Medicare Compliance & Reimbursement

Beware denials that result in LUPAs Congress should expand national coverage for off-label uses of cancer drugs, the American Society of Clinical Oncology argues in the July 1 Journal of Clinical Oncology.
 
Congress should require Medicare contractors to consider peer-reviewed literature as they make coverage decisions about off-label cancer drugs, ASCO says. Non-Medicare insurers should follow Medicare rules on off-label cancer drug use, ASCO adds. RHHI Denies 75 Percent Of Claims With 1 Nursing, 4 Therapy Visits When you submit a claim with one nursing and four therapy visits, you'd better be ready to defend it.
 
Regional home health intermediary (RHHI) 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. Fill Out 855 Forms Online To Save Time In Future CMS is offering pdf files of the 855 enrollment form, it says. The forms "can be filled out online and saved for future reference or to notify CMS of any future changes," a CMS spokesperson says. "This presents a significant savings in terms of time and energy for the practitioner."
 
Download the forms at www.cms.hhs.gov/CMSForms/CMSForms/list.asp -- search for "855". In Other News...  • 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. 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.  • Prosecutors accused the owners of Leonza Health Management Group Clinic of billing Medicare for injected drugs that they didn't administer, administered in smaller quantities than billed, or administered in return for kickbacks. They billed $7.5 million [...]