Home Health & Hospice Week

Feds will examine cases where one visit translates to additional thousands of dollars.

Just where do you fall in relation to your peers when it comes to episodes barely exceeding the LUPA threshold? The answer may land you in hot water with the feds, as a government watchdog agency takes on manipulation of the payment mechanism as a new topic of scrutiny.

The HHS Office of Inspector General has announced “Review of Home Health Claims for Services With 5 to 10 Skilled Visits” in its newest crop of Work Plan items. The OIG notes that under the Home Health Prospective Payment System, home health agencies get paid a modest Low Utilization Payment Adjustment per-visit amount for visits one through four. “Once a fifth visit is provided, an HHA will instead receive a full 60-day payment based on episode of care,” the OIG notes on its Work Plan website.

The OIG, the Centers for Medicare & Medicaid Services, and others have worried about HHAs gaming LUPAs since the inception of PPS in 2000. The addition of one single visit can mean the difference in payment, for example, between $567.36 (four skilled nursing visits at 2018 unadjusted per visit rates) and $3,039.64 (unadjusted 2018 base episode rate). That difference can increase steeply for pa-tients in high-paying case mix groups, such as those for high therapy.

Now the OIG says it “will review supporting documentation to determine whether home health claims with 5 to 10 skilled visits in a payment episode in which the beneficiary was discharged home met the conditions for coverage and were adequately supported as required by Federal guidance.” The agency expects to issue a report on the subject next year.

LUPAs May Affect You More Under Reform

Things have been fairly quiet on the LUPA front for a while. But the OIG may be exhibiting renewed interest in the topic thanks to the aborted Home Health Groupings Model proposal included in last year’s Home Health Prospective Payment System proposed rule, says attorney Robert Markette Jr. with Hall Render in Indianapolis.

Reminder: Under HHGM, CMS proposed a complicated LUPA structure where the number of visits triggering the adjustment varied based on the case mix category, from two to seven visits (see Eli’s HCW, Vol. XXVI, No. 27-28). Combined with the switch from 60-day to 30-day billing, the payment reform model would have put second billing episodes at much higher risk of LUPAs, experts predicted.

HHGM’s LUPA changes may be motivating the OIG to examine the adjustments now, Markette suggests. CMS may have withdrawn its HHGM proposal last year, but observers expect to see an only somewhat-modified version of it re-proposed in the imminent 2019 payment rule — likely with LUPA changes intact.

Markette worries about the OIG “second guessing” HHAs’ clinical decisions with the benefit of hindsight. “That’s not appropriate,” he tells Eli.

Some HHAs may be committing outright fraud and gaming the LUPA payment mechanism, Markette says. In those cases, the feds should prosecute those providers, he exhorts. Otherwise, “don’t pretend every five-visit LUPA episode is a problem,” he chastises.

Plus: It’s a bit of a stretch to say that a 10-visit episode is barely exceeding the LUPA threshold, Markette adds.

There are a variety of legitimate reasons that episodes last only five or six visits, Markette points out. They range from clinical appropriateness to patients refusing visits and terminating their own service once they start to feel better. “PPS is based on averages,” Markette maintains. “Some patients only need five to six visits.”

Note: The link to the Work Plan item listing is at https://oig.hhs.gov/reports-and-publications/workplan/index.asp in the “What’s New” column.