Home Health & Hospice Week

You'll see more medical review for pressure reducing support surfaces if a federal watchdog gets its way. Inappropriate Medicare payments still abound for pressure reducing support surfaces, says a new report from the HHS Office of Inspector General. They amounted to about $33 million for these items during the first half of 2007 alone.

Background: The Centers for Medicare & Medicaid Services categorizes support surfaces into three groups based on the complexity of their features and Group 2 is the largest, the OIG notes in a new report.

The OIG found that 80 percent of group 2 support surface claims did not meet Medicare's clinical coverage requirements. And 33 percent of claims did not meet supplier documentation requirements. Over three-quarters of the claims that did not meet supplier documentation requirements also did not meet Medicare's clinical coverage requirements.

The review also found that 38 percent of the claims were undocumented, 22 percent were medically unnecessary, 17 percent had insufficient documentation, and 3 percent had other billing errors. For the claims that did not meet supplier documentation requirements, the supplier delivered the support surface before obtaining the physician order, did not have a physician order, was missing proof of delivery, or the physician order was not dated.

CMS contractors also had limited safeguards in place to prevent improper payments for group 2 support surfaces, the review revealed. Among other things, the OIG urges CMS "to conduct additional prepayment and postpayment medical reviews of group 2 support surface claims." The OIG also wants CMS to educate home health agencies on coverage criteria for the items. The report is online at www.oig.hhs.gov/oei/reports/oei-02-07-00420.pdf.

• Medicare's offensive against home health agency outlier fraud is capturing mainstream press attention. A Miami Herald article highlights CMS's proposal to cap HHA outlier payments at 10 percent per agency (see Eli's HCW, Vol. XVIII, No. 28, p. 219).

Miami-Dade is "an albatross because it was weighing us all down," the National Association for Home Care & Hospice's William Dombi told the newspaper. "It's beyond an embarrassment it's harmful to everyone across the country."

"They have been robbing the bank for so many years, it's time to shut them down," Bobby Lolley, executive director of the Home Care Association of Florida, told the Herald about the fraudsters.

"Even if some legitimate people are not served, the greater good is served by cleaning up Miami-Dade."

Medicare has suspended payments to a total of 30 HHAs for suspected outlier billing fraud and abuse, the newspaper says. Bad-actor agencies pay $100 bribes to doctors for each referral and up to $1,500 in monthly kickbacks to patients to use their Medicare numbers, prosecutors say. Agencies also bribe patients with groceries, housekeeping, and even flat-screen TVs.

"I sincerely think it's going to take a lot companies out of business," Vincent Carmona, administrator of Serenity Home Health Care in Miami, told the Herald about the 10 percent cap proposal. "If they cannot obtain their patients ethically, this will even the playing field. I'm willing to weather the storm."

• A snafu is holding up HHA claims at regional home health intermediary Cahaba GBA. When a final claim rejects with an "X" in the TPETO- TPE (tape-to-tape) field, the system is applying a cancel DCN (document control number) to the Request for Anticipated Payment (RAP), Cahaba reports in an e-mail to providers. "However, a cancel date is not applied to the RAP," the RHHI notes. That leads a resubmitted final claim to return to provider (RTP) with reason code 38107 or U5391 because there's no RAP on file, the intermediary explains.

However: "Keep in mind that not all final claims in the RTP file with reason code 38107 are affected by this issue," Cahaba cautions. "Final claims receive reason code 38107 or U5391 appropriately when the RAP was not billed or processed prior to the submission of the final claim, or the RAP auto-cancelled because the claim was not submitted timely, or key fields do not match between the RAP and final claim." HHAs that encounter the incorrectly RTP'd claims should contact the intermediary for help, Cahaba says.

• With surety bond and accreditation requirements fast approaching, durable medical equipment suppliers have a lot to get in order. CMS "reminds DMEPOS suppliers that each practice location of a DMEPOS supplier must be enrolled in the Medicare program" for surety bond purposes, the agency says in an e-mail to providers. Each location needs its own National Provider Identifier (NPI) and Provider Transaction Access Number (PTAN), formerly known as the National Supplier Clearinghouse (NSC) number. Unless it's a sole proprietorship, there should be a 1-to-1 relationship between a DMEPOS supplier's NPI and its PTAN, CMS instructs.

• Home care professionals have another tool at their disposal to help stroke survivors cope with post-stroke depression. The nurse-led behavioral intervention program called "Living Well with Stroke" provides individualized counseling sessions using social interactions and physical activity as a way to elevate mood. Researchers conducted a clinical trial involving more than 100 stroke survivors who exhibited symptoms of post-stroke depression and compared LWWS against usual post-stroke care. The study included participants from 25 to 88 years old, with more 70 percent having experienced at least one episode of depression prior to their stroke, while 60 percent were taking an antidepressant medication at entry into the study. Depression scores in the LWWS group were significantly lower after treatment and at a one-year follow-up. At two years, depression scores continued to decrease and remission rates continued to increase, according to the study, funded by the National Institute of Nursing Research, a component of the National Institutes of Health.

• HHAs that saw over- and underpayments due to a recent claims system glitch that dropped zeroes from payment amounts should have those resolved soon. RHHI Palmetto GBA sent letters about the refunds or recoupments earlier this month, it says on its Web site. Agencies with overpayments don't have to submit a check to Palmetto, the RHHI assures. The intermediary will automatically recoup the amount from future payments.

• Don't freak out if your wage index in CMS's proposed rule for 2010 HHA payment doesn't look right. CMS used the wage index tables for inpatient rehab facilities in the Aug. 6 Federal Register notice, NAHC points out. The correct HHA tables are in the Aug. 13 Federal Register, CMS says.

• Home care schemes feature prominently in the HHS Office of Inspector General's new Medicaid Fraud Control Unit report for 2008. MFCU investigators busted home care scams in Minnesota, New York, Ohio, Oregon, and Washington state, according to the report. The schemes ranged from billing for services not rendered to paying a spouse for a no-show job at anHHA to falsely certifying that a patient needed home care services. More information is in the report at www.oig.hhs.gov/publications/docs/mfcu/mfcu_2008.pdf.

• CMS is ironing out the paths of communication between your regular Medicare contractor and the Recovery Audit Contractors (RACs). Medicare contractors must provide RACs with provider addresses and tax ID numbers, in addition to the previously spelled out provider numbers and names, CMS says in Aug. 7 Transmittal No. 156 (CR 6582). Contractors must update the list of providers every six months at least, CMS adds.

• If you receive high Medicare payment per patient or are a new provider, expect some extra scrutiny from RHHI Palmetto GBA. Those issues are topping Palmetto's medical review hit list, the intermediary says in its newly released Home Health Coalition Questions and Answers from July 13. Reviewers are also targeting high-reimbursement diagnosis codes in Texas and Florida, but Palmetto doesn't give details on which codes. Finally, audits based on high outlier utilization are ongoing, Palmetto says.

• Walgreens is joining forces with Vanderbilt Medical Center in Nashville, Tenn. to launch a home infusion and home respiratory unit called Vanderbilt Home Care, the Deerfield, Ill.- based company says in a release. The new joint venture will start with home infusion and expand into home respiratory services later this year, Walgreens says. The chain has similar joint venture arrangements in Idaho, Ohio, and Oregon, it adds. Vanderbilt already runs a traditional HHA, which will support the new unit with infusion nursing services, Walgreens says.

• HHA chain Amedisys Inc. is entering the hospice market in two southern states. The Baton Rouge, La.-based company has acquired a hospice company with nine locations in South Carolina and one in Mississippi.

The purchase of Winyah Community Hospice Care will allow Amedisys to serve the entire state of South Carolina and Allcare Hospice will provide access to 17 counties in Mississippi. The company has annual revenues of $17 million, Amedisys says in a release.