Home Health & Hospice Week

Don't assume high-dollar claims are the only ones that will end up on medical reviewers' desks. In addition to LUPA claims, HHH Medicare Administrative Contractors are focusing on low case mix weight claims for medical review, reports consultant Betty Gordon with Simione Consultants in Westboro, Mass. They seem especially interested in such claims for recertified patients, Gordon tells Eli.

With such claims, MAC reviewers want to know why the patient is homebound and in need of skilled services when their functional scores are so low and they don't have a case mix diagnosis, Gordon observes.

"Auditors cross reference diagnosis, functional scores, and care provided to determine [whether] the claim should be denied," explains consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C.

Auditors also seem interested in claims that barely exceed the five-visit low utilization payment adjustment (LUPA) threshold. HHAs sometimes try to fudge on a nursing or therapy visit to get the big bump-up in pay from a LUPA to a regular episode, Laff notes.

Bottom line: "It will be the agency's responsibility to validate that the patient is truly homebound and that the care provided was skilled," Laff reminds providers.