Home Health & Hospice Week

ALJs' independence threatened with new proposed rule.

You could have a much tougher time getting a fair shake at the administrative law judge level if a new proposed rule is finalized.

The Department of Health and Human Services wants to compel ALJs and the HHS Departmental Appeals Board to follow published guidance issued by HHS or its components--including the Centers for Medicare & Medicaid Services.

The proposed rule aims "to ensure that the final administrative decision of the Department reflects the considered opinion of the Secretary of Health and Human Services," according to a notice in the Dec. 28 Federal Register.

The rule "would permit the Secretary an opportunity to review DAB [and ALJ] decisions to correct errors in the application of law, or deviations from published guidance, in such disputes," the notice adds.

This is exactly the kind of interference providers feared when the ALJs transferred from the Social Security Administration to HHS, opponents say (see Eli's HCW, Vol. XIII, No. 36).

Speak out: HHS will take comments on the rule until Jan. 28. The rule is at www.access.gpo.gov/su_docs/fedreg/a071228c.html --scroll down to HHS.

• Providers in Boston, Chicago and their surrounding areas will be the first to participate in CMS' Post Acute Care Payment Reform Demonstration (PAC-PRD). The demo will pilot the CARE patient assessment tool across post-acute provider settings (see Eli's HCW, Vol. XVI, No. 33 for tool details).

The demo will eventually include 10 cities. Boston providers will begin training and data collection in March, while the remaining nine markets will begin on a staggered schedule between May and September. The other sites are Dallas; Lakeland/Tampa, FL; Lincoln, NE; Louisville, KY; Rapid City, SD; Rochester, NY; San Francisco; and Seattle/Tacoma, WA.

The PAC-PRD, mandated by Congress in the Deficit Reduction Act of 2005, will allow CMS to collect and compare information about the health of beneficiaries and the care or clinical services they received in various post-acute settings, including home health, according to the agency's news release.

To see the news release, go to www.cms.hhs.gov/apps/media/press_releases.asp and scroll down to Dec. 19, 2007 and "CMS Announces Selection of Sites for Demonstration to Revise Post Acute Payment."

• President Bush has signed into law the Medicare package Congress passed last month. On Dec. 29, the President approved S. 2499, the Medicare, Medicaid, and SCHIP Extension Act of 2007, which provides a 0.5 percent Medicare payment increase for physicians for six months and extends the State Children's Health Insurance Program (SCHIP) through March 31, 2009.

Home care providers have heralded the bill as a victory since it contained no additional cuts or rate freezes for them (see Eli's HCW, Vol. XVI, No. 44). Cuts for home health agencies, oxygen providers and wheelchair suppliers were all on the budget negotiation table.

But providers also were disappointed that the Medicare package didn't fix the HHA cut for case mix creep or durable medical equipment competitive bidding and oxygen transfer issues. The law also extends the current therapy cap exception, which applies to outpatient therapy under Part B only, not therapy furnished under a home health plan of care.

Keep watch: Lawmakers will return to the Medicare issue soon since the doc payment fix is only good for six months, industry representatives warn. Stay alert for budget cuts proposed early this year.

• There are 1,836 possible HIPPS codes under the 2008 PPS. If you want to know the resulting case mix weight and routine medical supplies reimbursement amount for each of these possibilities, CMS has just the document for you.

Go to www.cms.hhs.gov/HomeHealthPPS/03_coding&billing.asp and select "HH PPS HIPPS Code Weight Table."

• You have three new codes bundled into PPS as of Jan. 1 and three old codes cut from the home health bundling list.

Your HHA is responsible for paying for non-routine supplies A5083 (Continent Device, Stoma, Absorptive Cover for Continent Stoma) and A6413 (Adhesive Bandage, First-Aid Type, Any Size, Each) in your per-episode payment, according to Dec. 14 Transmittal No. 1391 (CR 5829).

CMS also adds therapy code 96125 (Stand-ardized Cognitive Performance Testing Per Hour) to the consolidated billing list.

Supplies code A5105 is now redefined as "Urinary Suspensory With Leg Bag With Or Without Tube, Each," the memo adds.

You are off the hook for these deleted codes: A6200 (Composite Dressing, Pad Size 16 Sq. In. or Less, Without Adhesive Border, Each Dressing), A6201 (Composite Dressing, Pad Size More Than 16 Sq. In. But Less Than or Equal To 48 Sq. In., Without Adhesive Border, Each Dressing) and A6202 (Composite Dressing, Pad Size More Than 48 Sq. In., Without Adhesive Border, Each Dressing).

Resource: The entire HHA consolidated bil-ling list is at www.cms.hhs.gov/HomeHealthPPS/03_coding&billing.asp under the "Downloads" section.

• You may be seeing claims rejections if you're not on top of NPI issues. As of Jan. 1, Medicare requires providers' claims to have a National Provider Identifier number in the primary provider (billing and pay-to) fields, CMS notes in a message to providers.

But even if you do include your NPI, you could still see rejections if the NPI doesn't match the legacy number you're also using on the claims.

Do this: If you're submitting an NPI and legacy number pair and seeing rejections, "go into the NPPES website located at https://nppes.cms.hhs.gov and validate that your NPPES information is correct and that you reported your Medicare legacy identifier in the appropriate Medicare sections of the 'Other Provider Identification Numbers' field," CMS instructs.

If the information in your NPPES record is correct and contains your Medicare legacy identifier, "print the screen (so you have a copy of this portion of your NPPES record on paper), call your Medicare contractor, and ask that they confirm that this information is present in the Medicare NPI Crosswalk," CMS details. "If your contractor confirms you are not on the crosswalk, please ask them to validate what information they have in their provider file."

• You should be ready to defend your claims for patients with the lowest HIPPS code. Claims with the lowest HIPPS code, HAEJ1, are seeing high denial rates under Cahaba GBA medical review, the regional home health intermediary says in its January newsletter to providers.

A widespread edit for HAEJ1 claims saw a whopping 72 percent denial rate for the quarter ending Sept. 30, Cahaba reports. The edit "has had [a] high incidence of errors for over two years," the RHHI adds.

Of 89 such claims reviewed during the quarter, Cahaba denied 68. "Thirty-two of the 68 denials were related to lack of documentation of homebound status," the intermediary says.

• A federal court has slapped a Louisiana home health agency owner with millions in fines and damages for physician kickbacks. Last February, the U.S. District Court for the Western District of Louisiana ruled against Monroe, LA-based Aging Care Home Health Inc. CEO and owner Janice Davis in a Stark II and Anti-Kickback lawsuit.

Based on a whistleblower case, the government alleged that Aging Care and Davis paid physicians for referrals via "sham" compensation arrangements with the docs (see Eli's HCW, Vol. XVI, No. 8). The ruling came after a magistrate judge opinion that had sided with the HHA.

Now the federal court has found that Aging Care and Davis violated the False Claims Act as well as Stark II and has ordered Davis to pay nearly $4.7 million in damages and fines. Aging Care is out of business.

"The court finds that Davis and Aging Care acted with knowledge that they were violating the Stark laws with regard to their payments to advisory board physicians, their presentation of claims to Medicare and their failure to refund Medicare amounts received," says the opinion, according to the Monroe News-Star.

• Minnesota is going after Medicaid fraudsters. The state's attorney general's office is investigating St. Paul-based Perfect Home Care Inc. for billing Medicaid for $120,000 worth of personal care assistants when there is no documentation to support the claims.

The state's Medicaid Fraud Control Unit is investigating whether the agency billed for visits never furnished and falsified visit records, according to the St. Paul Pioneer Press.

The AG sought a search warrant for the case, the newspaper notes. The warrant affidavit alleges the agency paid a client's mother $100 for changing her story about lack of services.