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Home Health & Hospice Week

Industry Notes:

Implementation Of Rulings First Among Contractors' Appeals Priorities

Published on Fri Sep 05, 2003

The double standard for Medicare contractors versus Medicare providers is evident once again in appeals priorities issued by the Centers for Medicare & Medicaid Services.

Intermediaries and carriers should use the priorities set out by CMS in Aug. 22 program memorandum AB-03-133 when "the budget amount is insufficient to adequately perform the required functions" for appeals, CMS says.

"If providers are even a day late, they are out of the ballpark," protests Burtonsville, MD-based attorney Elizabeth Hogue. "But there is so much leeway for contractors that [appeals] time-lines almost seem meaningless."

"It almost looks like contractors could say they didn't meet targets because they were too busy," Hogue says.

Topping contractors' appeals priority lists are implementing decisions from a variety of bodies ranging from administrative law judges and the Departmental Appeals Board down to medical review. At the bottom of the priority list are forwarding hearing files that don't contain the necessary documentation in the required timeframes, CMS says in the memo.

"I really wish that there were some 'teeth' here," Hogue continues. "For example, why not penalize contractors financially when they don't meet deadlines?"

  • Three more specific codes for speech-generating devices will replace K0542 in the New Year, CMS says in Aug. 22 program memo AB-03-128. K0542 (speech generating device, digitized speech, using pre-recorded messages, greater than 8 minutes recording time) will fall by the wayside in favor of three codes that specify devices with recording times of 8 to 20 minutes (K0615), 21 to 40 minutes (K0616) and 41 minutes or longer (K0617).

    Carriers and intermediaries will implement the coding changes Jan. 1, 2004, but they are effective July 1 of this year.

  • Add three new SARS-related diagnosis codes to the list that takes effect Oct. 1. Codes for SARS-associated coronavirus (079.82), pneumonia due to SARS-associated coronavirus (480.3) and exposure to SARS-associated coronavirus (V01.82) were left off CMS' original list to its contractors because the National Center for Health Statistics only recently issued the new codes, CMS says in Aug. 22 memo AB-03-129.

  • Legislators return from August recess to Washington this week and will continue negotiating an agreement on the bill including Medicare changes and a prescription drug benefit. Home care lobbyists will follow shortly after, with the National Association for Home Care & Hospice and the American Association for Homecare staging a "March on Washington" Sept. 10.

    Observers still doubt whether an agreement can be reached on the controversial drug benefit. Instead, a separate bill on other Medicare issues - including home health copayments, durable medical equipment competitive bidding and other home care provisions - may emerge before this year's session wraps up.

  • The home health prospective payment system needs a lot of fine-tuning, and CMS should hop to it. That's the message the National Association for Home Care sent to CMS in its comments on the 2004 PPS rates, published in the July 2 Federal Register (see Eli's HCW, Vol. XII, No. 24, p. 186).

    CMS should consider lowering outlier thresholds since Medicare is spending less than 5 percent of home care funds - the projected outlier amount - on those cases, NAHC argues. And CMS should considering cutting partial episode payment adjustments altogether, NAHC adds, since PEPs weren't used in calculating PPS rates to begin with. At the very least, CMS should prorate PEP segments with more reimbursement awarded on the front end of the episode, when the HHA incurs the most costs.

    Finally, CMS should increase per-visit rates for low utilization payment adjustments. Under LUPAs, agencies are paid a per-visit amount for episodes with fewer than five visits, but the per-visit rate rarely covers the cost of the visit when administrative overhead is included, NAHC says.

  • Don't worry if you soon get a call from the Joint Commission on Accreditation of Health-care Organizations. JCAHO will be calling accredited providers to make sure they're aware of the survey changes resulting from the Oakbrook Terrace, IL-based accrediting body's "Shared Visions - New Pathways" initiative. Organizations with surveys due in January will be the first to receive calls.

  • A new lawsuit over average wholesale price focuses on drugs commonly used with durable medical equipment. Minnesota Attorney General Mike Hatch says the state has filed suit against two drug manufacturers for grossly inflating AWP for four inhalant drugs, reports the Associated Press.

    The suit filed in state court alleges that Dey Pharmaceuticals and Warrick Pharmaceuticals engaged in various types of fraud, false advertising and unjust enrichment in setting AWP prices for albuterol sulfate, cromolyn sodium, acetylcysteine and ipratropium bromide. More drug companies might be added to the suits later, Hatch said.

    Similar AWP suits against the companies are pending in five other states, AP says.

  • Continental Home Healthcare Ltd. has reported a net loss of $277,923 on revenues of $5.4 million for the quarter ended June 30, compared to a loss of $944,798 on revenues of $5.0 million for the same period in 2002. The Glendale, CA-based DME company says it suspended new sales efforts while it got its billing and collections processes under control, but now it will again aggressively pursue DME market share.

  • For-profit hospice chain Odyssey Healthcare Inc. has acquired Heritage Hospice, which has three locations serving 482 patients in Utah. Dallas-based Odyssey also acquired the hospice program of Omaha, NE-based Grace Inc. with 35 patients, the company says. The Heritage acquisition will mark Odyssey's first locations in Utah, it notes.

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