Home Health & Hospice Week

Court must approve funds for operations.

CMS and the OIG aren't the only federal agencies cracking down on home care fraud.

The Federal Bureau of Investigation searched the office of Home Care Hospice Inc. in Philadelphia, reports the Philadelphia Daily News. At the same time, an Oct. 6 temporary restraining order signed by U.S. District Judge Legrome Davis forbids HCH and four defendants from conspiring to defraud the Medicare program.

The defendants are HCH President Alex Pugman, Pugman's wife Svetlana Ganetsky, Mat-vei Kolodech, and Kolodech's wife Malvina Yako-bashvili, the Daily News says.

The restraining order instructs the defendants not to falsify patient records, backdate service records or revocation requests, submit bills for service not provided, or bill Medicare for a reimbursement rate higher than allowed under federal law.

The home health agency and hospice can still operate. But the agency must submit requests to the court for funds to support operations. The defendants have $8.5 million in 39 bank accounts that they may not move, the newspaper adds.

• If you're getting claims returned due to reason code 31147, regional home health intermediary Cahaba GBA is offering you a helping hand.

Remember: Claims will bounce back "if the fifth position of the HIPPS code billed contains the letters S, T, U, V, W, or X and supply revenue codes 027X or 0623 are not present on the claim," Cahaba explains about the nonroutine supply edit that began on Oct. 1 (see Eli's HCW, Vol. XVII, No. 34, p. 266).

You must report the NRS -- including revenue codes, units, charges and a date of service that falls within the "FROM" and "TO" date of the home health claim -- on the claim for it to go through. Or if you didn't furnish NRS, change the fifth digit to a number 1-6 depending on the NRS level.

More information and instructions are at www.cahabagba.com/rhhi/claims/home_health/supplies_nr.htm and http://www.cahabagba.com/rhhi/claims/home_health/supplies_changes.htm.

• The Centers for Medicare & Medicaid Services continues to move forward with competitive bidding for durable medical equipment. CMS is calling for nominations for the Program Advisory and Oversight Committee on DME bidding.

"Medicare is committed to making sure that beneficiaries and taxpayers get the highest value for their health care dollars, and evidence from pilot projects has proven that competitive bidding for certain types of DMEPOS items and services can be a major tool in achieving that goal," CMS Acting Administrator Kerry Weems says in a release. "We look forward to working with the new PAOC members to bring people with Medicare higher quality durable medical equipment items and services at lower prices."

CMS is ending the current PAOC members' terms because the Medicare Improvements for Pa-tients and Providers Act delayed bidding and extended its implementation timeline, the agency says.

"In the absence of competitive bidding, Medicare pays for DMEPOS under fee schedules derived from historical charges adjusted for inflation, even though the same items may be available at lower prices in the market," CMS warns.

But the DME industry continues its fight against the program. The American Association for Homecare has created a task force to develop an alternative to competitive bidding. "The Association will work to get Congress to consider a different approach to the bidding program which manifested many shortcomings during its flawed implementation," the trade group says in a release.

"The bidding program would have negative effects on both HME providers and the patients who require these items and services," AAHomecare's Tyler Wilson says. "The bidding program has the potential to eliminate approximately 90 percent of Medicare providers in specified markets and aggressive bidding will lead to a significant reduction in services and quality of care."

• Don't make the mistake of discharging all your patients or you're as good as giving up your Medicare business.

"A federal district court in Texas upheld the Medicare termination of a home health agency that had discharged all of its patients while waiting for Medicare to approve the pending change of ownership (CHOW)," reports the National Association for Home Care & Hospice.

Even if a state agency tells you to do it, it will close your business, NAHC warns in its member newsletter. "Cessation of business, which includes discharging all patients, has been held to be a provider's voluntary termination from the Medi-care program," the trade group says. "Medicare can deny enrollment or terminate a provider's billing privileges for failing to be operational."

Tip: "Agencies need to remain operational before seeking Medicare certification and throughout the time that the agency wants to retain its Medicare certification," NAHC stresses.

• A new Medicaid final rule could remove home care patients from the safety net created by home health agencies.

Under the rule, states can change their programs to allow benes to hire, direct, train, or fire their own personal care workers. That includes hiring family members.

And the rule published in the Oct. 3 Federal Register allows states to give benes a cash allowance to hire aides or buy medical equipment. "States choosing this option must have necessary quality assurances and other safeguards in place to assure the health and welfare of participants," CMS adds. "States must also furnish sufficient information, training, counseling and assistance to participants in order to help them effectively manage their budgets and their personal assistance services."

• Nov. 1 is the deadline for the revised ex-pedited determination notice forms. "The renewed, OMB-approved Notice of Medicare Provider Non-coverage (CMS-10123) and Detailed Explanation of Noncoverage (CMS-10124) are now available for download and immediate use," CMS says on its Beneficiary Notices Initiative Web page.

The forms contain only slight revisions from the current ones, the National Association for Home Care & Hospice notes.

Since 2005, home health agencies and hospices have had to issue the notices at least two days before discharge so patients can request an appeal from the Quality Improvement Organization, if they wish (see Eli's HCW, Vol. XIV, No. 23, p. 178).

The new forms are online at http://www.cms.hhs.gov/BNI/06_FFSEDNotices.asp.

• Sen. Ron Wyden (D-Ore.) and Rep. Edward Markey (D-Mass.) have introduced legislation that would create a Medicare demonstration project that would expand at-home services for some beneficiaries with multiple chronic health conditions. The bills (S. 3613 and H.R. 7114) call for a three-year demo project in 26 states that would aim to contain the high costs of chronically ill patients.

Independent contractors known as "Inde-pendence at Home organizations" would coordinate care for such beneficiaries, the bills say. A physician or nurse practitioner would be part of the home care team for the demo.

• The Department of Justice has joined in a whistleblower lawsuit against a major DME and a major nursing home company for kickbacks and fraud, it says.

According to a DOJ press release, McKes-son Corp. set up a sham DME company to bill for medical equipment McKesson furnished to Beverly Enterprises nursing home patients. Beverly is now known as Golden Gate.

Beverly Enterprises got to keep all the sham company's profits, even though a McKesson Corp. subsidiary ran it, in exchange for Beverly referring its nursing home residents to McKesson for DME, the feds allege.

The DOJ press release is at http://www.usdoj.gov/opa/pr/2008/October/08-civ-898.html.

• CMS may be exempting medical professionals like physicians and therapists from DME accreditation requirements, but the same isn't true for pharmacies.

"Pharmacists and pharmacies were not in-cluded in this provider exemption and do need to ob-tain accreditation," CMS says in a clarification to providers. "For example, if a pharmacy is providing DMEPOS supplies to Medicare beneficiaries, such as diabetic supplies and enteral/parenteral nutrition, they would need to be accredited by the September 30, 2009 deadline."

More information about DME accreditation is at http://www.cms.hhs.gov/medicareprovidersupenroll/.

• Don't forget to celebrate National Home Care & Hospice Month in November with your staff and your community. The 2008 theme for the month is "Preserving Health Independence and Freedom," NAHC says. The hospice theme is "Love in Action."

This year Nov. 9-15 is home care aide week, with the theme of "Honoring Those Who Honor Others," NAHC says.

For media resources and ideas on how to celebrate, go online to http://www.nahc.org/HCHPCMonth/08/about.html.