HCA and Providers Gather to Address Home Care Financial Challenges

Nearly 100 home health CFOs and CEOs assembled in Saratoga this week for HCA's Senior and Financial Managers Retreat, a program designed to help agencies navigate thorny reimbursement issues and surmount other financial challenges intrinsic to the delivery of home care services in New York.

Managed Care Issues

The two-day Senior and Financial Managers Retreat, held at the Saratoga Hilton, began on August 7 with a slate of programs that zeroed-in on ways home care agencies can improve their experiences with managed care plans.

HCA developed the program agenda in response to member concerns about the ongoing challenges faced by the home care community in their interface with managed care organizations. These challenges include: payment denials for services; difficulty obtaining prior authorization especially when a plan's staff are unavailable but a patient's need for home care services is urgent (i.e., when a patient is approved for discharge from the hospital and the physician's order calls for home care services over a weekend); difficulty identifying where to direct required prior authorization requests when a patient's enrollment in a managed care entity is unknown; and discrepancies over contracted payment terms for covered services.

Leading off the program was Jeff Gold, Vice President of Managed Care and Special Counsel at the Healthcare Association of New York State, who highlighted different strategies, tools and resources hospitals have learned to use to enhance their market leverage and negotiating strength with managed care organizations.

Mr. Gold offered many specific recommendations for positive changes that home care agencies can adopt in their interface with managed care organizations. Specifically, Mr. Gold advised providers to assemble a Claims Denial Management Task Force within each agency — much as some hospitals have done — to identify and repair internal practices that may result, or already have resulted, in managed care claim denials.

Meanwhile, he said, any "risk points" uncovered through the process of internal review should be communicated to direct-care personnel in the field, averting possible claim-denial vulnerabilities at the point of care delivery.

Building on Mr. Gold's presentation, panelists from three HCA provider agencies also shared lessons learned from their experiences identifying ways home care can use its leverage in managed care negotiations.

Mary Ellen Connington, Vice President of Managed Care for Visiting Nurse Services of New York, said communication between provider and payor is key. She noted that home care agencies should look to their inherent leverage by showing managed care plans that a cooperative relationship can be mutually beneficial.

Ms. Connington, a nurse by trade who in the past has worked both on the provider and managed care sides of the equation, also noted that agencies can better learn the rules by tapping into the flow of industry-related policy communications from state government regulators to managed care companies.

Thursday's HCA-member panel session was moderated by HCA Board Member Mark Murphy, Vice President for Case Management and Ambulatory Services at St. Joseph's Hospital Health Center Certified Home Care. Panelists also included HCA Board Member Laurie Neander, CEO of At Home Care in Oneonta, and Hector Rueda, Senior Vice President of Operations and Finance of VNS in Westchester.

Mr. Rueda advocated for a strong system of internal review and early claims submission in order to avert possible denials. Ms. Neander noted that early submission of claims can be aided by emerging technologies, such as laptops and wireless devices used by clinicians in the field for transmitting case information to an agency's records system. With state-mandated Administrative and General (A&G) expenditure caps, and other cost challenges, Ms. Neander also recognized the limited capacity of some agencies to hire new administrative staff for the purpose of resolving claims issues with managed care entities.

State Regulators and Stakeholders

Conference attendees on Thursday also learned that state regulators are available to serve as a resource in navigating managed care relations. Vallencia Lloyd, Deputy Director for the Division of Managed Care in the State Office of Health Insurance Programs, and Troy Oechsner, Deputy Superintendent for Health from the State Insurance Department, offered their assistance on regulatory compliance issues with respect to managed care plans.

Ms. Lloyd's office provided specific guidance on the issue of enrollee verification and the Department of Health's transitional care policy, applicable to patients who have moved from Medicaid fee-for-service to Medicaid Managed Care - a trend that will likely continue for medically needy patient populations, according to recent state policy directions.

The Division of Managed Care advises agencies to verify patient enrollment with the Medicaid Eligibility Verification System on the first and tenth of each month. For patients identified as having switched enrollment from fee-for-service to managed care, agencies should notify the new plan that the patient is receiving home care services in order to assure prior authorization and avert potential claim denials in the future.

Ms. Lloyd's office also noted that a health plan must authorize care for a transitional period of 60 days from the effective date of new plan enrollment if a patient elects to continue receiving care from a non-participating provider for "a life threatening disease or condition, or a degenerative and disabling disease or condition," according to a letter issued by the Department of Health (see related article on page 5).

The afternoon panel discussion, entitled "Stepping Up to the Challenges of Home Care Managed Care — Insights from Stakeholders and Regulators," also included Paul Macielak, President and CEO of the New York Health Plan Association. Mr. Macielak offered further insight into the perspectives, expectations and constraints of managed care plans and offered to work collaboratively with HCA on issues pertaining to provider interactions with managed care.

Business Community Involvement

Day one of HCA's Senior and Financial Managers Retreat concluded with a presentation by Westchester County Association President William Mooney who invited the home care provider community to engage New York's non-health-care business community in advocating for an environment of improved managed care market practices.

Mr. Mooney described his association's work to seek changes at the state level after the business community in Westchester County began to realize the impact of managed care on the home care infrastructure in the county. Mr. Mooney emphasized the need for home care agencies to work with business community members who can assist in communicating to policymakers the need for a strong health care infrastructure in their communities, including a health insurance structure where more of the premium dollar is devoted to care.

HCA Managed Care Legislation

Addressing many member concerns related to difficulties in working with managed care organizations, HCA has collaborated with Senator Kemp Hannon on legislation (S.8091) that would take a first step toward improving the position of home care agencies in their interface with managed care plans. Specifically, the HCA-backed bill would:

• Strengthen health plan/home care provider contract terms by adding as a contract term the specification of the method and criteria by which nursing, therapy and aide services will be authorized and reimbursed, including emergency referrals or other referrals for care on a time-sensitive, expedited basis, as contained in a plan of care authorized by the patient's physician. This provision would mitigate a major concern of home care providers that was discussed during the Senior and Financial Managers Retreat.
• Require that managed care contract terms clarify the care management responsibilities between the health plan and the home health agency — assuring that home care providers retain the responsibility.
• Require enrollee information to include a description of home care services offered in the plan, as well as highlight for providers how those services will be authorized and paid.
• Ensure that home care patients have access to the expedited internal and external appeal processes in cases where home care services have been denied. This provision also would address a pressing concern of agencies that participants at the Senior and Financial Managers Retreat discussed with the presenters.
• Require the Commissioner of Health, in conjunction with the Superintendent of Insurance and stakeholders (including home care providers), to establish protocols for the HMO to notify home care providers when individuals covered under Medicare or Medicaid enroll in the HMO. The provision would greatly reduce and prevent confusion, payment disputes and coverage gaps when the coverage of such individuals changes from fee-for-service to managed care.
• Require the Commissioner of Health, in consultation with the Superintendent of Insurance and stakeholders, to examine and strengthen the standards for the marketing of HMO contracts so as to promote informed decision-making by consumers, particularly Medicare beneficiaries.

This legislation will continue to be a centerpiece of HCA's managed care advocacy program.

Day 2: Federal Issues

HCA's Senior and Financial Managers Retreat resumed today, August 8, in Saratoga with a presentation on the latest federal issues affecting agency finances by William Dombi, Vice President for Law at the National Association for Home Care & Hospice (NAHC). Consultant Rhonda Will of Fazzi Associates also provided guidance on maximizing agency success in the Medicare Prospective Payment System (PPS) environment.

Mr. Dombi discussed the home care community's challenges in the federal policy arena, specifically mentioning the recent Medicare legislation, which was passed and overwhelmingly supported in a bipartisan fashion by members of the U.S. House of Representatives and Senate. The legislation preserves the full Medicare home health market basket update for providers.

Mr. Dombi also highlighted HCA's support and aggressive advocacy for the preservation of the update factor during Congressional consideration of the bill, which was vetoed by the President last month but overridden in both Houses of Congress. In addition, Mr. Dombi highlighted the need for continued advocacy on the NAHC and HCA-supported legislation that would reinstate the five percent rural add-on to Medicare payments. This has not yet received Congressional action.

Mr. Dombi also discussed NAHC's support for New York State's Third Party Liability Demonstration program, which was not granted a Centers for Medicare and Medicaid (CMS) extension. HCA has advocated strongly to CMS and New York's Congressional Delegation for an extension of this important program, which significantly reduces the administrative burdens and financial liability of providers when trying to determine the appropriate payor for cases involving patients eligible for both Medicare and Medicaid. Should a legislative vehicle become available, Mr. Dombi indicated that NAHC would assist HCA in efforts to legislatively direct CMS to make the program permanent.

Concluding the program was a presentation by Rhonda Will, RN, BS, on the "First Six Months of PPS." Ms. Will presented survey results and data on the PPS experience, as well as data and examples concerning the connection between the clinical and fiscal aspects of the OASIS.

Her examples showed how clinical and functional accuracy led to more accurate payment, with implications for significant payment differences. She challenged agencies to review their own confidence levels as to whether internal functions and clinical leadership were producing the appropriate results.

Ms. Will also reviewed various benchmarks as well as Fazzi audit results for 2008 concerning a range of factors, including case-mix weights, effects of correcting OASIS response items, and OASIS items most likely to be changed post audit, among others. Throughout her presentation, she stressed the importance of careful consideration of patients' therapeutic needs as well as thorough documentation regarding patients' needs for services generally.

For more information, please contact a member of HCA's Policy staff.