Managing back-end operations is arguably as critical to the success of a home health agency as the clinical aspects of the business facing the patient. Even so, that task has often been put on the back burner in the past.
But with the inception of non-paid RAPs, Patient Driven Clustering Model (PDGM), Review Choice Demonstration (RCD) in select states, and COVID-19, optimization of back-end functions has become become one less option. That’s especially true for operators in Florida and North Carolina this August, and the RCD is scheduled to go live on September 1.
Generally, the best way to improve an organization’s outlook begins internally, according to Melinda Gaboury, CEO and co-founder of Healthcare Provider Solutions. Gaboury spoke about optimizing back-end operations Tuesday at the National Association for Home Care and Hospice (NAHC) Financial Management Conference.
“I receive emails and phone calls at least once a week from an agency telling me that a doctor is refusing to carry out a plan of care. How is it possible that this happens? “Gaboury said.” It happens because he received a referral from the hospital that says the patient’s PCP is this [doctor], and no one bothered to pick up the phone and make sure the doctor knew he had a patient who was referred for home care. No one got his approval to carry out that home health case and episode. “
Nashville, Tennessee-based Healthcare Provider Solutions is a consulting firm that assists hospice and home health agencies with billing, revenue management, coding, and other areas of operations.
Just because an agency has the doctor’s name does not mean that the doctor has agreed to anything with respect to the patient. That tracking, while apparently a small detail, is one of the key components to having a valid reference, Gaboury said.
“Therefore, you need to ensure that there are measures in place to ensure that there is a doctor on board and that he sees this patient from day one,” he added. “This is not new, but it is still a problem.”
While that’s an old problem that some agencies haven’t gotten used to yet, there are new challenges on the horizon, including some that could hurt providers if they don’t have their ducks in a row.
While non-physicians can now certify home health, clarifications continue to appear from the U.S. Centers for Medicare and Medicaid Services (CMS), even in the most recent proposal for health payment rules. In the home.
Specifically, CMS noted that the specialist nurse must be willing to conduct a face-to-face meeting, unless an agency is using a face-to-face meeting from a stay in a center where the patient is being referred directly to health services in the center. home, Gaboury. saying.
Right now, in RCD states, the pre-claim review (PCR) process is more lenient than that in some cases.
That sounds like a good thing on the surface, but it may not be in the long run.
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“Under PCR in the RCD states, they are accepting other things besides that,” Gaboury said. “And what scares me about that is that, while they may be accepting it, the auditors [may not]. And the reality is that if they don’t, you have nothing to stand on. … So regardless of what may be going on or what may be getting your way, especially when it comes to PCR, you need to make sure that whatever you are doing, especially right now in relation to the face-to-face face encounters – you are specifically following the regulatory guidelines in the Medicare manual. “
RCD states include Illinois, Ohio, Texas, North Carolina, and Florida.
For the participating agencies, not having any dedicated workers on these issues will probably not be feasible or sustainable in the future.
Even if one person is all an agency can afford, it would bode well for them to have a backup plan, or someone else with the ability to manage and monitor these kinds of details.
“Some of you are going to be an agency that cannot pay a single person dedicated to order management. I understand that, but someone has to have it as part of their job responsibilities, ”Gaboury said. “There is no doubt that you need it. I heard: ‘We have a person who is responsible for this and is on maternity leave for six weeks.’ That cannot happen. You must have established processes. “