complaints (and subsequent law suit) to cms nomnc) end of hhabn_oct 29/o… · iahc october 29,...

IAHC October 29, 2013 Annette Lee of Provider Insights, Inc. [email protected]

1

Iowa Alliance for Home Care October 2013

1

Complaints (and subsequent law suit) to CMS regarding lack of communication with patients in home setting re: plan of care/discharge

HHABN- Home Health Advanced Beneficiary Notice

Expedited Determination Notices (Now NOMNC) ◦ Generic ◦ Detailed

ABN (Advanced Beneficiary Notice) and HHCCN (Home Health Change in Care Notice)

2


2

Formal documentation of conversations ◦ Protects patient and HHA

To inform: ◦ Services won’t be covered by Medicare- and shifts

financial liability (HHABN Option 1, now ABN)

◦ Services are decreasing (HHABN Option 3, now HHCCN)

◦ Services are stopping

HHA coverage assessment for patient (NOMNC)

For “cause” (safety, FTF, staffing= HHABN Opt 2, now HHCCN)

To allow appeal of Discharge (NOMNC/Detailed)

3

HHAs must provide notice Instead of Now Use

• When going to provide a service that is usually provided by Medicare, but you determine Medicare will not pay due to coverage factors (homebound, skilled need)

-Shifts financial responsibility

HHABN Option Box 1

ABN (CMS-R-131)

• Due to HHA’s decision not to provide care due to staffing, safety

HHABN Option Box 2

HHCCN (CMS-10280)

• Prior to reduction of services not anticipated in original POC, but now ordered.

-Could be a reduction in frequency of visits -Could be DC of one discipline, but other(s) continue

HHABN Option Box 3

HHCCN

• Discontinuation of all services due to coverage

-Goals met, or custodial level -Not Homebound

Notice of Medicare Non-Coverage (NOMNC)

Notice of Medicare Non-Coverage (NOMNC) 4


3

December 9, 2013 the HHABN is officially retired

May implement ABN and HHCCN now, but must use by December 9, 2013

The HHCCN is solely for HH ABN is used in many health care settings Both are for Medicare (FFS) patients

The NOMNC (Generic and Detailed) is still

current, and used for Medicare and Medicare Advantage plans

5

Forms must be maintained per standards ◦ One page- can be expanded to legal size to

accommodate agency info in header ◦ 12 pt font, same font as published (no bolding, italics,

etc) ◦ Insertions in blanks can be typed or hand printed ◦ Can color code- but must be lighter paper and dark font ◦ Can insert/pre-print common phrases “therapy ending” ◦ Both patient and HHA need copy. (can do many ways)

HHA must ensure patient/reps understand information provided ◦ Choose from English or Spanish ◦ Document any translation assistance used ◦ In-person delivery is preferable, but not required

6


4

7

(REMOVE LETTERS PRIOR TO USE!)

8


5

9

● Form # CMS-R-131, www.cms.gov/BNI

» You determine Medicare is not the expected payer because:

» Not medically necessary/custodial

» Patient not Homebound

» SN not intermittent

» Used for mandatory/voluntary liability notification for all Medicare FFS benefits

» Instructions for using revised ABN available in zip file with form, and updated Manual

10


6

● Required at initiation of care » When HHA expects Medicare will not cover any

item(s) and/or service(s) delivered under planned course of treatment from start of spell of illness, OR

» Before delivery of one-time item(s) and/or service(s) Medicare not expected to cover

» Example: Dually eligible patient at SOC, whom you do not plan on billing to Medicare because she goes to BINGO daily at Senior Center

11

● Reduction of Medicare Covered Care » Example: When you notify that therapy will be

ending due to a plateau, but nursing is continuing. » Provided an HHCCN to notify of reduction » If patient requests to pay privately for therapy to

continue, an ABN must be issued to shift financial responsibility

» End of Medicare Covered Care » Example: A patient has stabilized and no longer has

a skilled need. The patient still needs med set ups and wants to pay privately, or has another payer.

» Provided NOMNC to end Medicare, and ABN to shift financial responsibility for the upcoming services

12


7

13

14

● All information completed by HHA must be

» Legible

» Comprehendible for a patient

» Avoiding jargon, abbreviations

● Rationale for issuing ABN to ensure patient makes informed choice

» Must be able to understand information AND

» Reason why HHA issuing notice


8

15

● One-page notice with five sections

» 1. Header: area above the notice title

– HHA may add identifying information (name, logo,

billing address)

» Sections A-F and H can be pre-filled prior to visit

» 2. Body: describes services and rationale why

coverage is in question

» 3. Options: Patient has three responses to the notice

» 4. Additional Information: optional

» 5. Signature box/date

16


9

Agency’s name, address and telephone # ◦ TTY if applicable

May be included in a logo

May be typed, written, pre-printed on labels, etc

17

“B”- Patient name to include first and last ◦ Middle name should be used if on Medicare card

◦ Mis-spelled name does not “invalidate” notice, as long as patient recognizes name

“C”- Identification Number ◦ Optional use for agency tracking

◦ Medicare # NOT to be used

◦ Social Security # NOT to be used

18


10

19

May pre-print

HHA’s name

Provide clear, specific reason for non-

coverage Examples: “You can now leave your home unaided” or “You have met your goals.”

♦ Must describe items/services anticipated to be non-covered ♦ May use general descriptions (e.g. physical therapy)

♦ Language used must be understood by layperson (no

abbreviations; Examples: SN, OT, PT)

20

♦ Must give estimate of total cost of items/services listed in “D” section

♦ What amount would patient pay out of pocket? May be listed as a range, or as a maximum “Up to $500”

♦ Example: “$500 for 4 weekly nursing visits between 3/1 –

3/28/11.”


11

21

Services

The HHA can not choose or pre-populate the option for the patient

Option #1: Requests Medicare be billed for an “official determination” (condition code 20/demand bill).

Patient wants service- agrees to pay privately, but wants a Medicare decision in writing

This will also be used if the patient’s insurance to be billed requires a Medicare denial

Educate to use this choice for dually eligible patients when your state requires Medicare denial

22


12

#2: Patient wants services- acknowledges Medicare will not pay, and is not being billed ◦ Agrees to pay private

◦ Agrees to have other insurance billed (Can add in “Additional Information”, section “H”.

#3: Patient declines services- acknowledges Medicare will not pay ◦ Can not later appeal

23

24

Can document here when billing other insurance, Medicaid, etc.

Patient or representative. If Rep, should be noted as such. Print

name if illegible.

Patient or representative should date


13

25

26

Instructions for header info same as

ABN

Should be future date,

when changes will

begin

Explain what is being decreased or terminated.

Ex: On November 2, your occupational therapy will end, and on November 3rd, your nurse visits will decrease to twice a week.

Insert reason change(s) occurring. For Dr. orders, can state “Your doctor has changed your order for this care.” For agency related, be specific, “Your dog repeatedly threatened staff. We are unable to safely enter your home”


14

27

28

Could use this for additional information to assist patient. Could insert physician’s number, etc.


15

29

30

● Required at reduction of care

» When HHA reduces or stops some item(s) and/or service(s) during spell of illness, while continuing others

– Includes when orders for one home health discipline to DC, but others continue

– Includes a reduction due to shortage of staff

– Reduction was not planned

– Examples: Daily wound care, now 3x/week because caregiver able to now do other days; Therapy met goals early, and will DC, while nursing continues.


16

31

● Termination of care

» If patient discharged from Medicare services and no other care will occur due to:

» Not medically necessary/custodial/goals met

» Patient not Homebound

» SN not intermittent

» Give “Notice of Medicare Provider Non-Coverage” Form # CMS-10123 (Expedited Review), www.cms.gov/BNI/06_FFSEDNotices.asp

– Allows for appeal of discharge

– Used for traditional Medicare or Medicare Advantage

– See “Home Health Expedited Determination Process” at: www.cgsmedicare.com

32

● HHCCN should be used if DC for “cause”- the HHA determination of unsafe conditions, or unable to staff (Not Medicare Coverage related)

● HHCCN should be used if no FTF is obtained

● All cases where the patient can not appeal – so no Expedited Determination form used


17

● In addition to NOMNC form, ABN required

» When HHA ends delivery of either all Medicare-covered care, or all care in total AND

» Non-covered care continues, per patient choice

CMS also states that if services are ending with physician order changes, a NOMNC must still be provided and the HHCCN may also be provided, but is not necessary

33

When can a patient appeal after a notice? 1. Agency gives HHCCN because of no FTF

2. Agency gives Notice of Non-Coverage due to assessment that the patient is no longer HB

3. Agency gives ABN at start of care because the patient is not HB- and their other insurance will pay, so patient chooses Option “2”

4. Agency gives HHCCN because the Dr ordered discontinuation of physical therapy

34


18

Color coding of notices forms helpful

ABN= Green like $$

HHCCN= Yellow like Caution – slowing of services, or yielding of some services, or stopping of services due to agency decisions

NOMNC= Blue

35

Which form is used to notify a patient when a HHA is Discharging because the home environment is so unsafe. 1. ABN

2. HHCCN

3. Notice of Medicare Non-Coverage

36


19

37

● Entire ABN must be completed

» HHA responsible for ensuring complete, correct, valid information

– If not, ABN may be voided

● Results in HHA, not patient, liable for non-covered Medicare services

● Must use choice of Option #1

» May only submit demand bill if patient authorizes billing Medicare

38

● Reviewed first for reason listed on Advance Beneficiary Notice (ABN)

» If reason for no payment by Medicare fully supported in medical record, no further review

» If no ABN sent or ABN reason not supported, or valid, record fully reviewed

– Denied if

● Conditions for payment or Medicare coverage guidelines not met


20

Home health and hospice agencies use

Two parts: Generic and Detailed ◦ Detailed Notice- provides patient and QIO with

more information on why discharge

Updated for May 1, 2012- FFS and MA plans

Notice provided when all care ending ◦ For reasons such as no longer HB, goals met, no

skilled services ◦ Exception: Pt chooses discharge, DC for cause, no

FTF completed

General- two day minimum notice of discharge ◦ Allows patient to appeal discharge to QIO ◦ QIO notifies HHA

39

40


21

Must be provided at LEAST two days prior to discharge date ◦ Should not be a surprise

◦ Can be given more than two days

Allows patient to appeal the discharge ◦ If patient gives you feedback that appeal likely- do

the Detailed Notice

41

Additional form/info regarding patient specific reasons for discharge

If patient appeals, QIO will notify HHA- must visit patient to deliver/discuss the Detailed Notice- send to QIO ◦ Could anticipate if patient indicates desire to

appeal, and provide at that time

Ensure very SIMPLE language– the key is that there is no question it is understood by patient

42


22

43

What if you find yourself at the last visit, and the notice has not been given yet?

CMS OASIS Q&A Question (Category 4, Q 19.4) ◦ www.oasisanswers.com/aboutoas_links.htm

States the assessment visit can be completed today

Provide notice today

Do not “complete” DC assessment (M0090) for two days

If no changes, and discharge OK in two days- complete M0090/M0906

44


23

45

complaints (and subsequent law suit) to cms nomnc) end of hhabn_oct 29/o… · iahc october 29,...

Documents