Utilization Review (UR) for the Medicaid Hospice Program monitors and evaluates medical necessity and appropriateness on a concurrent and retrospective basis. Hospice eligibility, length of stay and Continuous Home Care (CHC) are part of the review.
As a consultant, I have the privilege of being invited into agencies throughout Texas to review their documentation and practices. What I frequently find is that agencies with a sincere desire to meet and exceed regulatory expectations are unintentionally missing a couple of the required elements for successful payment of claims. It’s very important to know that all rules carry the same legal weight. One single step left out of the process can lead to claim denials.
Here are a few of the lesser-known or overlooked details that lead to claim denials:
The agency must document why social work or chaplain services were needed and what was accomplished during continuous home care.
The plan of care must include the needs of the recipient; identification of the services, including management of discomfort and symptom relief; and the scope and frequency of the services needed to meet the needs of both the recipient and family.
Prior to providing continuous home care, the provider must advise and discuss with the family or responsible party that temporary alternate placement may be necessary at the end of the five consecutive days. The provider must document the discussion with the family or responsible party in the recipient's records.
The provider must have a physician's order and a documented medical need for skilled nursing care in the recipient's record and in the plan of care.
The services may be provided for up to five consecutive days. Extension requests may be filed
DADS defines a crisis as: A sudden paroxysmal intensification of symptoms that appropriate medical intervention and nursing services could reasonably be expected to ameliorate.
The Conditions of Participation do not allow Continuous Home Care for:
A patient who is imminently dying with no acute skilled pain or symptom management needs
For caregiver breakdown with no acute skilled pain or symptom management needs. If a patient’s caregiver has been providing a skilled level of care for the patient and the caregiver is unwilling or unable to continue providing care, this may precipitate a period of crisis because the skills of a nurse may be needed to replace the services that had been provided by the caregiver
Respite care
For safety concerns in the absence of a need for skilled interventions (for example: falls, wandering)
As an alternative to paid caregivers or placement in another setting
Continuous Care is not paid during an acute hospital stay, in a skilled facility or inpatient hospice facility stay (CMS Ch. 11 – See link below)
Continuous Home Care is a challenging care level to manage. Agencies should continually audit and monitor its practices related to Continuous Care as a component of their compliance and QAPI programs. Specifically, hospices should evaluate:
Policies and procedures related to CHC that include eligibility and documentation requirements;
Procedures for assessing and referring patients for CHC, obtaining physician orders and updating the patient’s plan of care
Billing staff regarding CHC billing/coding requirements;
Procedures related to ongoing discharge planning to ensure the patient returns to Routine Home Care as soon as feasible; and
Clinical records to ensure that documentation supports the patient’s need for continuous care on each day it is provided and that the care provided effectively addresses that need.
References:
http://tx.eregulations.us/rule/title40_chapter30_sec.30.54
http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/clm104c11.pdf