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Home Health & Hospice Week

Industry Notes:

Pricing Changes Cause Claims Payment Delays

Published on Thu Jan 01, 2004

RAPs are exempt from the hold.

If you admit and discharge a patient between Jan. 1 and Jan. 19, you might have to wait a bit on payment.

Fiscal intermediaries are testing software that will implement changes from the Medicare Prescription Drug, Improvement and Modernization Act (MPDIMA), intermediaries Palmetto GBA, United Government Services and Cahaba GBA say in notices on their Web sites. They are authorized to hold all claims, except requests for anticipated payment, with dates of service beginning Jan. 1 until Jan. 19.

Home health agencies should be left fairly unscathed by the hold-up, says the HomeCare Association of Louisiana in an email message to members. Home care episodes initiated prior to Jan. 1 aren't affected, a Palmetto representative told HCAL. And RAPs will continue to be processed for episodes started after Jan. 1, so only those episodes' final claims would be affected by the delay, HCAL explains.

  • Health care consultants will want to watch closely a case against Ernst & Young that focuses on the national accounting firm's billing advice to hospital clients. A complaint filed by Pennsylvania U.S. Attorney Patrick L. Meehan alleges that Ernst's faulty billing advice to nine hospitals caused them to submit false Medicare claims for lab payments.

    The government is seeking to recover from Ernst more than $900,000 in damages resulting from the allegedly improper claims, according to a release. "It is the responsibility of an independent reviewer to be alert to fraud and abuse and certainly not to ignore it," said Meehan. "Ernst & Young kept itself deliberately ignorant of the facts."

    In a statement, Ernst said its services for the hospitals were "fully consistent with professional standards" and Medicare billing guidelines at the time, reports The New York Times.

  • Providers can say goodbye to local medical review policies (LMRPs) and hello to local coverage determinations (LCDs). Starting last month, contractors began issuing LCDs instead of LMRPs, and launched the two-year process of converting existing LMRPs to LCDs and related articles, according to a notice on regional home health intermediary Cahaba GBA's Web site.

    The main difference between the two formats is "that LCDs consist only of 'reasonable and necessary' information, while LMRPs may also contain category or statutory provisions," according to Cahaba. "Any non-reasonable and necessary language a contractor wishes to communicate to providers must be done through an article," the RHHI explains.

  • The home care waiver program in Pennsylvania has saved the state an estimated $3.8 million in nursing home costs, reports the Philadelphia Inquirer. And some changes to the program may cause home care utilization and the resulting savings to grow.

    The state has raised from $2,000 to $8,000 the asset amount a Medicaid beneficiary may possess and still receive free home care services under the waiver, the newspaper says. Since the change was made Oct. 1, 2003, the number of waiver participants has increased.

    The state also is piloting a project to speed up the qualifying process for the waiver program, the Inquirer says.

  • The Joint Commission on Accreditation of Healthcare Organizations has modified its national patient safety goals to more accurately reflect home care, the Oakbrook Terrace, IL-based accrediting body says.

    JCAHO has removed goal #4, on wrong-site, wrong-procedure and wrong-patient surgery, from the home care goals altogether.

    The Joint Commission also has modified slightly the wording of the following goals to reflect home care, it says: #3 (improving the safety of high-alert medications), #5 (improving the safety of using infusion pumps) and #6 (improving the effectiveness of clinical alarm systems).

  • Former Centers for Medicare & Medicaid Services chief Tom Scully has accepted a partnership with Washington D.C. law firm Alston & Bird. Scully joins a team with former Sen. Bob Dole and the Senate Finance Committee's lead staffer on the Medicare bill, Colin Roskey.

  • Tulsa, OK-based Trinity Hospice has expanded its Western Oklahoma presence and entered into Texas with two new acquisitions. Trinity acquired Elk City, OK-based New Season Hospice and Dallas-based Castle Peak Hospice, according to the company that says it is the nation's sixth-largest provider of hospice services.

    Following recent hospice mergers and acquisition trends (see story, "VITAS SELLS FOR $410 MILLION"), Trinity says it plans to expand its current 15-location network throughout the southern U.S. Texas especially has "enormous growth potential," the company says in a release.

  • Continucare Corp. plans to sell its home health agencies to three different undisclosed entities by mid-February, the Miami-based company says in a release. The HHAs had an operating loss of about $1.8 million during the fiscal year ended June 30, 2003, according to the company.

    The sale will allow Continucare to focus on its core business of furnishing primary care medical services, it says.

  • St. Louis-based Unity Health Services will pay $877,174 to settle charges that it improperly billed Medicare for durable medical equipment including oxygen, wheelchairs and hospital beds, according to Missouri U.S. Attorney Ray Gruen-der. Unity, which did business as Provide Medical, voluntarily disclosed to the government that it lacked medical necessity documentation for the affected claims.

  • An HHS Office of Inspector General audit of Region A DME regional carrier HealthNow New York turned up about $318,000 in overstated costs, including $42,000 in excessive executive compensation. But HealthNow generally had adequate systems for reporting costs, according to the report at http://oig.hhs.gov/oas/reports/region2/20301012.pdf.

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