Home Health & Hospice Week

Brace for complex medical review based on medical necessity and eligibility.

Get ready to feel the RAC pain other pro-viders have become accustomed to.

Region C Recovery Audit Contractor Con-nolly Inc. has posted this HHA issue: "Medical Necessity and Conditions to Qualify for Services." According to the RAC for 15 states and two U.S. territories, the "medical record will be reviewed to validate that the Home Health Services provided were both reasonable and medically necessary, and that the patient met the conditions to qualify for Home Health Services." The review will cover claims back to October 2007, Connolly says.

"This is definitely not good news," warns consultant Pam Warmack with Clinic Connec-tions in Ruston, La. "In my dealings with providers I find that documentation to support medical necessity is often lacking."

The problem: "Medical necessity is one of the top two reasons for denials from most of the MACs," Warmack laments. "Medical necessity can be difficult to explain and difficult to defend upon appeal."

Reasons for subpar medical necessity documentation vary. Sometimes, "patients are recertified and there is simply not clinical evidence to support the need for continued services," Warmack explains. Other times, "the problem is that the clinical staff -- most frequently nurses -- don't know how to document in a style that supports the need for care."

Bottom line: "I teach documentation classes over and over and over and find the same problems with documenting towards medical necessity persisting," Warmack tells Eli.

Solution: "Providers really, really need to take heed of this newest threat and get their clinicians in compliance with documentation requirements," Warmack urges.

RAC Targets Hospices, DME Too

Connolly also has received Centers for Medicare & Medicaid Services approval for three hospice issues addressing separate billing for services unrelated to the terminal diagnosis. While the issues are technically hospital topics, the hospitals will come looking for payment from hospices if the RAC recoups money due to services being related to the terminal diagnosis, experts predict.

Plus: Add two home medical equipment products to the list of items scrutinized by RACs. Region A RAC DCS has posted Complex Enteral Nutrition Infusion Pumps (A000752012) and DME -- Group 2 Pressure Reducing Support Surfaces (A000952012) as issues on its website.

Note: Details about Connolly's issues are at www.connolly.com/healthcare/pages/ApprovedIssues. aspx and DCS's issues are at www.dcsrac.com/IssuesUnderReview.aspx.