Beware denials that result in LUPAs.
When you submit a claim with one nursing and four therapy visits, you'd better be ready to defend it.
Regional home health intermediary Cahaba GBA has been reviewing claims with that visit mix for nearly a year, it notes in a June 27 posting to its Web site. And in the quarter spanning January through March, Cahaba denied 239 of 313 such reviewed claims.
Top denial reason: For 132 claims, the intermediary denied the skilled nursing visit as medically unnecessary due to lack of documentation.
Beware: Denying just one visit in a five-visit episode pushes the claim into the rock-bottom per-visit low utilization payment adjustment (LUPA) rate.
"Generally, if the skilled need for the nurse is observation and assessment, there is greater need than a one-time visit," Cahaba says in the notice at
www.cahabagba.com/part_a/whats_new/20060627_denials.htm. • Missouri is wrong to deny coverage of medical equipment under Medicaid, a federal appeals court says in a June 22 ruling.
The decision by the 8th U.S. Circuit Court of Appeals gives new life to a lawsuit over last year's Medicaid cuts in Missouri (see Eli's HCW, Vol. XIV, No. 32). It was unreasonable of Missouri to deny coverage of certain equipment to most low-income adults, the court suggests. Specifically, the appeals court says Missouri's policy of covering some DME items but not others appears unreasonable under federal Medicaid rules and court precedent.
States have discretion to determine the optional services in their Medicaid plans, the ruling says. But "failure to provide Medicaid coverage for non-experimental, medically necessary services" within a Medicaid category is both "unreasonable and inconsistent with the stated goals of Medicaid," according to the decision. • New legislation approved by the Senate Budget Committee could lead to home care cuts. The Stop Overspending Act of 2006 (S. 3521) calls for across-the-board spending cuts in Medicare if certain spending levels are reached and other mechanisms for cutting Medicare and Medicaid spending.
The SOS bill may not have much chance of passage in this election year but could be "a harbinger of things to come," warns the National Association for Home Care & Hospice. Consideration of "dramatic cuts in Medicare underscores the continuing need for grassroots action by the home care community to protect the Medicare market basket inflation update for home health care and hospice," NAHC warns. • A lawsuit by House Democrats that seeks to nullify the Deficit Reduction Act should be dismissed, the U.S. Justice Department says.
The lawsuit rests on the fact that the House and Senate failed to approve identical versions of the bill. The Senate version stipulated that Medicare could pay to rent some items of medical equipment for 13 months, while the House passed a version that [...]
