Home Health & Hospice Week

Make sure your low case mix weight claims are well defended. Don't assume high-dollar claims are the only ones that will end up on medical reviewers' desks. In addition to LUPA claims, HHH Medicare Administrative Contractors are focusing on low case mix weight claims for medical review, reports consultant Betty Gordon with Simione Consultants in Westboro, Mass. They seem especially interested in such claims for recertified patients, Gordon tells Eli. With such claims, MAC reviewers want to know why the patient is homebound and in need of skilled services when their functional scores are so low and they don't have a case mix diagnosis, Gordon observes. "Auditors cross reference diagnosis, functional scores, and care provided to determine [whether] the claim should be denied," explains consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. Auditors also seem interested in claims that barely exceed the five-visit low utilization payment adjustment [...]