Home Health & Hospice Week

Billing, OASIS top RAC hit list.

Recovery Audit Contractors continue to crank up their review of home health and hospice claims, so smart agencies will beef up their documentation accordingly.

For example: Region C RAC Connolly Inc. approved a new hospice issue in February. “Providers are billing with Core-Based Statistical Area (CBSA) codes that are invalid or no longer in use,” Connolly says of the CBSA issue on its website. The RAC approved the same topic for home health agencies in December.

Connolly has more hospice and home health issues approved by the Centers for Medicare & Medicaid Services than any other RAC, going from one approved topic to seven in the last 15 months. Other topics include validation of late episode timing (approved in January), OASIS not completed timely (approved last November), medical necessity (approved last June), and partial episode payment (PEP) adjustments (approved last November) and billing (approved in January).

Connolly also is hunting down payments for items or services that should have been bundled into hospice payments. It has that topic approved in the home health, inpatient hospital, outpatient hospital, physician, and durable medical equipment settings. Other RACs aren’t just ignoring home health and hospice, however. Region A RAC Performant Recovery and Region B RAC CGI Federal Inc. both received CMS approval last October for “Skilled Nurse Length of Stay” and “No Skilled Service” topics.

“Home health late episodes (third and later) receive increased payment, therefore payment incentives exist for extended home health care,”

Performant and CGI note on their sites. “Medicare covers skilled nursing services when they are reasonable and necessary. Extended nursing care for observation and assessment may not be covered. Claims for nursing services into the third episode and after will be reviewed to determine if all Medicare coverage criteria is met.”

HHH Medicare Administrative Contractors have been hitting the skilled nursing topic hard as well, observers note.

Region D RAC HealthDataInsights Inc. researches hospice issues only for payments to hospitals and DME suppliers that the hospice should have covered. Likewise, its only home health-related topic is aimed at DME suppliers who were paid for supplies that should have been covered under the home health prospective payment system.

Region A RAC Performant, formerly DCS, tested a few home health topics last year that don’t seem to have made it onto the CMS-approved list. DCS investigated high therapy episodes and high recertifications (see Eli’s HCW, Vol. XXI, No. 21.7).

All four RACs list their approved issues on their websites.