Perfect Storm Takes Aim at Florida

Published: 1/1/0001

For those who haven’t seen the movie "The Perfect Storm" with George Clooney, it’s basically the story of a fishing boat that encounters a confluence of meteorological events, all hitting at once, and ultimately leading to devastating results.

  • In two weeks, Pre-Claims Review Demonstration (PCRD) will be introduced in the state of Florida.
  • In January 2018, revenues for 50% of the agencies in the state will either be going up or down 3% because of Home Health Value Based Purchasing.
  • If you have failed the first round of probe and educate, and find yourself failing round two, you will be headed towards more ADR’s according to CMS contractors.
  • All this while ZPIC probes, audits, and investigations are increasing each day.

And finally: Don’t forget the annual March madness from Med Pac, who for the fifth year in a row continues to advocate for the removal of therapy visits as a payment driver, and an additional 5% reduction in the base rate.

Florida is used to its storms, but nothing like this.

So, what does this mean to you?


If you’re using a form to capture the face-to-face requirement, you’re missing the point.

Many agencies believe the F2F "form" is the actual face-to-face encounter note; this is a mistake. Medical review teams require the "actual" face-to-face note or discharge summary note from the physician that includes the date of the encounter by the NPP or Physician.

The note is required to include the date of the encounter, and the documentation must be related to the primary reason home health services are necessary. There is no requirement the note contain a declaration of "homebound status", "if" the physician incorporates a homebound statement, it can only help.

In short, no note = no referral


Pre-claims Review is the evaluation of compliance with long standing requirements established in regulatory statutes. There is nothing new about what is required other than the form to fill out and submit to Palmetto.

As such, the referral intake process, and the OASIS processes are the key factors to your success. Agencies starting the case prior to assurance of compliance with these requirements are frequently being disappointed with denials. In several parts of the state, ZPIC investigations have found "altered" physicians’ documents being utilized in home health episodes to authorize care. As such, we are running into many physicians who are extremely reluctant to share their notes with agencies for fear that something nefarious may happen with the documents and they themselves will be visited by the ZPIC's.

OperaCare’s proprietary processes engage the QA staff in the office with the nurse in the home during the OASIS visit, producing a RAP ready claim shortly after the clinicians are done.


The implementation of OASIS C-2 and the changes in the grouper and case mix compilation make it much more difficult to obtain accurate acuity scores reflective of the patient's actual abilities and deficits. Many agencies are submitting very "light acuities" with very heavy service utilization triggering the ZPIC's radar, causing further problems in the form of probe edits, prepayment review, and occasionally millions of dollars in extrapolation.

OperaCare understands that clinicians have an inherent understanding of what their patients need; yet struggle to translate that need into OASIS data supportive of the care to be provided. Our two person Live QA processes routinely align the expectations of the clinician with the data to be transmitted resulting in large increases in case-mix, and reductions in ADR risks.


The inability to accurately score the OASIS assessment effectively, and in a consistent manner between clinicians virtually dooms an agency to failure in the HHVBP.

If you do not leave room for improvement between the start of care and discharge, you have made it impossible to transmit positive outcomes.

The difficulty primarily lies in the fact that a single clinician is sent into the home without any accountability of how the assessment is performed, and as such, the consistency between assessing clinicians inside of an agency creates a haphazard data pattern which is subsequently submitted to CMS and then owned by the agency.


The OperaCare solution acknowledges all the above, and those agencies that use the OperaCare OASIS processes can accurately complete 4 or more OASIS events per clinician, per day, while submitting their RAP's and Plan of Care documents, prior to the close of business each day. If you are in Florida, or Illinois, you can have your PCR submission ready as well.

This ultimately is a practical, possible, and a cost-effective business practice that enhances compliance, increases case-mix revenue, and places your agency on a rapid cycle cash flow track, which is essential to any successful business.