In order to understand the prospective payment system (PPS) for home health agencies (HHA), CMS has put together some easily accessible and useful information, which can be found directly on their website.
Outlier claims are inconsistent throughout the country, with some areas having suspiciously much higher percentages than others. The new 10% cap outlier policy was created to regulate the billing activities that may be in conjunction with the integrity issues that take place within the activities of certain home health agencies.
Though CMS has taken into consideration the needs of those patients who fall into the outlier category, such as those who are diabetic and are insulin dependent, those with CHF, and those who need wound care, there are still concerns as to the determination of the outlier policy's 10% cap being based on the number of outlier payments in the urban areas compared to the suburban areas. For instance, Los Angeles County in California, one of the concerned cities targeted by CMS, consists of approximately 10 million people. Of this population, approximately 10.5% consists of individuals who are at least 65 years old and over. With such a high population, other factors must also be considered, such as the diversity in all groups, the number of patients who live alone, and various other factors. When compared to other agencies in less populated areas that have outlier dollars below 10 percent of their total payments and are assumed not to be affected by the new outlier policy, the comparison appears to be unfairly considered. More services provided as a result of highly populated areas usually mean that more outlier claims will be billed.
It is no question that fraudulent activity in all areas must be regulated. However, it is also a known fact that organizations, corporations, companies, and individuals are driven through incentives. When a home health agency has to wait 60 days to be paid for services provided, it suffers, along with those who are directly providing the services. Home health has been proven to improve and minimize Medicare costs through the decreased number of hospital visits as a result of services provided by home health professionals. With insufficient amounts of available funds to compensate home health service providers, how are agencies expected to survive?