Home Health & Hospice Week

Even though recently approved RAC audit issues don't target hospice claims directly, they could have a direct impact on your bottom line if you get sloppy with your documentation and otherprocesses.

Region D Recovery Audit Contractor HealthDataInsights recently received Centers for Medicare & Medicaid Services approval for two audit issues related to hospice -- "DME While in Hospice" and "Hospice Related Services -- B" (see Eli's HCW, Vol. XIX, No. 9, p. 66).

The reviews will look for equipment and services that should have been bundled into a patient's hospice payment, but received separate payment from Medicare. This could cause durable medical equipment suppliers, hospitals, nursing homes, physicians, and others to come knocking on hospice doors for payment for claims dating as far back as Oct. 1, 2007.

The good news: Because HDI is auditing the other suppliers or providers and not you, money for items the RAC thinks should have been bundled won't come out of your pocket, points out attorney Rachel Hold-Weiss with Arent Fox in New York City. HDI will recoup money from the supplier, hospital, or other provider who furnished the items or services to the patient.

The bad news: The providers that see recouped claims are likely to turn around and bill you for the items or services furnished while the patient was in a hospice stay. If you have a contract with the provider and the item or service provided legitimately should have been included in the hospice payment, you'll need to pay them, Hold-Weiss says. Otherwise, it's not the hospice's responsibility, she says.

Hospices can choose to help out the other provider by furnishing a letter or copies of documentation  howing why the item or service should not have been bundled. "But they're under no obligation to do so," Hold-Weiss maintains. "It's the [other provider's] responsibility to fix the problem, not the hospice's."

Watch out: You may have to pay the other provider if your documentation doesn't show why the item or service was unrelated to the terminal illness, even if it really was, warns attorney Mary Michal with Reinhart Boerner Van Deuren in Madison, Wis.

HDI is likely to go after "slam dunk" data matching items first under these audit topics, expects attorney Connie Raffa, also with Arent Fox.

For example: Hospitals often bill Medicare directly by mistake when patients are in a hospice inpatient unit for general inpatient (GIP) level of care, Raffa tells Eli. Hospices can anticipate seeing bills for GIP from hospitals that have made this error, once the audits catch them.

Another example: Nursing homes often bill in error for medications provided for patients under hospice. The homes should bill Medicare Part D or Medicaid only for meds that are not related to the terminal illness, but they sometimes bill those payors directly for all the patients' medications. While some items are fairly cut and dried, many other services and items are less clear in terms of bundling, cautions consultant Heather Wilson with Weatherbee Resources in Hyannis, Mass. "Figuring out related vs. non-related is a gray area at best and by no means a slam dunk," Wilson says. "Do the RACs understand this?"

HDI will probably use automated review for these audit topics, but in many cases a more complex review will be necessary to determine what is -- and isn't -- related to the terminal illness.

HDI may start out getting the low hanging fruit, such as the hospital GIP error above, with a lowresource- using automated review, Hold-Weiss speculates. Then if those audits prove lucrative, it may move into doing complex review on gray area topics.

Remember: RACs are paid on a contingency basis, receiving a percentage of the funds they recoup. This gives them the incentive to use the least resources to recoup the most payments.

If HDI's hospice-related audits seem productive, you can expect RACs in other regions to jump on the bandwagon with their own hospicerelated topics.