Back-End Problems Continue to Haunt Home Health Agencies

Managing back-end operations is arguably as paramount to a home health agency’s success as the patient-facing, clinical aspects of the business. Even so, that task has often been put on the back-burner in the past.

But with the onset of no-pay RAPs, the Patient-Driven Groupings Model (PDGM), the Review Choice Demonstration (RCD) in select states and COVID-19, optimizing back-end functions has become less of a choice. That’s especially true for operators in Florida and North Carolina this August, with RCD slated to kick in come Sept. 1.

Generally, the best way to improve an organization’s own outlook starts internally, according to Melinda Gaboury, the CEO and co-founder of Healthcare Provider Solutions. Gaboury touched on optimizing back-end operations Tuesday at the National Association for Home Care & Hospice (NAHC) Financial Management Conference.


“I get emails and phone calls at least once a week from an agency saying that a physician is refusing to carry out a plan of care. How does that even happen?” Gaboury said. “It happens because you got a referral from the hospital that says the patient’s PCP is this [doctor], and nobody cared to pick up the phone and make sure the doctor knew he had a patient that was recommended home health. Nobody got his approval to actually carry out that case and home health episode.”

Nashville, Tennessee-based Healthcare Provider Solutions is a consulting company that helps home health and hospice agencies with billing, revenue management, coding and other areas of operations.

Just because an agency has the physician’s name does not mean that that physician has agreed to anything regarding the patient. That follow-up, while seemingly a small detail, is one of the key components to having a valid referral, Gaboury said.


“So you’ve got to make sure there are things in place to ensure that a physician is on board and taking care of this patient from Day 1,” she added. “This is not new, but continues to be a problem.”

While that’s an old problem that some agencies still haven’t gotten the hang of, there are new challenges on the horizon, including ones that could hurt providers if they don’t have their ducks in a row.

While non-physicians are now able to certify home health, clarification from the U.S. Centers for Medicare & Medicaid Services (CMS) keeps on popping up, including in the most recent home health payment rule proposal.

Specifically, CMS noted that the nurse practitioner has to be willing to conduct a face-to-face encounter, unless an agency is using a face-to-face encounter from a facility stay where the patient is being directly referred to home health, Gaboury said.

Right now, in RCD states, the pre-claim review (PCR) process is more lenient than that in some instances.

That sounds like a good thing on the surface, but may not be in the long run.

“Under PCR in RCD states, they are accepting things other than that,” Gaboury said. “And what scares me about that is that while they might be accepting it, auditors [may not]. And the reality is that if they don’t, you have nothing to stand on. … So regardless of what might be happening or what you might be getting away with, especially when it comes to PCR, you need to make sure that whatever you’re doing — especially at this moment in relation to face-to-face encounters — is specifically following the regulatory guidelines in the Medicare manual.”

RCD states include Illinois, Ohio, Texas, North Carolina and Florida.

For participating agencies, having no worker dedicated to these issues likely won’t be feasible or sustainable moving forward.

Even if one person is all an agency can afford, it would bode well for it to have a back-up plan, or someone else with the capability to manage and oversee these sorts of details.

“Some of you are going to be an agency that can’t afford one single person dedicated to orders management. I get it, but somebody has to have it as part of their job responsibilities,” Gaboury said. “There’s just no doubt that you need that. I’ve heard, ‘We have one person who’s responsible for this and she’s on a six-week maternity leave.’ That can’t happen. You’ve got to have processes in place.”

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