Home Health & Hospice Week

Medicare overpaid HHAs $192 million for episodes slightly exceeding LUPA thresholds.

LUPAs are more of a moving target under PDGM, but it’s your agency that could become the target of claims scrutiny if you don’t pay attention to your documentation for periods that flirt with the LUPA threshold.

In a new report, the HHS Office of Inspector Gen-eral says Medicare overpaid home health agencies to the tune of $192 million for episodes from 2017 with five to seven visits. The OIG had an independent review contractor examine claims in which visits barely exceeded the five-visit Low Utilization Payment Adjustment threshold because at the time, prospective payment system reimbursement took a big jump when it went from LUPA per visit to episodic pay.

The OIG had 125 claims reviewed and found that 25 claims did not comply with Medicare requirements. “Medicare improperly paid HHAs for a portion of the payment episode for 14 claims and for the full payment episode for 11 claims, totaling $41,613,” the report says. The OIG then extrapolated that error rate.

Don’t think you don’t have to worry about LUPA scrutiny anymore under the Patient-Driven Groupings Model. “The majority of these improper payments would still be improper under the home health PPS methodology that uses the PDGM, effective January 1, 2020, which revised the LUPA threshold from four visits to a threshold varying from two to six visits based on the HIPPS payment code billed,” the OIG warns the Centers for Medicare & Medicaid Services in the report. “Even with the new payment methodology, there is still a significant risk of improper payments for HHA claims with visits slightly above the applicable LUPA threshold.”

In its comments on the report, CMS agrees to have contractors recoup money from the 25 identified claims and to “encourage the Medicare Administrative Contractors to perform data analysis and risk assessments of claims with visits slightly above the applicable low utilization payment adjustment threshold,” among other measures.

Watch out: Homebound status is likely to dog near-LUPA claims, warns the National Association for Home Care & Hospice in its member newsletter. “The criteria for meeting homebound status has been a persistent area of vulnerability for claim denials for home health agencies. Determining whether the beneficiary meets the criteria can be very subjective and requires clear and accurate documentation to support the homebound status,” the trade group says.

NAHC “has long been concerned about the accuracy of claims denials when reviewing for subjective criteria and believes that interrater reliability strategies should be part of any medical review process for denials related to subjective coverage rules,” the group says.

Note: The 28-page report is at https://oig.hhs.gov/oas/reports/region9/91803031.pdf