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Re- Certification/s and Focused Medical Review Part 1

Re- Certification/s and Focused Medical Review Part 1

Agency: My patient population is sicker than everyone else in the County, State, and Country!

CMS: No problem; send us 30 charts and prove it- 

And the audit begins…

The supreme court affirmed more than once that chronic care for Medicare beneficiaries is valid. Re-Certification of patients is permissible; I would say encouraged when the situation warrants such. It is the creation of the proper“Situation” that most agencies are failing to establish.

There is no problem having data metrics in your profile that sit well outside of what CMS perceives to be the norm as long as you can explain them in a convincing compelling manner. The most costly problems only start when you cannot.

Why do agencies with recertification rates of 50 plus percent do so well during audit, whilst others who have the same rates or half that of their peers struggle, fail, and go bankrupt in an audit?

The answer: MARKETING, Patient Management, Census Management, Acuity, Diagnosis + Comorbidities, FCD of services. As we discussed in the CBR report article it is imperative that you know your data profile/s, and actively manage them and the patients you serve. .

A client a few years back had an 84% re-cert rate before the ZPIC came knocking. We fully expected the knock, knew it was just a matter of time and prepared for it just as one would prepare for state survey, but with a twist. This Survey Prep focused on the Conditions of Payment not the Conditions of Participation. Good survey prep makes for good surveys always has always will, no real surprise here.

The agency owner buried deep in a concentrated market also understood the rule of three perfectly. As such a primary service line was created for an underserved population in the county served. Re-Certifications were the norm with this service line. When ZPIC contractors wanted an explanation, it was easy to provide with minimal audit losses. What this agency did not do was rely on teaching and training as the primary service line. Neither do I say most, yet an in depth examination of clinical notes often reveals a very different and costly fact. A financial bomb waiting for the pin to be pulled.

Payment denials frequently cite “repetitive teaching” and “simplistic teaching” when issued, any agency entangled in FMR will tell you this. The "teaching and training not reasonable and necessary" denial is second only to the face-to-face denial after the first two levels of appeals are done and the QIC has issued an opinion.

Medicare states the following with great clarity:

In determining the reasonable and necessary number of teaching and training visits, consideration must be given to whether the teaching and training provided constitutes reinforcement of teaching provided previously in an institutional setting or in the home or whether it represents initial instruction.”

Where the teaching represents initial instruction, the complexity of the activity to be taught and the unique abilities of the patient are to be considered.

Where the teaching constitutes reinforcement, an analysis of the patient's retained knowledge and anticipated learning progress is necessary to determine the appropriate number of visits.

Skills taught in a controlled institutional setting often need to be reinforced when the patient returns home. Where the patient needs reinforcement of the institutional teaching, additional teaching visits in the home are covered.

Re-teaching or retraining for an appropriate period may be considered reasonable and necessary where there is a change in the procedure or the patient's condition that requires re-teaching, or where the patient, family, or caregiver is not properly carrying out the task. The medical record should document the reason that the re-teaching or retraining is required and the patient/caregiver response to the education.

The documentation must thoroughly describe all efforts that have been made to educate the patient/caregiver, and their responses. The health record should also describe the reason for the failure of the educational attempts.

What foundation have you established-

Are your Re-Certifications as defendable as you believe them to be-

What are you doing to prepare for the audit scheduled to come...

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