Carrier and Intermediary Medical Review quarter, 100 percent of admissions to that facility are reviewed in the subsequent quarter. To identify utilization and quality-related problems in skilled nursing facilities, intermediaries have developed a range of procedures and protocols which may include examination of diagnostic codes, hospital length of stay, nursing facility length of stay, or patient outcomes (such as readmissions to acute care hospitals or deaths). The identification of quality of care issues is typically a byproduct of the prepayment and postpayment reviews. There are no official guidelines for identifying premature hospital discharges, but if one is suspected, intermediaries are required to report it to HCFA. Intermediaries can report suspected premature discharges identified in reviews directly to the local PRO, but this is not required by HCFA. Intermediaries are instructed to report these cases to the HCFA regional office, which then is to report the cases to the PRO.14 Home Health Review Like the nursing home benefit, the home health benefit is directed primarily at patients recovering from acute episodes and is used by only a small proportion of Medicare beneficiaries.15 Medical review of home health claims (about 5 million bills per year) is designed to promote consistent coverage decisions and minimize payment for noncovered services.16 Intermediaries review about 52 percent of all home health bills. The information for coverage determinations is drawn from the standardized plans of treatment that providers submit with the basic billing forms, but intermediaries may also request additional information or copies of medical records. Postpayment reviews are performed to ascertain whether plans of treatment and providers' medical updates match the information contained in patients' medical records. Annually, the 14This policy was clarified in a memorandum sent to HCFA regional offices on December 14, 1987. (See appendix VII.) 15 According to the Commission on Professional and Hospital Activities, about 5.4 percent of 1984 Medicare discharges were reported by hospitals to be discharged to home health care; some of these may not have been to Medicare-covered home health care. (Otis R. Bowen, M.D., Secretary of Health and Human Services, Report to Congress: The Impact of the Medicare Hospital Prospective Payment System, 1985 Annual Report, draft 1987.) 16 Medicare payment for home health care is limited to situations where the patient has an acute condition; covered services are limited to people who are confined to their homes under the care of a physician and in need of part-time or intermittent skilled nursing care or physical or speech therapy. When provided in conjunction with skilled nursing care, home health aides, occupational therapy, medical supplies, and the use of medical equipment may also be covered. The services must be furnished under a plan of care prescribed and periodically reviewed by a physician. Carrier and Intermediary Medical Review Comprehensive Outpatient entire medical records of 20 randomly selected beneficiaries per provider are reviewed on site to determine the accuracy of the information reported to HCFA and to identify inappropriate or noncovered care for which claims should have been denied. If reviewers find evidence of poor or questionable quality of care, they are instructed to report this information to the HCFA regional office. The intermediaries reported to us that they use a variety of optional edits or screens to identify possible utilization problems, such as screens that flag cases with high numbers of home health visits for particular diagnoses, claims for services that were previously denied, or claims indicating high costs for supplies. They do not generally employ screens specifically designed to identify quality of care problems. Comprehensive outpatient rehabilitation facility claims are reviewed in 17 Covered services include speech, occupational, physical, and respiratory therapy; social and psychological services, drugs and biologicals which cannot be self-administered; and prosthetic and orthotic devices and training in the use of these devices. These services are covered only if they would be covered as an inpatient hospital service. They are not covered if they are determined to be unnecessary or not reasonable for the diagnosis or treatment of illness or injury or to improve the function of a malformed body member. Also, there must be some potential for restoration or improvement of lost or impaired functions associated with use of the service. 18 HCFA records do not distinguish outpatient rehabilitation bills so as to provide numbers of payments to comprehensive rehabilitation facilities. Altogether, HCFA processed about 6.3 million comprehensive outpatient rehabilitation facility, occupational therapy, and physical therapy claims in 1987; about 5 percent were subject to medical review. Identifying a comprehensive outpatient rehabilitation facility is complicated by the fact that these facilities may also be home health agencies or medical equipment suppliers. Carrier and Intermediary Medical Review Part B Intermediary Although guidelines for intermediary review of outpatient physical therapy claims have been developed and published in the Intermediary Manual, systematic screening of these claims has not yet been implemented.19 HCFA guidelines issued in November 1986 would require intermediaries to apply 67 HCFA-developed screens to all outpatient physical therapy bills under Medicare part B that are submitted by skilled nursing facilities, hospital outpatient departments, and home health agencies that do not provide physical therapy in addition to home health services, or other outpatient rehabilitation agencies.20 These screens are designed to ensure that payment is made only for services that are necessary or reasonable and that are provided by qualified skilled therapists.21 The screens are based on diagnostic codes, duration and frequency of treatment, and date of onset of illness or symptoms.22 Any bill failing a screen would be reviewed by the intermediary's medical review staff, preferably by physical therapists. HCFA also developed criteria for determining whether physical therapy services are covered. This involves reviewing a 10-percent sample of bills that pass all the initial screens. As with comprehensive outpatient rehabilitation facility claims, the emphasis is almost exclusively on the identification of unnecessary and noncovered services; there are no instructions in the Intermediary Manual regarding the identification of quality of care problems. HCFA plans to implement the guidelines (revised as necessary) in early 1988.23 In addition, PROS will assume some responsibilities for reviewing 19See U.S. General Accounting Office, Medicare: Rehabilitation Service Claims Paid Without Adequate Information, GAO/HRD-87-91 (Washington, D.C.: July 1987). 20 The screens do not apply to physical therapy furnished under home health plans of treatment or physical therapy services furnished by comprehensive outpatient rehabilitation facilities. 21 A patient must be under the care of a physician to qualify for outpatient physical therapy and speech pathology services. A plan of treatment must set out the type, amount, frequency, and duration of the services to be furnished to the patient, and indicate the diagnosis and anticipated goals of the therapy. Like all Medicare services, outpatient therapy does not cover custodial care, routine services, or nonphysician services provided to a hospital patient that were not provided directly or arranged for by the hospital, or any other services generally excluded from Medicare coverage. 22 For example, screen 2 identifies for review bills with a diagnosis of Parkinson's disease with more than 18 treatments in a 6-week period. 23 Implementation of outpatient physical therapy guidelines was delayed when the Office of Management and Budget (OMB) determined that the guidelines should have been submitted through its regulatory review process. While the guidelines were undergoing OMB review, intermediaries were instructed that they could not request medical records for reviewing outpatient therapy claims. OMB clearance was obtained in October 1987, at which time intermediaries were informed that they could begin requesting medical records from physical therapy providers. However, implementation of the screening guidelines was suspended pending meetings between HCFA and physical therapy provider representatives to discuss the clinical significance and appropriateness of screen elements. Carrier and Intermediary Medical Review outpatient therapies as part of the intervening care review conducted for readmission cases.24 Hospice Review Intermediaries' review of hospice benefits is unique in that they are The Intermediary Manual states that the interviews are intended to find out how well the hospice program is working in order to help current and future hospice patients. The manual suggests that interviewers inquire about the patients' experiences with the program, including why they elected to use the hospice benefit, what types of services they are receiving, whether other services are needed, their satisfaction with the care, whether the hospice has billed for any services, and how, in general, they feel about the hospice program (relative to the patients' treatment). Intermediaries have also been instructed to check on specific complaints concerning hospices' delivery of services to make sure there are no misunderstandings and that patients' plans of care are being followed. If deficiencies are identified, these are to be reported to the appropriate oversight agency (for example, certification officials, HCFA inspector general, and so on). Deficiencies could include failure to follow the patient's plan of care, inappropriate discharges, underprovision of services, and failure to deliver services. Written narrative reports of all home visits, including all questions asked by the reviewer and respondents' answers, as well as descriptions of any problems identified, are sent to the HCFA regional office within 30 days of the visit. However, intermediaries do not routinely report any summary information on the type or incidence of quality of care problems identified in hospice medical reviews. 24See appendix VII. Carrier and Intermediary Medical Review HCFA Evaluation of In addition to the quality-oriented home visits, intermediaries review hospice claims to ensure that the services provided were stipulated in the plan of care signed by a physician, that these services are necessary for the palliation or management of the beneficiary's terminal illness, and that the services were adequately provided and appropriately classified for payment purposes. The hospice benefit is designed to be primarily a home benefit. Home visits are categorized into three types ranging from relatively brief visits to continuous 24-hour-a-day care. All continuous home care hospice claims are subject to intermediary medical review. For these claims, plans of care and medical records are reviewed to determine whether the beneficiary needed and received continuous services (which are defined as more than 50 percent skilled nursing services). Intermediaries review at least 20 percent of inpatient hospice claims, using plans of care, and medical records if necessary. In addition, intermediaries review all hospital admissions for hospice patients to determine whether the admission is related to the patient's terminal illness. Hospital care can be reimbursed for hospice patients only if the services were medically necessary and appropriate for the control of pain or acute or chronic symptom management as outlined in the patient's plan of care or if the care was for a condition not related to the terminal illness.25 Intermediaries also review all instances where beneficiaries give up their enrollment in the hospice program and return to regular Medicare coverage, which is termed a "revocation." All revocations are reviewed immediately prior to beneficiaries' receiving Medicare hospital, skilled nursing facility, or home health benefits for conditions related to their terminal illness, and during beneficiaries' last election period for hospice benefits. This review is designed to ensure that patients are not being coerced by providers into forfeiting hospice benefits, thus allowing providers to be reimbursed for the individual services that might not be separately reimbursable under the hospice benefit. Intermediaries, like carriers, are evaluated under HCFA's performance evaluation system. In 1987, the Payment Safeguards-Medical Review standards addressed seven aspects of intermediary medical review activities, including the cost-effectiveness of medical review, the level and accuracy of medical review determinations in hospital-based and 25 Inpatient days are not supposed to exceed 20 percent of total hospice days. |