HHRG and medicare billing

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    I was a home health field nurse for 2 years and I am familiar with the OASIS and HHRG scoring. I also understand HHRG was initiated in 2000 to establish a set payment after assessment of the patient so the HH agency could manage their care within that episode. I am now the HH Case Manager for a medicare advantage plan which follows the same exact medicare guidelines. I have been reading (and someone please help if you can) that all disciplines must complete their assessement of the patient for the accurate HHRG within 5 days of the first episode day........The problem I am having is that some agencies will send in an initial HHRG after the first OASIS (with a low score) after only the RN has seen the patient and get their authorization.....After that, they send in therapy evals and by the time they bill, there is a huge difference in payment request........Some are even doing therapy evals 21 days into the episode!......That can't be right, can it?........My agency that i worked for had all evals completed within 5 days, no if's and or but's........
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  4. 9 Comments so far...

  5. 0
    I'm not all that familiar with the HHRG, but I believe I understand what you're saying. Our docs always add the therapy and/or HHA requests to their referrals, so we know when the RN goes out to do the SOC, that this pt will be/not be a PT/ST/OT candidate. Our therapy referrals are made within that 5 days window.

    That said.. there ARE times, however, that as the nurse continues to see the pt, and she notices that the pt. is realy more feeble or weak than initially thought, she can still request therapy at a later date, too... in other words, it's not always set in stone that therapy can only be requested the first 5 days.... (although this is usually the case).

    I have also heard that we might be getting away from the "lump sum" payment for services and going back to the previous version of "pay for service".. where the agency can bill for the exact services they provide... whether it's 3 visits a week or seven visits a week. I believe this is how it used to be some years ago... and I believe we're headed back to that agin in the near future.
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    The 5 days has to do with whether the PT/OT/ST frequencies will be included on the 485. If those evals are not completed within the 5 days they cannot be included in the start of care and an order must be written to initiate these services. And thus the HHRG score is affected negatively and the payment may also affected.
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    CMS is now automatically adjusting payment at the end of the episode based on how many therapy visits were actually done. This does nothing to help with utization review at the beginning of care, but at least the payment will be correct in the end.

    I have not heard anything about "pay for service", but have heard rumors that "pay for performance" is coming, in which you are reimbursed based in part on your outcomes, ACH rates, etc. This has been rumored for a long time.
    RNRutRO likes this.
  8. 0
    From what I have learned about OASIS C, the "pay for performance" is her--JAN 1st. There is more details on admit OASIS and then the d/c OASIS is more detailed also. The RN's will really no longer be able to do just a SOC and D/C since the pay will be based on the outcome.

    If someone else knows something different, please share
  9. 1
    Quote from RNRutRO
    From what I have learned about OASIS C, the "pay for performance" is her--JAN 1st. There is more details on admit OASIS and then the d/c OASIS is more detailed also. The RN's will really no longer be able to do just a SOC and D/C since the pay will be based on the outcome.

    If someone else knows something different, please share

    I have taken a two day course on transitioning to OASIS-C in addition to participating in the CMS training sessions and have heard nothing like this. The new process measure questions will be publicly reported as outcomes currently are.

    Perhaps your agency is reviewing their reimbursement policies in some way so that the actual clinicians will not be reimbursed for poor patient outcomes and clinical performance, but CMS has not changed their reimbursement system at all. We are still on PPS, payment based on HHRG scores. In fact, the OASIS-C was designed in such a way that reimbursement should not be impacted at all.
    RNRutRO likes this.
  10. 0
    Thanks for your input. I wonder if we are getting mis-information. What about "out lyers" patients? The 3-4 time a day diabetic patients? What are other agencies doing with those patients. From what we've been told, this is a change that has happened in the last 6 weeks.
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    To my knowledge, there is absolutely no change in reimbursement methods or Medicare guidelines. There should be no impact whatsoever in the way we manage our patients other than implementing some Best Practices related to the OASIS-C process measure questions.

    BTW, the Best Practices are not required, but response to related OASIS questions is, and these process measures will be publicly reported, so it would seem foolish not to initiate them (if your agency hasn't already).
  12. 0
    HmarieD-

    Not sure if your agency has out-lyer patients or not. If so, according to what we've been told, it can only make up 10% of your revenue. Our agency has about 40%--so we are trying to figure out what to do with these patients. It's sad. Honestly, there are no alternatives---except nursing homes. We have several diabetic patients that are seen more than once a day. And all of the RN's have tried to work with diet/medication management to decrease this. But as you and I know, some people just can't go without 4 x's a day injections.

    If you do not have these types of patients, then you are right, it should not change your reimbursement. In fact, we were told in our OASIS C class, that we should expect about a $10 per patient increase. Of course that will be eaten up in the customer survey.

    Ahhh, doesn't everyone love change?
  13. 0
    We have a few outliers, but well within 10% of our census. Hadn't really thought about that aspect.

    Two heads are always better than one.


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