A Healthesystems publication

Fall 2013

Bringing Visibility to Hidden Home Health Costs

High dollar home health cases can become difficult to close or settle because of the expectations already in place with the claimant and the claimant’s family or caregivers.  Programmatic management can provide the oversight and information needed to keep a home health claim from spiraling. 

Although less than half of one percent of medically active workers’ compensation claims include home healthcare services, these costs can approach two percent of total medical costs. That is partly because cases involving extensive use of home health are often severe in nature or involve major surgery.  Healthesystems sees the majority of home health services ordered for registered nurses, licensed practical nurses, certified nursing assistants and companion care. They are ordered for a variety of tasks ranging from wound care and dressing changes to catheter care, helping patients ambulate and assisting with activities of daily living. 

Payers generally manage home health services informally rather than programmatically — relying on individual claims adjusters or nurse case managers to monitor services and determine if they are being provided properly.  The logic is that these claims make up such a small portion of the overall mix that it would be too difficult to automate associated processes for managing and monitoring them.

Home Health Claims on Autopilot

In many cases,  home health services are provided without objective case review to ensure that the services provided are relevant and appropriate to the injured worker’s needs.  For example, a physician may order a set number of hours for a home health registered nurse to visit an injured worker who was discharged from the hospital post operatively — without specifying details of the services needed.  A registered nurse might be sent daily at great expense to perform wound care when a licensed practical nurse could perform the service with weekly supervision at a significantly lower cost. Essentially, home health services are put on autopilot and patients may not receive the proper type or level of services.  

Closer case management with a third party’s involvement to ensure objective case review can put payers back in control of their home health spending.  In the case of the injured worker discharged post operatively, a well-managed home health care program might include an initial home assessment and the development of a care plan that adjusts everything from the services provided, frequency of visits and the skill level of the provider, to the patient’s changing needs to keep costs from spiraling.  

Cases involving high dollar home health spends can become difficult to close, settle or manage retrospectively because of the expectations already in place with the claimant and the claimant’s family or caregivers. They may be reluctant to change caregivers, even if such a change may result in significant savings.

Details Provide the Big Picture

Payers should be able to answer these questions at both a program and claim level, especially when it is clear that home health services are going to be needed long-term and will likely represent significant dollars.

Most payers have difficulty answering these questions at both levels because the information about the services is generally provided by bill review data which lacks the transparency and consistency that payers need. The payer has a limited ability to aggregate data about the quality, complexity or other details of the services provided. 

Healthesystems has long recognized the value of quality data and its role in managing home health services through our ancillary benefits management program (ABM). Another key to effectively managing home health services is to implement unique identifying codes for every type and level of home health service to allow payers to identify the quantities, increments and intensity level of each service, as well as the expertise level of its provider.  

Having this granular level of detail in a master product and service catalog provides payers with transparency into the services an injured worker is receiving — information that is not available through HCPCS and CPT-4 coding alone. Payers get a full understanding of exactly what services the patient is receiving, who is providing them and at what cost. It also levels the playing field across billing entities, state jurisdictions and regional preferences and allows for a true apples-to-apples comparison of results and outcomes. 

Unmasking the Mystery

The most commonly-provided resource in home health is the aide or certified nurse assistant. In the latest version of the HCPCS coding manual, there are at least three different codes that can be used to identify these types of services. 

Depending on the billing entity’s definition of the service, additional codes are also available. By creating a proprietary coding and mapping process used by all connected partners, there is transparency into exactly what service is being provided. 

This holds true for miscellaneous HCPCS or CPT-4 codes such as 99600, which are sometimes used in home health, though more appropriate codes are available. While miscellaneous codes appear less frequently in home health than they do in durable medical equipment, they still represent over five percent of paid amounts.  Some agencies and providers are accustomed to billing the majority of their services under the miscellaneous code making it impossible for the payer to know what they are paying for.  In addition to variability in coding, there is also wide variation in the paid amounts for some of the most commonly-supplied services. 

An effective ancillary benefits management program that incorporates insights garnered from detailed coding and service authorizations can provide payers with the information they need to achieve better outcomes for injured workers and sharply focus on how home health dollars are spent.  

Coding Can Vary for Similar Services

HCPCS Code Description
S5125 Attendant Care Services; Per 15 Minutes
S5126 Attendant Care Services; Per Diem
S5130 Homemaker Service, NOS; Per 15 Minutes
S5131 Homemaker Service, NOS; Per Diem
S5136 Companion Care, Adult (LADL/ADL);Per Diem
*G0156 Services Of Home Health/Hospice Aide In Home
Health Or Hospice Settings, Each 15 Minutes
S5120 Chore Services; Per 15 Minutes
S5121 Chore Services; Per Diem
*S9122 Home Health Aide or Certified Nurse Assistant,
Providing Care In The Home; Per Hour
T1004 Services of a Qualified Nursing Aide, Up To 15 Minutes
*T1021 Home Health Aide or Certified Nurse Assistant, Per Visit
T1022 Contracted Home Health Agency Services, All Services Provided Under Contract, Per Day

*Codes most commonly used for home health aides.

Cost for Similar Services Can Vary Widely

HCPCS or CPT-4 Code Description Rank of Code Based on % of Paid Value Range in Paid per Unit Hourly Rate
S9122 Home Health Aide Or Certified, Per Hour 1 299.53  
S9124 Nursing Care In Home By LPN, Per Hour 2 1,050.73  
S9123 Nursing Care In Home By RN, Per Hour 3 1,126.14  
99600 Unlisted Home Visit Service or Procedure 4 574.56  
T1030 RN Home Care, Per Diem 5 542.39  
G0154 Home Health Services of RN/LPN, Each 15 Min 6 534.38 2137.52
G0156 Home Health Services of Aide, Each 15 Min 7 156.11 584.44
S5136 Adult Companion Care, Per Diem 8 457.77  
S5125 Attendant Care Services, Each 15 Min 9 414.00 1656.00
S9097 Home Visit Wound Care 10 200.91  

Programmatic Oversight Benefits All Stakeholders

A review of historical bill data of claims involving expenditures for home health services prior to entering Healthesystems’ ancillary benefits management program found both cases that were properly managed along with others that realized significant annual savings when Healthesystems applied closer case management and review.  We are certain that our ancillary benefits management program can keep home health claims off of autopilot and offer payers additional opportunities for savings through multi-faceted review and coordination with key stakeholders.

A Single Portal

The programmatic management of home health services creates efficiencies for claims professionals at a time when adjusters and nurses are hard pressed to be more efficient and productive. The Healthesystems program arranges order fulfillment, service delivery and program management electronically through a nationwide network of connected partners. Healthesystems supplies the system platform and overall program management processes but these partners are key stakeholders in managing the care. 

All transactions are managed in a single online portal, which eliminates these common time-intensive activities for claims professionals: 

Claims are adjudicated prospectively, virtually eliminating appeals. Less than one percent of home health bills processed through Healthesystems have an appeal while the industry sees 15 percent or more of the bills appealed or in many cases, just rebilled. When needed, payers can find home health notes quickly and easily in electronic format. 

As a part of Healthesystems’ best practices, claims are reviewed regularly and at the time of reauthorization to determine if services remain appropriate to the patient’s needs. Real-time edits based on client protocols are applied at initial authorization, reauthorization and as services are delivered, relieving claims professionals and nurse case managers of many administrative burdens. When milestones or other events occur in the service or life of a claim, stakeholders are automatically alerted to take appropriate action or initiate processes specific to the management of the situation. 

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