Keeping Your Agency Competitive

in an Evolving Marketplace with the

Right Home Health Software

AN WHITE PAPER

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Executive Summary Without a doubt, the home care market is facing enormous challenges on all fronts. This $81.6 billion industry that serves nearly 8 million people is experiencing levels of growth and transformation that threaten the success—and even the survival—of home health agencies that don’t properly prepare for the future.1 In the coming years, home health agencies of all sizes must adjust their operations to increased competition and declining reimbursements. Additionally, in an attempt to control healthcare costs while improving health outcomes, government regulators are advocating for a pay-for-performance revenue model to apply to home health agencies in a manner similar to its application to hospitals and other healthcare providers.

It is crucial that operators of home health agencies stay apprised of the rapid developments in the industry as well as emerging best practices. To stay competitive, forward-thinking operators are looking to diversify their income streams and leverage the latest technology to help them optimize their business operations and drive continued success.

By deploying the right home health software, home health agencies will be prepared for whatever the future holds. A fully-integrated, web-based, and mobile software solution helps agencies stay in compliance with changing regulations, grow their business with less staff, bill more payers faster, get paid faster, and take advantage of diversified revenue streams.

1 Launch Factory, 2014 Home Health Care Market Outlook, 2014.

This $81.6 billion industry that serves nearly 8 million people is experiencing levels of growth and transformation that threaten the success—and even the survival—of home health agencies that don’t properly prepare for the future.

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The Evolving Home Health Industry Landscape The highly fragmented home health industry holds opportunities for home health agencies of all sizes. According to analysts, this $81.6 billion industry grew at a rate of 3.6% between 2009 and 2014. Thanks to an aging population, it remains in the growing stage of its life cycle.2 However, as home health agencies position themselves to benefit from the projected growth of the industry, they must also deal with many new challenges. Agencies will face greater competition from new entrants into the market. They must also maintain compliance with new regulations that are intended to reduce costs, eliminate fraud, and support better health outcomes. Here are a few of those major changes, challenges, and opportunities.

Pay-for-Performance Is on the Horizon Whether it is referred to as value-based purchasing or pay-for-performance, a broad set of payment strategies that link financial incentives to performance is on the horizon for home health agencies. In accordance with the Affordable Care Act, the Centers for Medicare & Medicaid Services (CMS) has implemented a value-based purchasing program to reward hospitals based on the quality of care they provide to Medicare patients, adherence to best clinical practices, and how well the hospital enhances the patient’s experience of care.

2 IBISWorld.com, Home Care Providers in the US: Market Research Report, December 2014.

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Although the current regulations don’t apply to home health agencies, in November 2014, CMS announced in Final Rule CMS-1611-F their intent to implement a home health value-based purchasing program. Testing of a model program is set to take place in five to eight states beginning in 2016.3

The program will provide value-based financial incentives for meeting quality standards and will be designed to coordinate with current home health requirements to minimize the burden of implementation. To survive the transition from fee-for-services to pay-for-performance in the coming years, home health agencies must start now to deploy innovative, integrated software solutions that improve efficiency, increase accuracy, simplify reporting, and support better patient outcomes.

The Growing Importance of Electronic Health Records

During the transition to a pay-for-performance Medicare reimbursement model, technology will play an increasingly important role in the successful operation of home health agencies. Agencies will need to have the ability to create interoperable electronic health records that allow them to share information with other healthcare professionals. Those home health agencies that continue to rely on paper files and disparate software systems will struggle to compete in an environment where other healthcare professionals are sharing data with ease. They will also face difficulty with submitting the information required to justify Medicare reimbursement, increasing their risk of a CMS audit.

3 Home Care Florida Magazine, CMS Considers a Value-Based Purchasing Program for Home Health Care Agencies, Winter 2015.

The highly fragmented home health industry holds opportunities for home health agencies of all sizes. According to analysts, this $81.6 billion industry grew at a rate of 3.6% between 2009 and 2014. Thanks to an aging population, it remains in the growing stage of its life cycle.

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Many Home Health Agencies Don’t Pass CMS Audits Medicare made $34.6 billion in improper payments in 2013.4 Of that amount, they made $3 billion in improper payments to home health agencies.5 In a sustained effort to reduce the amount of improper payments, CMS has increased scrutiny of the documentation submitted by healthcare providers through its Recovery Audit Program. As of mid-2014, the program has recovered more than $8.9 billion.6 Improper payments occur when funds go to the wrong recipient, the right recipient receives an incorrect payment amount, documentation is not available to support a payment, or the recipient uses funds in an improper manner.

The 4 Major Audit Triggers

Even though only a small fraction of audits uncover actual fraud, they do reveal unintentional errors in claims preparation and processing. Operators of home health agencies must do everything within their power to comply with

4 PaymentAccuracy.gov, Medicare Fee-for-Services, 2015. 5 cagw.org, Medicare Fraud: All Talk, No Action, April 2014. 6 AmericanActionForum.org, Primer: Recovery Audit Contractor Program and the “Two Midnight” Rule, December 2014.

NO DOCUMENTATION

The provider fails to comply with requests for medical records

supporting the claim.

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INSUFFICIENT DOCUMENTATION

The medical documentation

submitted is inadequate to support payment for

the services billed.

MEDICAL NECESSITY

Based on the medical records submitted, the services billed were not

medically necessary based upon Medicare

coverage policies.

INCORRECT CODING

The provider submits medical documentation

supporting a service that was performed by

someone else.

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Medicare reimbursement rules, so that they can reduce the risk of an audit and emerge from an audit without having to repay any funds received in error. Miami-Dade County, Florida serves as a clear example of the dramatic impact CMS audits can have on the survival of home health agencies. Since the Care Fraud Prevention and Enforcement Action Team began focusing on that market, the number of home health agencies has fallen from 958 in 2009 to 471 at the start of 2015.7 Proper record keeping through the use of the latest home health software is one of the best ways to reduce audit risk. When integrated with an electronic visit verification feature, the software improves an agency’s ability to document the care they provide with maximum accuracy. Learn more about audit triggers, audit processes, and audit preparation in our white paper entitled The CMS Audit and What It Means to Your Organization.

HHCAHPS Survey The Home Health Consumer Assessment of Healthcare Providers and Systems (HHCAHPS) survey is designed to measure the experiences of patients who receive home healthcare. CMS requires Medicare-certified home health agencies that have served 60 or more patients over the previous 12 months to conduct HHCAHPS surveys.8 Participation is optional for agencies that don’t meet these requirements. Because these surveys provide such valuable feedback, it is advantageous for all home health agencies—regardless of the number of patients they serve—to conduct the survey. Additionally, once the pay-for-performance model is put in place for home health agencies, all agencies will be required to conduct HHCAHPS surveys, the results of which will be posted on the Home Health Compare Website.

7 ModernHealthcare.com, CMS Plans Pilot to Better Estimate Home Agency Fraud, January 26, 2015. 8 HomeHealthCAHPS.org, Home Health Care CAHPS Survey, 2015.

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By gaining a deeper understanding of the care delivered by nurse and therapy clinicians, and how patients experienced their services, operators of home health agencies can:

1. Improve patient outcomes – Adopting a standardized survey instrument such as HHCAHPS, home health agencies gain the actionable insights they need to improve patient care in ways that are measurable.

2. Catch potential audit issues – Even though the HHCAHPS isn’t directly aligned with CMS audits, the analytic and benchmarking capabilities of HHCAHPS gives home health agencies a broad view of their audit risks. They can apply corrective action and monitor the progress of their comprehensive risk reduction strategy.

3. Use survey results as a marketing tool – Because surveys are published publicly on the CMS’s Home Health Compare website, higher ranking agencies can use the results as a marketing tool to grow their business.

4. Prepare for value-based purchasing – Agencies that use HHCAHPS to better align with initiatives that focus on the quality of care will transition into a value-based purchasing program more easily.

The Home Health Compare Website The medicare.gov Home Health Compare website showcases information to the public about the quality of care provided by Medicare-certified home health agencies.9 The objective of the website is to help individuals choose a quality home health agency. Because the results of the HHCAHPS home care survey are posted on the Home Health Compare website, the public has an objective source of information to help them shop for a home health agency.

9 Medicare.gov, Medicare Home Health Compare, 2015.

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Agencies that are required to conduct the survey, and those that participate voluntarily, can leverage the website to grow their business. Just like with retail websites, positive reviews influence sales. Individuals seeking care will tend to select from the group of top-performing agencies in their area. Of course, the opposite is also true. It will be clear to visitors of the Home Health Compare Website which agencies are underperforming. Consequently, those agencies that are delivering a lower quality of care stand to lose business.

Beware of the Risk of Auto-Cancelling RAPs Effective revenue management is essential for the survival of every home health agency. Soon, agencies that fail to ensure that their Requests for Anticipated Payments (RAPs) and final claims are billed within Medicare’s timeline will face the possibility of having their RAPs set to process with zero payment by Medicare Administrative Contractors. Agencies must fine tune their billing procedures to avoid this consequence and keep this significant portion of their revenue flowing. In addition to closely monitoring the submission of RAPs and final claims, agency operators will benefit from deploying home health software that streamlines the billing process.

The Coming Transition to ICD-10-CM Coding Effective October 1, 2015, coding for all claims covered by the Health Insurance Portability Accountability Act (HIPAA), Medicare, and Medicaid must be processed with the new ICD-10-CM code set. The transition from ICD-9-CM coding to ICD-10-CM coding is necessary because the older code set allows for limited data about a patient’s medical conditions, uses outdated terms, has limited room for code expansion, and is inconsistent with current medical practice. The transition to ICD-10-CM will significantly impact home health agencies. Because of the increased complexity of the new coding system, it may take

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longer to code and process documents and claims accurately. As with other changes in regulations and procedures, it helps to have a home health software solution that can easily accommodate these types of coding transitions.

Diversifying Services is a Matter of Survival Home care agencies account for the largest portion—$45 billion—of the total home care market. Hospice care is a $17 billion market, and private duty care is a $6 billion market.10 To grow their business and stay competitive, many home care agencies are diversifying their lines of service to include private duty care and hospice care. For some agencies, diversifying the services they offer is a matter of survival. Diverse revenue streams help agencies build a strong financial foundation, allowing them to withstand financial setbacks in one or more of the markets in

which they operate. It’s important to remember that with this diversification comes the need for home health software that is versatile enough to process claims for non-Medicare patients through private insurance or direct payment.

In-Home Private Duty Care In-home private duty home care is a natural extension of

the services that home health agencies already provide. With some thoughtful planning, agencies can decide what type of additional services they would like to offer. In addition to skilled nursing services, private duty care providers deliver a broad range of services including performing personal care and grooming, assisting with mobility, preparing meals, escorting to appointments, paying

10 Launch Factory, 2014 Home Health Care Market Outlook, 2014.

Home care agencies account for the largest portion—$45 billion—of the total home care market. Hospice care is a $17 billion market, and private duty care is a $6 billion market.

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bills, and providing transportation. The goal is to provide the aged, ill, or disabled with the services they need to live independently in their own home.

In-Home Hospice Care Diversifying into in-home hospice care is a logical move for Medicare-certified home health agencies. That’s because Medicare covers approved hospice care services. Also, patients can still receive Medicare benefits for illnesses that aren’t related to their terminal illness. Even agencies that are not Medicare-certified may find it beneficial to enter the hospice market because most private insurance plans also cover hospice care. Although the extent of coverage will vary for each insurance plan, the hospice services typically covered by private insurance, Medicare, and Medicaid include:11

Nursing care

Medical equipment like wheelchairs or walkers

Medical supplies like bandages and catheters

Hospice aide and homemaker services

Physical and occupational therapy

Speech-language pathology services

Social worker services

Dietary counseling

Grief and loss counseling for the entire family

Any other covered services needed to manage the terminal illness and related conditions as recommended by the hospice team

11 Centers for Medicare & Medicaid Services, Medicare Hospice Benefits, January 2015.

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The Crucial Role of Home Health Software To survive and stay competitive in an evolving industry, home health agencies must continue to deliver high-quality care while being increasingly efficient. While fighting slim margins and attempting to keep costs down, many struggle with outdated recordkeeping and reporting tools. These operational inefficiencies interfere with revenue management and increase the risk of audits. For those agencies that have begun to focus on upgrading their technology, many are still using fragmented recordkeeping and reporting systems. Because their systems don’t communicate well with each other, and with external data systems, those agencies aren’t achieving the maximum return on investment they expected. Agencies can benefit from a home health software solution that delivers all of the functionality they need to thrive in today’s and tomorrow’s healthcare landscape. Such a solution makes daily operations, billing, compliance, and collaborating with other healthcare providers easier to manage.

Fully-Integrated Software Increases Efficiency There are a wide range of complexities involved with operating a home health agency. It makes good business sense to select a software solution that fully integrates all of the tools necessary for navigating those complexities. By having clinical, administrative, billing, scheduling, human resources, compliance, and reporting capabilities all in one secure location, home health agencies can streamline operations and improve patient outcomes.

Compliance Regulatory compliance will always be a moving target. That’s why agencies must deploy home health software that helps them stay in compliance in real-time and keeps them compliant as regulations change and as new regulations go into effect. Because the right software solution supports the adoption of

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best practices when an agency is audited they are more likely to pass, and with less disruption to their business operations.

Electronic Visit Verification Supports Compliance Consistent regulatory compliance doesn’t result from a single act. It results from consistent effort. Using home health software with an Electronic Visit Verification (EVV) feature helps create a culture of compliance within the home health agency. That’s because EVV automatically verifies the date, time, and location of each patient visit. EVV supports compliance because clinicians are able to prove that they delivered care at the scheduled time and place. This automated documentation reduces errors, eliminates fraud, and provides proof of care in the event of an audit. In addition to compliance benefits, agencies that implement EVV systems find that they save money on labor costs, especially in the areas of quality assurance and payroll services. The need for spot checks is reduced, and the billing and payment process is accelerated.

Billing Flexibility Supports Diversified Services Home health agencies that are seeking to diversify their service offerings need a billing system that can handle more than Medicare. It needs to be able to handle private insurance as well. Ideally, the billing system will feature an easy-to-use interface that allows the user to process claims and bills electronically so the agency can get paid faster, regardless of the payer source.

Web-Based Software is Essential It is essential that an agency’s home health software solution be web-based. By being located securely in the cloud, it allows for easy and convenient access anywhere, anytime, and on any computing platform. An additional benefit of web-based software is that any new feature is immediately available to an unlimited number of users. There is no need to

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purchase upgrades, and nothing ever needs to be installed on desktop computers.

Home Health Software Must Leverage Mobile Although web-based software is essential, mobile technology helps take the quality of care that home health agencies are able to provide to a higher level. By being able to use a home health mobile app that integrates seamlessly with the web-based home health management application, caregivers always have a point-of-care solution in the palm of their hands. The mobile app gives the caregiver the ability to schedule and track visits in real time. It also allows for instant access to care plans and the collection of vital signs, reducing documentation burdens and allowing for more time to be spent on patient care. Electronic visit verification is also an essential feature of the mobile app. It gives caregivers the ability to capture a patient’s signature on the device, automatically recording the time and location at the point of care.

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Conclusion Surviving and thriving in the ever-evolving home health marketplace will continue to be challenging for home health agencies of all sizes. New and changing regulations, increased competition, and declining reimbursements threaten the financial stability of agencies on a daily basis. To stay competitive, home health agencies need a robust home health software solution that empowers them to streamline operations, facilitates compliance, and supports their efforts to diversify their income streams. That’s why Axxess created AgencyCore™ and its mobile solutions. To learn more about AgencyCore, the home health software developed by Axxess, visit Axxess.com. You can also schedule a demo at your convenience.

About Axxess Axxess is a healthcare technology and solutions company with roots firmly embedded in consulting and software development. Established in 2007 as a consulting firm specializing in the home healthcare industry, Axxess identified an unmet need for software that is comprehensive, fully-integrated, user friendly, and scalable. After assembling a multi-disciplinary team of technology experts, home health agency veterans, physicians, nurses and therapists, Axxess launched AgencyCore. Available as web-based software and as a mobile app, AgencyCore helps home health agencies run their businesses efficiently. A nationwide leader in providing integrated software to home health agencies, Axxess is the first and only home health software provider accredited by the American Nurses Credentialing Center, a subsidiary of the American Nurses Association.