Home Health & Hospice Week

Intermediary offers solution for erroneously inactivated RAPs.

A claims system mix-up may be holding up your home health agency payments, but you can fix it with some intermediaries.

Problems began when claims, including requests for anticipated payment (RAPs), in location status PB9997 (Paid/Processed), DB9997 (Denied), RB9997 (Rejected) and TB9997 (Returned to Provider) were moved to IB9997 (Inactivated) location status. The claims had paid and showed up on remittance advices, but then moved to the inactivated location, regional home health intermediary Palmetto GBA explains on its Web site.

A RAP in the inactive location means your final claim for that episode will Return to Provider (RTP) due to there being no matching RAP, RHHI Cahaba GBA says in a post to its Web site.

Try this: Cahaba advises agencies to search for the missing RAP if a claim is RTP'd with reason code 38107. "If the RAP is in [Inactive] status/location PB9997 and has not been auto-canceled, access the claim from your RTP file, and press F9 to allow the claim to continue processing," the intermediary tells HHAs.

If the RAP has been auto-canceled or is not there for some other reason, resubmit the RAP and F9 the corresponding claim to start it processing again, Cahaba instructs.

More information is at www.cahabagba.com/part_a/whats_new/20070216_claims.htm.

• Don't miss this federal update if you're a supplier of durable medical equipment. On Feb. 23, the Centers for Medicare & Medicaid Services published a revised version of the general Advance Beneficiary Notice (CMS-R-131).

Public comments are requested during the 60-day comment period and will be considered as part of finalizing the revised ABN, federal officials note.

To view the Federal Register announcement and requirements for submitting comments, go to www.gpoaccess.gov/fr/advanced.html. On this page, under "Search by Issue Date," select "Specific Date," select "On" and enter "02/23/2007." After "Search:" in the next line, enter "CMS-R-131".

To obtain copies of the ABN and supporting documents, go online to www.cms.hhs.gov/PaperworkReductionActof1995.

• Medicare contractors should process "other-than-clean" claims within 45 days, CMS says in Transmittal 1173 (CR 5355). These claims require "investigation or development" outside of the contractor's Medicare operation on a prepayment basis.

If the contractor sends the provider a request for additional information five days after receiving the claim, the contractor will only have 40 days left to finish processing the claim and notify the provider of the result, CMS adds.

But the 45-day clock stops when the contractor sends the development letter and resumes when the carrier receives a response, CMS explains. "Other-than-clean" claims don't include those that have been delayed by a glitch in the Common Working File (CWF).

The transmittal is online at www.cms.hhs.gov/transmittals/downloads/R1173CP.pdf.

• Systems at Palmetto GBA fouled up, causing the contractor to start collecting overpayments through the "offset process." Normally, when the carrier identifies an overpayment, it sends you a demand letter asking for a refund. If you don't send the money within 30 days, interest begins to accrue. After 40 days, the carrier takes the money back from your other payments.

What went wrong: The contractor began taking back payments from current reimbursement before the 40-day timeline had passed. In some cases, Palmetto says it was recouping payments before the provider had even received notification of the overpayment.

Palmetto says it issued checks on Jan. 26 for the amounts it took back by mistake. If providers already had other outstanding debts that were more than 40 days old, Palmetto applied the refunds to the outstanding debts.

• Watch for claim denials if you bill for negative pressure wound therapy.

TriCenturion, the Program Safeguard Con-tractor for Jurisdiction A/B, just issued a final report that cited a 75 percent denial rate on such claims.

The report springs from a widespread pre-payment probe by Tricenturion.

Details: The overall charge denial rate for the review was 75.55 percent. The contractor denied 41 percent of the claims because the medical information submitted didn't demonstrate the policy criteria were met.

The most common problems were: supplier-created forms submitted as a substitute for requested medical information; no medical information submitted; physician orders incomplete; no wound measurements documented; wound measurements unchanged from previous month; initial coverage criteria not met; and therapy longer than four months.

The report also notes that 30 percent of the claims were denied for non-response to the request for documentation.

To see the report, go to www.tricenturion.com/content/pcalpet.cfm.

• Amedisys Inc. earnings continue to soar. The Baton Rouge, LA-based regional chain reported a record $11.4 million in net income on revenues of $144.0 million for the quarter ended Dec. 31, 2006. That's compared to a $7.3 million profit on revenues of $118.9 million for the same period in 2005.

For all of 2006, the company reported $38.3 million in net income on revenues of $541.1 million. That's up from a $30.1 million profit on $381.6 million in revenues for 2005.

Amedisys expects to launch 40 start-up HHAs and four to five hospice locations in 2007, the company says in a release.

Revolving door: Another Amedisys CFO, John Giblin, has also departed. Giblin left for personal reasons, the company says. Amedisys already has appointed capital and management consultant Dale Redman as interim CFO and plans to make him permanent CFO shortly, according to the release.

• With the help of a major acquisition, home health giant Gentiva Health Services Inc.'s annual revenues have topped the $1 billion mark.

The Melville, NY-based national chain reported net income of $20.8 million on revenues of $1.1 billion for 2006. That's compared to a $23.4 million profit on $868.8 million in revenues for 2005, according to a company release.

Gentiva reported mixed earnings for the latest quarter ended Dec. 31. The company recorded a $5.5 million net income on $293.1 million, compared to a $6.3 million profit on $222.0 million in revenues for the same period in 2005.

The company's earnings include the $454 million acquisition of The Healthfield Group Inc. last year (see Eli's HCW, Vol. XV, No. 2). Atlanta-based Healthfield had 130 locations in eight southeastern states plus Michigan offering home nursing, hospice, durable medical and respiratory equipment, and infusion therapy services.

• Ohio chain Cambridge Home Health Care has opened its 27th office in the state. The Akron-based company serves more than 2,200 Medicare, Medicaid, Waiver, PASSPORT and private pay patients with more than 1,600 staff, it says in a release.

• DME suppliers bent on fraud can run but they can't hide. That's the message federal prosecutors in Miami sent Feb. 9, announcing that they had recovered more than $10 million from bank accounts holding funds related to cases of Medicare fraud.

The prosecutors also said that they filed civil lawsuits seeking an additional $30 million in other accounts of suspect clinics and DME companies.

The recovery effort, Operation Equity Excise, targeted bank accounts of "nominee" owners of clinics and DME companies, according to R. Alexander Acosta, U.S. Attorney for the Southern District of Florida.

"In an effort to avoid detection from law enforcement, these companies often closed abruptly, abandoning bank accounts," the statement said. "Some of these bank accounts contained high balances," said Acosta in a written statement.

Links to a list of the civil complaints and copies of two complaints filed are at www.usdoj.gov/usao/fls/PressReleases/070209-01.html.