Home Health & Hospice Week
RACs Pile On More Home Care Review Topics
Brush up on bundling to combat RAC pressure. Some observers thought that RACs' permanent program reviews would stick to examining providers with big pockets -- hospitals and perhaps physicians. RACs have hit those providers hard, but the four national contractors have also gotten 24 durable medical equipment topics approved for review, too. The DME issues range from oxygen to wheelchairs to respiratory drugs. Audits can go as far back as 2007. (For a free detailed list of the DME topics approved for audits, e-mail editor Rebecca Johnson at rebeccaj@eliresearch.com with "RAC Topics" in the subject line.) RACs' willingness to target DME when the sector represents such a small piece of the larger Medicare pie may mean they're prepared to hit HHAs and hospices soon too. "I think it is just a matter of time," says hospice consultant Because RACs get paid on a contingency basis, they have an incentive to go after "every type of provider allowed," Wilson tells RACs have to branch out from the hospital, physician, and DME supplier areas they've already covered, notes attorney Hospices May Make Juicier Targets Don't run screaming for the hills just yet, though. RACs have to jump through a lot of hoops before they can initiate HHA and hospice reviews, points out consultant Tom Boyd with Rohnert Park, Calif.-based Boyd & Nicholas. They have to secure approval of the topics from the Centers for Medicare & Medicaid Services; coordinate review with the regional home health intermediaries/home health Medicare Administrative Contractors; publish the topics; and hold open meetings for the provider community. Coordinating with the RHHIs/HH MACs may be a more serious obstacle than usual to this process because final contracts for the MACs haveyet to be settled, Boyd notes (see Eli's HCW, Vol. XVIII, No. 9, p. 70). RACs also may avoid HHA claims because they involve a lot of clinical review, rather than easy data mining where the contractors can reject claims without time-draining chart reviews. With their profit margin in mind, "RACs are all about efficiency," Markette thinks. Even though the ratio of DME payments in the program is small, RACs probably consider DME claims "easy pickings" and thus worth review, Boyd says. The latest CERT report found more than half of DME claims improper, for example (see Eli's HCW, Vol. XIX, No. 8, p. 60). HHA claims probably won't be so easy to downcode or deny, so RACs have less incentive to review them, Boyd believes. He expects to see RACs initiate HHA reviews no earlier than 2012. "I still tend to believe that home health is way down the list on RAC targets," agrees RAC expert Mark Sharp with BKD in Springfield, Mo. Watch out: "Hospice, on the other hand, could become a target of RACs much more quickly than the home health agencies," Sharp predicts. That's because unlike HHAs, hospices have a higher claims review limit, meaning RACs can review more of their claims. RACs can review 10 percent of a hospice's average monthly paid Medicare claims (maximum of 200) per 45-day period, per NPI, notes law firm Arent Fox on its Web site. In contrast, for HHAs, RACs can review just 1 percent of average monthly Medicare services (maximum of 200) per 45-day period, per NPI, Arent Fox says. And for DME, they can review 1 percent of average monthly paid Medicare services per 45-day period, per NPI. So why would RACs go after DME and not HHAs if their claims review limit is the same? "Since the home health claims tend to be smaller ... this limit does not allow the RACs to have a lot of opportunity to identify material improper payments," which means lower contingency fees for the RACs, Sharp explains. Thus, it may not "make it worth their efforts." Suppliers, on the other hand, can have a "more voluminous" number of claims, "with some claims being significantly larger in dollars than home health," Sharp notes. And numerous recent high-profile fraud busts in the HME industry probably don't help, Markette adds. Use Manual For Bundling Backup Even though HHAs and hospices aren't singled out for RAC scrutiny right now, some of the DME topics still will have an impact on them. That's because Region D RAC Health Data Insights recently received CMS approval for these issues: "DME while in Hospice," "Hospice Related Services " B," and "Medical Supplies and Home Health Consolidated Billing." All three reviews will be looking for things that should have been bundled into the hospice or HHA payment but received separate payment. This could cause suppliers, therapists, physicians, and others to come knocking on HHA and hospice doors for payment for claims dating as far back as Oct. 1, 2007. HHAs and hospices are getting a first taste of RAC audits through these tangentially related topics, Markette observes. Do this: That means now is a good time to brush up on the bundling rules for Medicare payment.You don't have to pay every invoice for therapy or supplies that comes your way under HHA consolidated billing. "When you get a letter, don't just say 'we'll cut you a check,'" Markette advises. HHAs have to pay for supplies and services provided under arrangement during a patient's episode, CMS explains in the Medicare Claims Processing Manual, Chapter 10, Section 20. "However, providing services either directly or under arrangement requires knowledge of the services provided during the episode," CMS explains. "An HHA would not be responsible for payment to another provider in the situation in which they have no prior knowledge ... of the services provided by that provider during an episode to a patient who is under their home health plan of care." In other words, if the therapist, supplier, or other provider didn't get a contract with you prior to furnishing services, they are on the hook for payment, not you. That means "before they provide services to a Medicare beneficiary, these providers or suppliers need to determine whether or not a home health episode of care exists for that beneficiary," CMS instructs in the manual. They can ask the beneficiary,check with Medicare contractors, and/or check theCommon Working File, the manual says. In addition to the financial reasons for not paying, you could be courting compliance problems if you pay for services or supplies that weren't medically necessary. If you plan to pay, you should ask the provider or supplier to justify the services first, Markette counsels. Tip: You can try using a letter like one that Boyd's client uses (
Home Health & Hospice Week
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