Reimbursement:
FEDS PROMISE NEW LEVEL OF SCRUTINY ON THERAPY CLAIMS
Published on Tue Sep 05, 2006
Ask yourself this: Would you survive an audit?
The new Work Plan from the HHS Office of Inspector General ups the ante for ensuring therapy claim accuracy, experts say.
For starters, the OIG plans to continue its examination of Medicare's enhanced payments to home health agencies for therapy services. That means ongoing scrutiny of OASIS item M0825 (Therapy need) and related documentation.
Coding alert: In a recent probe review of 80 claims with 10 to 15 therapy episodes for patients in their second episodes, regional home health intermediary (RHHI) Cahaba GBA found a 25 percent error rate. Cahaba found fault with the diagnosis coding in one-third of the denied claims. Be Sure About Medical Necessity In addition, the OIG pledges attention to home health agencies' use of rehabilitation services--specifically whether appropriate staff are providing the services and whether the services are medically necessary.
The strong focus on therapy isn't surprising, says Burtonsville, MD-based health care attorney Elizabeth Hogue. "Until the PPS system is modified to include some limitations, the OIG will continue to keep this issue at the forefront," says Hogue. Watch These Trouble Spots Other new areas of investigation include the following:
1. Home health outlier payments. The OIG plans to continue its look at whether recent outlier payments to HHAs were in compliance with Medicare laws and regulations.
Background: Medicare makes outlier payments as a loss-sharing mechanism for costly cases in which the estimated cost exceeds a threshold amount for each case-mix group.
But the limited use of outlier payments in home health makes some wonder why the scrutiny.
"The OIG might find clusters of outlier patients in geographic areas," speculates Hogue. But that alone doesn't indicate fraud or abuse, she notes.
"It is hard to justify expenditure of resources to look at an item that, as far as I know, doesn't involve a lot of claims or money," Hogue adds.
Timeframe: Look for a related report from the OIG in fiscal year (FY) 2007. 2. Cyclical noncompliance in Medicare home health agencies. If your agency has tripped up at survey time recently, beware. The OIG plans to continue to home in on the records of agencies that have a repeat history of survey and certification deficiencies.
Background: The Social Security Act requires that the Centers for Medicare & Medicaid Services survey every 36 months the quality of care and services furnished by home health agencies, as measured by indicators of medical, nursing, and rehabilitative care.
As part of its report on patterns of noncompliance, the OIG notes that it will explore "whether CMS applies appropriate sanctions to noncompliant HHAs."
Translated: That could add up to stricter enforcement of penalties for agencies that fall short on surveys.
Timeframe: The OIG plans to issue its report on noncompliance in FY [...]
