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Pending a possible government shut down, this bill would allow documentation from a home health agency to be considered when records are reviewed. 

Late on Feb. 5, the U.S. House of Representatives introduced a “bipartisan” bill to avoid another government shutdown. While the big healthcare news of this bill was the elimination of the dreaded therapy cap, there were also many other notable provisions, including some that may be of interest to the home health-related RACmonitor audience.

First, as we all know, there has been a large number of home healthcare denials related to lack of documentation by physicians of the need for home care services and the lack of proper documentation of homebound status. Section 2202 of the aforementioned bill will allow documentation from a home health agency to be considered when records are reviewed. The bill states that “for the purposes of documentation for physician certification and recertification made under paragraph (2) on or after Jan. 1, 2019, and made with respect to home health services furnished by a home health agency, in addition to using documentation in the medical record of the physician who so certifies or the medical record of the acute or post-acute care facility (in the case that home health services were furnished to an individual who was directly admitted to the home health agency from such a facility), the Secretary may use documentation in the medical record of the home health agency as supporting material, as appropriate to the case involved.’’

If many auditors accept this addition to the regulation, it will relieve a large burden on physicians who now must follow complex rules and documentation requirements to ensure that each patient’s homebound status is documented to the satisfaction of even the pickiest auditor.

The next section, 2203, establishes a settlement process for pending home health denials. As described, this process will be very similar to the settlement process used by the Centers for Medicare & Medicaid Services (CMS) in 2014 for the thousands of hospital denials that were awaiting hearings at the administrative law judge (ALJ) level. It will be an all-or-nothing process, and although there is no set payment rate, the bill does note that “in selecting such percentage, the Secretary shall consider the percentage used under the Centers for Medicare & Medicaid Services hospital appeals settlement that began on Aug. 29, 2014.”

You may recall that the first settlement was set at 68 percent of the net allowable amount, so one can presume that CMS will use a similar value this time. While the number of claims for home health is likely significantly fewer than hospital claims, home health agencies are also smaller and less able to withstand the loss of revenue. That may make this settlement offer, once finalized, quite appealing.

Of course, this bill has several steps to approval, but I am sure that those in the therapy and home health worlds are hoping for passage. 


Ronald Hirsch, MD, FACP, CHCQM, CHRI

Ronald Hirsch, MD, is vice president of the Regulations and Education Group at R1 Physician Advisory Services. Dr. Hirsch’s career in medicine includes many clinical leadership roles at healthcare organizations ranging from acute-care hospitals and home health agencies to long-term care facilities and group medical practices. In addition to serving as a medical director of case management and medical necessity reviewer throughout his career, Dr. Hirsch has delivered numerous peer lectures on case management best practices and is a published author on the topic. He is a member of the Advisory Board of the American College of Physician Advisors, a member of the American Case Management Association, and a Fellow of the American College of Physicians. Dr. Hirsch is a member of the RACmonitor editorial board and is regular panelist on Monitor Mondays. The opinions expressed are those of the author and do not necessarily reflect the views, policies, or opinions of R1 RCM, Inc. or R1 Physician Advisory Services (R1 PAS).

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