Home Health & Hospice Week

HHA appeals caseload nearly doubles from 2011 to 2012.

While the number of redeterminations for home health agencies has skyrocketed, all those extra appeals don’t seem to be doing agencies much good.

Why? From 2008 to 2012, the number of first-level appeals decisions for HHA claims (redeterminations) rose a staggering 700 percent — from 13,385 to 112,844, the HHS Office of Inspector General says in a new report (OEI-01-12-00150). But the percentage of those redeterminations that were favorable to the HHA appellants dropped from 24 percent to 4 percent in that time frame, the OIG reveals.

Spike: The volume of HHA redeterminations increased markedly just from 2011 to 2012, jumping nearly 100 percent from 58,713 to 112,844 during that time period, the OIG notes. But the percentage of decisions favorable to appellants fell drastically from 2009 to 2010, from 39 percent to 10 percent.

The growth of the Recovery Audit Contractor (RAC) program has increased the Part A appeals workload, as well as increases in medical review from various contractors including ZPICs, contractors reported to the OIG. Increases in prepayment edits also increased the appeals workload.

Therapy-related reviews may be the culprit for HHA claims specifically, suspects Chicago-based regulatory consultant Rebecca Friedman Zuber. Predictive modeling likely drove the prepay review increase, Zuber tells Eli.

Face-to-face requirements that took effect in 2011 may have contributed to the increase, says billing consultant M. Aaron Little with BKD in Springfield, Mo. And one of the most common reasons HHA claims get denied — failure to respond to an ADR — also may have played a part, Little suggests.

Increased review also has made HHAs more likely to take appeal action, suggests financial consultant Tom Boyd with Rohnert Park, Calif.-based Boyd & Nicholas. "Most providers feel they have to appeal and fight for every claim because if they do not the ‘sample’ or activity will be expanded and they will be assumed to be at fault — which carries a fear of being accused of fraud," Boyd notes.

Other factors: An increase in consultants who will do provider appeals for a percentage of the recovery to the provider and poorly conducted review resulting in obvious appeal cases may also have contributed, Boyd says.

Note: The report is at http://go.usa.gov/D6kF -- see home health appeal stats in Table A4.