Audits:
RAC Home Health Hit List Likely To Include Therapy
Published on Mon Mar 07, 2005
Pilot's medical review focus could spill over to other regions. The most confusing areas of billing under the prospective payment system may come back to haunt you when Recovery Audit Contractors hit high gear.
"Using an audit plan developed especially for Medicare, the RACs will analyze claims that have a tendency to be incorrect despite clear guidance from Medicare," the Centers for Medicare & Medicaid Services says in its most recent release on the contractors. "This includes occurrences where Medicare is not the primary payer, there are complicated payment calculations as well as complex procedure codes, and services that are 'bundled' as required by statute."
RAC reviews are targeted and random review is actually prohibited for these contractors, notes consultant M. Aaron Little with BKD in Springfield, MO. Also, RACs will use a mixture of automated review conducted by machines and complex review conducted by human reviewers, Little tells Eli.
Home health episodes using high therapy utilization (10 or more visits) are highly likely to make a top review target, predicts consultant Tom Boyd with Rohnert Park, CA-based Boyd & Nicholas. Those episodes that exceed the threshold only by a visit or two will be especially ripe for scrutiny, Little forecasts. Beware Scrutiny of M0175, Traumatic Fracture Codes RACs also may go ahead and catch errors related to the OASIS item on prior hospitalization (M0175) if CMS hasn't implemented its takebacks for them yet, Boyd expects.
Medicare Secondary Payer is clearly a focus, with some of the RACs dedicated entirely to MSP issues, CMS notes. For home health agencies, that means RACs could scrutinize traumatic fracture coding, offers consultant Lisa Selman-Holman with Denton, TX-based Selman-Holman & Associates. "People are billing Medicare as primary when Medicare shouldn't be primary" in some of these cases, Selman-Holman suspects.
HHAs also might see claims reviewed because they have listed their bundled supplies out separately on the claim form, Selman-Holman worries. CMS "told us to do that to begin with," she maintains.
Little expects additional billing scenarios likely to trigger RAC review will be episodes with:
significant changes in condition (SCICs) resulting in higher payment;
one to two visits more than the low utilization payment adjustment (LUPA) five-visit threshold;
high home health resource groups (HHRGs) with a low number of visits but that lasted a full 60 days;
high HHRG scores in the clinical domain billed with diagnoses that carry insignificant or no case-mix weight; and
high therapy HHRG scores and high number of therapy visits but no diagnoses codes that visibly support therapy need.
Watch out: If the RACs pick up on high error rates in any of these areas, HHAs can expect their own intermediaries to put them under the microscope as well, observers expect.
