Missing items on the POC

When the Plan of Care is missing some required elements, is it a survey issue or a claims issue?

When a home care provider fails to include certain items required by Medicare regulations in a patient’s plan of care (POC), should the penalty be a survey citation or a claim denial?

The Centers for Medicare and Medicaid Services (CMS) is re-thinking this issue, proposing to tweak some wording in home health regulations so that otherwise eligible claims won’t be rejected when items are missing from the POC.

Home health agencies would still have to answer for failing to include required items such as information about a patient's advance directives or potential for rehabilitation, but the reckoning would come later, when surveyors note the missing items, rather than when reviewers look at the claim.

“We believe that violations for missing required items are best addressed through the survey process, rather than through claims denials for otherwise eligible periods of care,” CMS states in the proposed Final Rule for 2020 made public last week. (View the document in its entirety here.) Here's what would change

Specifically, CMS is proposing to rewrite §409.43(a) in Medicare’s Conditions of Participation to state that the home health plan of care contents must include services necessary to meet patient-specific needs which have been identified in the comprehensive assessment.

Currently, §409.43(a) states that, for Medicare eligibility, the plan of care must contain all items listed at §484.60(a). The list of required items for the POC at §484.60(a) is lengthy and has been growing in recent years. Two new items – a risk assessment for hospital readmission with appropriate interventions and information about advance directives – were just added at the beginning of 2018.

Under the proposed regulations change, an agency's claim would not be rejected even when the POC lacks one or more of those items as long as the rest of the submitted claim meets eligibility standards.

“CMS has said it believes the current requirement may be overly prescriptive and may interfere with timely payment for otherwise eligible episodes of care,” said J’non Griffin, owner and president of Home Health Solutions.

Under the revised wording at §409.43(a), reviewers would determine the validity of a claim in part by looking within the POC for patient-specific needs, how those needs were determined during the comprehensive assessment, and how the home care provider intends to provide specific services to meet those needs.

The POC must identify the disciplines responsible for providing home health services, the frequency and durations of all visits, and items required by the CoPs that establish the need for those services (§484.60(a)(2)(iii) and (iv). “All care provided must be in accordance with the plan of care,” J’non added.