Home Health & Hospice Week

Keep an eye out for cash flow threats.

If you're still submitting claims that span the calendar years, you might run into reimbursement roadblocks.

"RAPs and Final Claims with 'from' dates for service in 2007 spanning into 2008 are being returned to the provider (RTP) with reason code 32403," reports regional home health intermediary Palmetto GBA on its Web site. "RAPs and Final Claims are RTPing back to the provider in error."

Look closely: But a returned claim with reason code 32403 isn't always the claims system's mistake, Palmetto notes. If you have a claim that uses the wrong year's HIPPS code, it will RTP correctly.

Example: If your claim has a from date in 2007 and a thru date in 2008 and the claim includes a 2008 HIPPS code, it's "not a system problem," Palmetto explains.

But if your claim uses the correct year's HIPPS code and still gets returned, it's due to the system'S glitch. For instance, if the claim has a from date in 2007, a thru date in 2008, a first billable visit in 2008 and a 2007 HIPPS code, the system will reject it in error, Palmetto says.

Palmetto has reported the problem, but "there is no estimated time on when this fix will go into place," the intermediary says.

Meanwhile, the Centers for Medicare & Medicaid Services has fixed another nagging problem. The system was incorrectly recouping RAPs when paying final claims, reports the National Association for Home Care & Hospice. Home health agencies served by Palmetto and National Government Services complained to NAHC about the problem, the trade group says.

History: The same RAP recouping problem occurred in 2006 and 2007, NAHC points out.

A fix put into place over the weekend of Feb. 10 should have solved the problem, CMS tells NAHC.

CMS also reissued the PPS refinement and rate update transmittal for calendar year 2008. The transmittal now specifies that CMS will issue payment rates annually in a "recurring update notification instruction," according to Feb. 7 Transmittal No. 1443 (CR 5879).

• Get ready to defend your claims for hypertension patients with long stays. RHHI Cahaba GBA is initiating a "continuing widespread review" of patients with a hypertension diagnosis in their third or later episode, the intermediary says on its Web site.

Top reason: In a widespread probe review on the topic, Cahaba medical reviewers denied 86 percent of claims reviewed. "The most problematic issue ... was that the documentation for the skilled nurse visits did not support medical necessity," Cahaba says.

HHAs shouldn't expect observation and assessment visits to hold up without supporting documentation. Observation and assessment are reasonable and necessary "when the likelihood of change in a patient's condition requires a skilled nurse to identify and evaluate the patient's need for possible modification in the patient's plan of care until the patient's treatment regimen is essentially stabilized," Cahaba reminds. "Indications such as abnormal/fluctuating vital signs, weight changes, or edema and respiratory changes may justify further observation and assessment."

Observation and assessment won't hold up when there is no attempt to change the treatment to resolve problems and they are a longstanding pattern, Cahaba says.

Reviewers found other problems including non-response to additional development requests (ADRs) and physicians' orders and plan of care problems--particularly verbal orders. The article is at www.cahabagba.com/part_a/whats_new/20080124_review.htm.

• Home health agencies got off relatively lightly in the HHS Office of Inspector General's newly released Health Care Fraud and Abuse Control Program report for 2006. The report touted the program's $2.2 million in judgments and settlements in fiscal year 2006. "The HCFAC account has returned over $10.4 billion to the Medicare Trust Fund since the inception of the program in 1997," the OIG notes.

The report lists two cases of egregious home health nurse abuse. In one case a nurse caused her patient's death and stole his money. She received a life sentence for homicide and a Medicare exclusion.

In another case, a nurse was sentenced to eight and a half years in prison for raping his home care patient who was a quadriplegic, developmentally disabled and suffered from spastic cerebral palsy. He was excluded from Medicare for 25 years.

However, the OIG dedicated a section to "Hospice Fraud" and listed Odyssey HealthCare Inc.'s $12.9 million settlement with the government over billing for allegedly non-terminally-ill patients. Odyssey also entered into a corporate integrity agreement (CIA) with the OIG.

Whistleblower: It was a former Odyssey regional vice president who brought the qui tam suit against the company that sparked the settlement, the OIG points out. The whistleblower receives $2.3 million of the settlement.

The OIG also singled out Alabama-based Faith Hospice Inc. for a false claims settlement of nearly $600,000. "The investigation was initiated when a review of a sample of Faith Hospice's medical records showed that more than half of its patients were ineligible for hospice care," the report says.

The report slams suppliers the hardest, with nine cases listed under the "Durable Medical Equip-ment Fraud Section." Many of the cases were in Houston and related to Operation Wheeler Dealer.

And the OIG highlighted the $10 million settlement Lincare Holdings Inc. reached over allegations that it paid kickbacks to physicians for referrals. The OIG alleges that Lincare gave docs gifts ranging from fishing trips to office equipment in order to capture referrals from 1993 to 2000.

The report is at www.oig.hhs.gov/publications/docs/hcfac/hcfacreport2006.pdf.

• Health care providers breathed a sigh of relief as Senate Democrats told HHS Secretary Mike Leavitt that there was no way Congress would pass President Bush's proposed budget for Medicare.

The President has proposed freezes and rate reductions for home health agencies, hospices and durable medical equipment suppliers (see Eli's HCW, Vol. XVII).

In a Senate Finance Committee hearing on the budget Feb. 6, Chair Max Baucus said "you've asked for huge, Draconian cuts, which this Congress is not going to make."

Even Republicans got in on the act. Sen. Pat Roberts (R-KS) criticized cuts for hospitals included in the proposal, according to press reports.

Warning: But that doesn't mean home care providers can relax yet. Lawmakers still will be searching for a way to avoid the 10 percent cut to physicians' Medicare payment rates that takes effect July 1, and home care providers are a tempting target for cuts to raise the funds.

• It remains to be seen how home health agencies will work with Medicare's Quality Improvement Organizations once the next contract phase commences in August 2008.

"CMS' perennial 'transparency' efforts are pretty cloudy" as far as HHAs' involvement, allows Bob Wardwell of the Visiting Nurse Associations of America, who tells Eli that he has contacted CMS for clarification on HHAs' opportunities in the QIOs' Ninth Statement of Work.

CMS has outlined areas in which home health agencies could play important roles, says Wardwell, but the agency also seems to be making home health "almost an afterthought with all the focus on hospitals and skilled nursing facilities."

• You can learn more about the new system that should make Medicare enrollment and cost reporting easier. CMS will soon offer the Provider Enrol-lment, Chain and Ownership System (PECOS) and Provider Statistical and Reimbursement Report (PS&R) online. To access the systems, providers must register with "a new CMS security system known as the Individuals Authorized Access to CMS Computer Ser-vices - Provider Community (IACS-PC)," the agency explains. More details are in a fact sheet at www.cms.hhs.gov/MLNProducts/downloads/IACSchart.pdf, which contains links to three MLN Matters articles on the new system.

• Hospice services furnished to nursing home patients is a big compliance hot spot in one state. Connecticut's Department of Public Health has alerted hospice providers that recent surveys of HHAs providing hospice services "have identified significant issues of non-compliance related to hospice services provided to nursing home residents," reports the Connecticut Association for Home Care in its newsletter.

"DPH reminded providers that they are obligated to maintain professional management of the care plan when the patient resides in a nursing home," CAHC points out. HHAs also must directly provide the core services of nursing, physician, medical social services and counseling, among other standards.

• Amedisys Inc. plans to buy a home care company with 24 home health agency locations, the Baton Rouge, LA-based regional chain says in a release. Amedisys will purchase the holding company that operates Family Home Health Care Inc. and Comprehensive Home Healthcare Services Inc., which have 21 locations in Kentucky and three in Tennessee.

Amedisys plans to pay $43 million for the agencies that generated $39 million in revenue in 2007, it says. Kentucky is a certificate of need state.