Medicare Compliance & Reimbursement

Appealing LUPA claim denials is costly. If you haven't seen extra scrutiny of your LUPA claims yet, that's likely to change. Home Health and Hospice Medicare Administrative Contractor NHIC has been performing medical reviews of low utilization payment adjustment LUPA claims, which have fewer than five visits, the MAC reports in a message to providers. "Many denials have been identified in these reviews," NHIC says. The additional development requests (ADRs) on this issue are "driving people crazy" in New England, says consultant Betty Gordon with Simione Consultants in Westboro, Mass. Consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. sees this problem frequently when auditing, she says. NHIC found three top reasons for denials: 1. No skilled observation. "The most common denial code for these claims was 55H3A, indicating that skilled nursing observation services were not reasonable and necessary," NHIC explains. Examples of denied services include administering oral [...]