Home Health & Hospice Week

The Government Accountability Office wants Medicare to step up its claims reviews for home health agencies. HHA claims review is woefully inadequate, the GAO says in a follow-up letter to an April hearing by the Senate Subcommittee on Federal Financial Management, Government Information, Federal Services, and International Security. The April hearing focused on Medicare waste, fraud, and abuse.

"In fiscal year 2007, only 0.5 percent of the more than 8.7 million home health agency claims processed were subjected to prepayment review," the GAO tells Subcommittee Chair Tom Carper (D-Del.) and Ranking Member John McCain (RAriz.) in the July 20 letter. "Of those claims that were reviewed, over 40 percent were denied in whole or in part."

Bottom line: "The extent of errors found would suggest that both prepayment and postpayment medical reviews should be increased to more effectively avoid or recoup overpayments," the GAO concludes.

The GAO also criticizes CMS for not routinely sending verification of services billed by HHAs to the authorizing physicians. The docs could "determine whether the type and frequency of home health visits were consistent with what physicians had authorized," the federal watchdog agency suggests. The GAO knocks durable medical equipment claims as well. The Medicare claims system doesn't identify DME claims patterns that show an atypical increase in billing, the letter says. And fraudulent providers in both the HHA and DME sectors can enter the Medicare program without much trouble, the GAO maintains.

The National Association for Home Care & Hospice is all for "well-directed Medicare and Medicaid program integrity efforts," it says. And it supports stronger credentialing of HHA managers.

But: Contractors' claims review may be getting overzealous. "NAHC is very concerned regarding recent claim determinations issued by Medicare contractors that are in direct conflict with the facts and the law," the association stresses. "Any increase in claims review should be preceded by expedited and comprehensive educational efforts by Medicare with its contractors to improve the quality and accuracy of their decisions."

The letter is online at www.gao.gov/new.items/d09838r.pdf.

• Your claims for osteoporosis drugs will have a new hoop to jump through in the new year.

A new Medicare claims system edit will check to make sure that home health claims for injectable osteoporosis drugs match a corresponding Medicare home health episode on file for the patient, says CMS in July 24 Transmittal No. 1773 (CR 6512). Currently, "there is no system requirement to ensure that a home health episode is present to correspond with all osteoporosis claims received by Medicare," the memo notes.

In other words, "the date of service on claims submitted for covered osteoporosis drugs must fall within the start and end dates of an existing home health prospective payment system (PPS) episode," CMS explains in an accompanying MLN Matters article.

The claims system will also continue to check that the patient is female and diagnosed with 733.01 (post-menopausal osteoporosis). The edit will begin in January 2010. If your claim fails the edit, the system will reject it with MSN message "Medicare cannot pay for this injection because one or more requirements for coverage were not met;" and claim adjustment reason code 177, "Patient has not met the required eligibility requirements," the MLN Matters article explains.

The transmittal is online at www.cms.hhs.gov/transmittals/downloads/R1773CP.pdf and the MLN Matters article is at www.cms.hhs.gov/mlnmattersarticles/downloads/MM6512.pdf.

• Now's the time to verify your CMS-855S information if you're planning on participating in DME competitive bidding. CMS hammers home the reminder in an MLN Matters article that also reviews the Individuals Authorized Access to the CMS Computer Services (IACS) security system that will be required for bidding.

When the bidding window opens, suppliers will have three user roles in IACS, CMS explains: Authorized Official (AO), Backup Authorized Official (BAO), and End User. Make sure all the AO's information on your 855S is up to date before the bid process begins or risk costly delays, CMS urges. The article is online at www.cms.hhs.gov/MLNMattersArticles/downloads/SE0915.pdf.

Meanwhile, the CMS Program Advisory and Oversight Committee (PAOC) on competitive bidding recently held a discussion about capacity required to serve each competitive bidding area, reports the American Association for Homecare. "No decisions were made during the call," the trade group notes.

Amore detailed Round One timeline will be forthcoming, AAHomecare adds.

• Don't forget about your Red Flags Rule responsibilities with Federal Trade Commission enforcement of the new ID theft requirement starting this month.

"After Aug. 1, 2009, any occurrence of medical identity theft ... exposes you to an FTC investigation," says Randy Green with Grant Thornton's. Advisory Services group. "We believe that enforcement of this rule will be complaint-driven, and given the staggering number of identity thefts, there will be no shortage of complaints." Home care providers will be subject to the Red Flags Rule requirements, industry experts warn (see Eli's HCW, Vol. XVIII, No. 15, p. 114).

Watch out: "Skipping red flags compliance will expose you to real regulatory, reputational, and litigation risks," Green cautions. Awhitepaper about the rule is at www.GrantThornton.com/redflags.

• Despite the feds' crackdown on home care providers in South Florida, utilization increases haven't let up. "Data shows that the utilization of home health services in South Florida's Miami- Dade county has grown tremendously over the past year," RHHI Palmetto GBA says in its August newsletter for providers. Palmetto is holding a one-day workshop in Dania to give "extensive training" to home health agencies on billing and eligibility basics, including "insulin administration appropriateness," it says. The Aug. 20 workshop costs $45.

• Oxygen cuts are hitting all suppliers hard, including national giant Lincare Holdings Inc. The Clearwater, Fla.-based company's net income has been nearly halved to $33.5 million for the quarter ended June 30 from $60.1 million in the year-ago quarter, notes the Tampa Bay BusinessJournal. Lincare's revenues were also down, from $428.4 million to $380.4 million.

The rough oxygen reimbursement environment might be clearing the playing field for the big companies, however. "We are experiencing strong growth in our core respiratory business as our competitors struggle to deal with the severe financial consequences of the Medicare price cuts," Lincare CEO John Byrnes says in a release.

• Gentiva Health Services Inc. plans to buy Magna Home Health in central Mississippi and west central Alabama. Both states require a certificate of need (CON), the Melville, N.Y.-based national chain says in a release. Magna is part of the Rush Health System. The acquisition will give Gentiva seven new counties in the two states.

• Amedisys Inc. posted record financial performance with net service revenue and net income increasing 37 percent and 69 percent, respectively, during the second half 2009, the Baton Rouge, La.-based company says in a press release. The national home care chain's net income increased to $62.1 million during the six-month period of 2009, compared to $36.8 million in 2008.

Revenues increased to $719.7 million compared to $525.8 million in 2008. The bulk of the revenue increase is related to growth through start-ups. "The continued focus of our three pronged business strategy of providing superior clinical services, growing our business aggressively and becoming as operationally efficient as possible is evident in the record revenue and earnings that we are reporting today," Amedisys CEO Bill Borne says in the release.

• You may get some relief from your worker shortage thanks to the economic stimulus bill. The Department of Health and Human Services will put $200 million in American Recovery and Reinvestment Act funding toward grants, loans, loan repayment, and scholarships to expand the training of health care professionals. HHS expects the funds to train 8,000 students and credentialed health professionals by the end of 2010, it says.