Home Health & Hospice Week

Home health agencies smarting at the looming 10 percent cap on home health PPS outlier payments may face even bigger woes ahead. If abusive billing of the outlier option continues even under the 10 percent cap that begins Jan.

1, the Centers for Medicare & Medicaid Services may cut outlier payments from the prospective payment system altogether. So says CMS in a new question and answer about the outlier payment changes.

"If CMS finds that the new CY 2010 outlier policy is not effective and/or achieving our goals, an alternative ... would be to eliminate the outlier policy altogether (in future rulemaking)," the agency warns in the Q&A.

Plus: In a separate Q&A, CMS clarifies that claims are subject to the new outlier cap if they are paid at the 2010 rate.

A link to the Q&As is online at www.cms.hhs.gov/center/hha.asp.

• Recent fraud busts are threatening home care providers with a bad reputation. In Memphis, an owner of a 30-year-old home health agency was sentenced to 18 months in prison for filing a false cost report.

Rosetta Perkins-Brown, owner of Elder Care Home Health Services Inc., falsely claimed $22,000 for professional fees, $146,000 for owner's compensation, $98,000 for sick pay, and $76,000 for vacation pay, according to Tennessee U.S. Attorney Lawrence J. Laurenzi.

The accountant, too: Elder Care's CPA, Larry Vernell Bullock, also pled guilty to Medicare fraud and was sentenced to 12 months in prison earlier this year, Laurenzi says in a release. Bullock assisted Perkins-Brown in filing the false claims, prosecutors say.

Meanwhile: In Los Angeles, the feds charged 20 durable medical equipment company owners and marketers with Medicare fraud in seven separate cases.

The DME owners and marketers billed tens of millions of dollars for wheelchairs, orthotics, and other supplies that were never furnished or that were medically unnecessary, according to a release from Acting U.S. Attorney George S. Cardona. One of the cases involved a suspect recruiting people to act as straw owners of four different supply companies.

The indictments and arrests were due to L.A.'s Medicare Fraud Strike Force, Cardona says. Recent articles by the Associated Press and in mainstream newspapers have pointed a finger at Medicare fraud, particularly the HHA fraud in the Miami area.

The Visiting Nurse Associations of America recently commended CMS for including the 10 percent outlier cap in its PPS rate update for 2010 to combat fraud. And the American Association for Homecare is endorsing new legislation, the "Prevent Health Care Fraud Act of 2009" (S. 2128), that adopts some of the fraud-fighting steps AAHomecare has been promoting, such as in-creased site inspections and real-time audits.

• DME suppliers have won some breathing room on the new physician NPI requirement for Medicare claims.This year, CMS began editing claims for physician National Provider Identifier numbers that are valid and contained in the Medicare Provider Enrollment, Chain and Ownership System (PECOS).

Currently the edits are informational only, but the system was set to start rejecting claims next month (see Eli's HCW, Vol. XVIII, No. 41, p. 318).

Now CMS has pushed off that requirement until April, it says in an e-mail message to providers. In the meantime, CMS will publish a list of physicians with their NPIs and PECOS information, so that suppliers can check to see if their referring physicians will pass the edits.

Tip: When residents order DME, suppliers can use the teaching physician and her NPI and PECOS information on claims, CMS instructs.

• If you're using Negative Pressure Wound Therapy (NPWT) devices (i.e., wound vacs), you'd better heed a new warning from the U.S. Food and Drug Administration. "FDA has received reports of six deaths and 77 injuries associated with NPWT systems over the past two years," the agency warns in a Nov. 13 health notice. Wound vacs can increase the risk of infection and bleeding, the FDA says.

Most of the deaths and serious injuries related to NPWT systems occurred in the home or in nursing homes, the FDA says. A list of safety reminders for home care patients is in the warning at

www.fda.gov/MedicalDevices/Safety/AlertsandNotices/PublicHealthNotifications.

• Get ready to defend more of your continuing claims for Alzheimer's Disease patients if your intermediary is Cahaba GBA. Cahaba will continue widespread review of HHA non-start-of-care claims with a primary diagnosis of Alzheimer's, the intermediary says in its December newsletter for providers.

Biggest reason for denial: The documentation for the skilled nurse visits did not support medical necessity. To claim observation and assessment, the patient's status must be unstable and treatment plan changing, Cahaba says.

Other reasons reviewers cited for denial were plan of care problems such as lacking physician's signature, care plan not specific enough, etc.

• You can no longer submit Medicare Secondary Payer (MSP) claims or adjustments on paper, CMS says.

You must submit your MSP claims using the American National Standard Institute (ANSI) ASC X12N 837 4010-A1 format, according to Change Request 6426. This means CMS will reject any claims or adjustments sent in the wrong format.

The change is designed to ensure that all providers submit as much information as CMS needs to process their claims and adjustments, according to the Change Request. For instance, many providers enter their adjustments directly into the Fiscal Intermediary Standard System (FISS) via Direct Data Entry (DDE); however, providers don't always use the CAS segments CMS needs to process their changes.

For those who meet the exception for submitting electronic Medicare claims, CMS has a process for accepting paper claims. Eligible providers must submit their claims via FISS DDE showing Medicare as the primary payer. The claim will be rejected (and you must allow up to 75 days for processing). You can then submit your hard copy adjustment to the rejected claim that includes all information regarding payment from the primary payer source.

Good to know: If your software vendor does not support the 837 format, you can use PCAce Pro32, a free Microsoft Windows-based claims submission software, CMS says. More information is at www.cahabagba.com/rhhi/claims/msp/index.htm.

• If Medicare deactivates your billing privileges, don't expect an appeal. "There is no legal basis for granting such [appeal] rights," CMS says in Nov. 27 Transmittal No. 314 (CR 6734). The transmittal also changes reactivation information in the Medicare Program Integrity Manual.

• Oxygen payment changes and their effects on patients are getting more widespread notice. A recent Wall Street Journal article noted the difficulties patients are having when they need to find a new supplier, due to moving, after they've reached the three-year cap.

The payment policy is driving patients into the hospital, the newspaper reports. "It's totally penny-wise and pound-foolish," Barbara Renzullo, a nurse and case manager at Massachusetts General Hospital in Boston, told the Journal.

Meanwhile, CMS has finalized new remark codes and messages to go on remittance advices (RAs) for suppliers and Medicare Summary Notices (MSNs) for beneficiaries, according to Nov. 27 Transmittal No. 603 (CR 6668). Remark codes M6, N370, N518, and N171 inform suppliers that payment is denied due to the 36-month oxygen cap.

• You may need to make a change to your hospice claims procedures.

Old way: Currently, CMS tells you to report the physician certifying the patient's terminal illness in the attending physician field on the notice of election (NOE) and claim, regardless of whether that physician was the beneficiary's selected attending physician, CMS notes in Nov. 27 Transmittal No. 1863 (CR 6540).

New way: Now, for dates of service starting Jan. 1, you'll put the attending physician and her NPI in the attending physician field and the certifying physician and her NPI in the "Other physician" field, CMS instructs in the transmittal.

• LHC Group Inc. has increased its presence in a certificate of need (CON) state. The Baton Rouge, La.-based chain has entered into a home health joint venture with Woods Memorial Hospital in Etowah, Tenn. The agency has annual revenue of about $1 million, LHC says in a release.