so far:

National Government Services, Inc. is not denying claims for lack of detail about particular Advanced Directives on the Home Health Plan of Care. The Home Health Conditions of Participation 42 CFR 484.60 state the Plan of Care must include “Information related to any advanced directives.” If a Medicare beneficiary has advanced directives, a home health agency is advised to indicate this on the Plan of Care, which signifies that the specific directives from the beneficiary have been obtained and documented in your records. It is not necessary to duplicate those specifics on the Plan of Care. If a Plan of Care is updated with an addendum to show advance directive information, it is not necessary to submit adjustments to processed claims. 

Palmetto said that providers should update plans of care with advanced directive information as suggested previously.  Again, the information that is being accepted on the plan of care is the type of advanced directive not the detail of what the advanced directive states.  For instance, an indication that the patient has advanced directives including a Living Will and Durable Power of Attorney (and any other advanced directive) is enough.  The plan of care does not need to contain the details of the Living Will, etc.

Source: NAHC

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