Eli's Rehab Report

Published on Wed Sep 25, 2013 PDF

Gear up for increased scrutiny of claims containing therapy visits.

Home health therapy visits are under the medical reviewer microscope in a hunt for fraud. And providers in Utah have been singled out for extra review, thanks to data mining by Home Health & Hospice Medicare Administrative Contractor CGS.

“Based on our most recent analysis of billing data, home health providers in the state of Utah have been shown to have greater aberrancies in comparison to the universe of CGS providers in average reimbursement per claim, average total visits, average total therapy visits, percent of claims with therapy services and percent of claims with 20+ therapy visits,” the MAC explains in a notice on its website.

The HHS Office of Inspector General also “identified the state of Utah as one of eight states that had high percentages of agencies with questionable billing practices,” CGS points out in the notice.

And a new supplemental report from Comparative Billing Report contractor SafeGuard Services points out that Utah has the highest number of average visits of any state at 27.89.

A state-specific widespread probe for all Utah home health providers with topic code 5012W will select claims with 10 or more therapy visits, CGS explains. “Once selected, the claims will be reviewed for valid FTF encounter documentation, medical necessity, compliance with all CMS coverage guidelines, and correct billing and coding,” the MAC says.

Note: The CGS notice is at www.cgsmedicare.com/hhh/pubs/news/2013/0813/cope23084.html.