Home Health & Hospice Week

Your PEPPER report could come in handy.

With attention on low-visit episodes heating up, now’s the time to make sure your related claims can stand up to reviewer examination.

In light of the HHS Office of Inspector General’s new Work Plan item, “Review of Home Health Claims for Services With 5 to 10 Skilled Visits,” consider the following expert advice on dealing with Low Utilization Payment Adjustment issues:

1. Know your risk. Reviewers realize that no home health agency will have zero episodes with five to 10 visits. But they will likely be looking at agencies whose barely-exceeding-LUPA-rate episodes are higher than their peers’. Take a look at your stats for episodes containing five to 10 visits to know where you stand, advises attorney Robert Markette Jr. with Hall Render in Indianapolis. Particularly focus on those episodes that exceed the LUPA threshold by only a visit or two.

The problem: The Centers for Medicare & Medicaid Services and the HHH Medicare Administrative Contractors haven’t issued readily available data on episodes containing five to 10 visits, notes Joe Osentoski, Reimbursement Recovery & Appeals Director with QIRT in Troy, Michigan.

The solution: You can look to your free PEPPER report from Medicare for a few stats that may help, Osentoski tells Eli. The PEPPER report includes metrics on “Episodes with 5 or 6 Visits” as well as “Non-LUPA Payments,” Medicare’s PEPPER contractor notes.

PEPPER data puts the national 5-to-6 visit episode occurrence around 7 percent. And data from 2016 cost reports analyzed by BKD put the median LUPA rate at 6.6 percent and the upper quartile at 10.3 percent, says the Springfield, Missouri-based firm’s M. Aaron Little.

Figures above those benchmarks “could put an agency at risk,” Osentoski cautions. However, keep in mind when looking at episodes with five to 10 visits, that the average would increase, he adds.

2. Boost your low-visit episode documentation. There are many good reasons that a patient’s episode will exceed the LUPA threshold, Markette points out (see story, p. 178). The key will be making sure your documentation supports those visits by illustrating the reasons.

“The OIG is saying, ‘we’re skeptical’” of episodes with five to 10 visits, Markette says. “When the OIG is skeptical, you need to make sure you’re compliant.” This is where sloppy documentation can come back to haunt you, he warns. Documentation must prove the medical necessity for every single visit.

3. Reconsider your low-episode billing. Be prepared to look at your low-visit episodes with new eyes, urges Washington, D.C.-based regulatory attorney Elizabeth Hogue. “Agencies with a high number of five to 10 visits during an episode should take a hard look at the appropriateness of these visits,” Hogue counsels. “If agencies identify instances when the fifth visit and above were not medically necessary or patients did not meet eligibility criteria, they should take action. Agencies may decide to back those claims out of the system electronically and resubmit them as LUPAs, if they are within the one-year timely filing period.”

4. Prepare for increased scrutiny. With the OIG focusing on episodes barely exceeding LUPA thresholds, don’t be surprised to see other Medicare contractors pick up the issue too, experts say. That focus may intensify once the Centers for Medicare & Medicaid Services issues its next payment reform proposal, particularly if the pay reform model rejiggers the LUPA as HHGM did.

Remember: “In last year’s proposed HHGM model, CMS built a major behavioral adjustment into that model that assumed providers would make extra visits to avoid LUPAs,” Little points out.