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Home Health & Hospice Week

Industry Notes:

OIG KEEPS FRAUD SPOTLIGHT ON DME INDUSTRY

Published on Fri Jan 09, 2009

Report singles out suppliers for scrutiny.

The HHS Office of Inspector General wants HHS to keep an even closer eye on the DME industry.

In its annual report of HHS management challenges, the OIG singles out durable medical equipment suppliers as requiring special scrutiny.

The "OIG continues to identify significant vulnerabilities related to Medicare payments for DMEPOS, including (1) DME suppliers circumventing enrollment and billing controls and defrauding the program, (2) high improper payment rates for certain types of DMEPOS, and (3) inappropriate payment rates for certain DMEPOS," the report says.

The OIG runs through the laundry list of reports it put out in 2007 and 2008 identifying DME-related fraud and abuse problems. "With increasing dollars at stake and a growing beneficiary population, the importance and the challenges of safeguarding this program are greater than ever," the OIG stresses. "Additionally, fraud, waste, and abuse schemes have become increasingly sophisticated and constantly adapt in response to the latest oversight efforts by Congress, CMS, OIG, and our law enforcement partners."

The report is online at www.oig.hhs.gov/publications/challenges/files/TM_Challenges08.pdf.

• Home health agencies furnishing Part B therapy in the home don't have to feel limited by therapy caps if their documentation is up to snuff.

Remember: The caps apply only to outpatient Part B therapy, not therapy furnished under a home health plan of care.

You can bill with the KX modifier after the patient reaches his $1,810 limit on skilled treatment,notes physical therapist Rick Gawenda, director of physical medicine and rehabilitation at Detroit Receiving Hospital and owner of Gawenda Seminars & Consulting. By using the KX modifier, you are telling your Medicare contractor that the Medicare beneficiary continues to require skilled therapy services above and beyond the therapy cap,Gawenda explains.

Your documentation would support the medical necessity of your therapy services and support that the services were skilled and could have only been provided by a therapist or an assistant under the supervision of a therapist, he tells Eli.There is no limit for the KX modifier, regardless of whether the diagnosis has changed, as long as youcan support medical necessity and skilled intervention in your documentation.

Other cap details: There are no major cap changes afoot. In a Nov. 7, 2008, transmittal addressing the caps, CMS merely pointed out the newest date extension for the exceptions process -- Dec. 31, 2009. After that, the exceptions process expires unless Congress takes further action.

• Growth of home health spending outpaced

growth of Medicare spending overall by 60 percent in 2007. Spending for "freestanding home health services" grew by 11.3 percent in 2007, CMS says in releasing its latest spending figures.

Medicare expenditures increased by 7.2 percent in the same time period, notes CMS's Office of the Actuary in a report published in health policy journal Health Affairs.

The home health increase "was partially due to an increase in price growth," CMS notes. However,"much of the growth continues to be influenced by non-price factors, such as use and intensity."

• CMS soon may rework its HCPCS coding

for negative pressure wound therapy (NPWT) devices. CMS and the Agency for Healthcare Research and Quality are reviewing the items. CMS is calling for "relevant studies and information for use in consideration of coding changes," it says in a message to providers. "CMS will use this review in its assessment of whether existing HCPCS codes adequately represent the technology and comparative benefits of NPWT devices."

"We are particularly interested in those well-conducted clinical trials that describe the comparative benefits of these devices," the agency adds. Submissions are due by Feb. 6.

More information is online at www.ahrq.gov/clinic/ta/npwtrequest.htm.

• You know how irritating it is when you can't bill for a patient who transferred from another home health agency, because that HHA hasn't submitted the final claim for her? Don't do that same thing to outpatient therapy providers, urges regional home health intermediary National Government Services in its January bulletin for providers.

"It is important that home health agencies discharge their patients in a timely manner," NGS says. "Patients treated under a home health plan of care should be discharged from the HHA when they are no longer homebound. They are then eligible to receive rehabilitation services on an outpatient basis."

Don't hold up the Part B therapy provider,NGS exhorts. "If the HHA does not file their claim in a timely manner, the rehabilitation agency is not able to bill Medicare for the services they provide."

• Maybe Medicare will consider adding coverage for telehealth now that the Veterans Administration has shown its benefits regarding hospitalizations.

A new VA study found a 25 percent reduction in the average number of days hospitalized and a 19 percent reduction in hospitalizations for patients using home telehealth, the VA says in a  release. The data also shows that for some patients the cost of telehealth services in their homes averaged $1,600 a year -- "much lower than in-home clinician care costs."

The study in the journal Telemedicine and e-Health looked at outcomes from 17,025 VA home telehealth patients. VA's home telehealth program has 35,000 patients and "is the largest of its kind in the world," the agency says.

"The results are not really about the technology,but about how using it helps coordinate the full scope of care our patients need," says Dr. Adam Darkins, chief consultant in VA's care coordination program, who led the study. "It permits us to give the right care in the right place at the right time."

• Your LUPA claims will have one less hoop to jump through starting Jan. 12.

The home health prospective payment system claims software was unnecessarily editing low utilization payment adjustment (LUPA) claims for episode sequence, CMS explains in Dec. 12 CR 6283 (Transmittal No. 413).

"Since LUPA claims are paid on a per-visit basis, whether a claim is an early or later episode does not affect the payment," CMS notes in the transmittal. "Including LUPA claims in episode sequence editing has caused problems with other Medicare systems processes."

So CMS is excluding LUPA claims from episode sequencing edits.

Add-on question: Don't worry that this process will mess up your add-on payments. "LUPA claim payments qualify for an add-on payment in the case that the episode is the first or only episode in a sequence of related episodes. This add-on payment is ensured by a separate process in Medicare systems, so it is unaffected by this Change Request," CMS assures.

• If you're a provider served by RHHI Palmetto GBA and are seeing claims return with reason codes 30918 and 30920, you're not alone.Such claims aren't processing, Palmetto says on its claims processing issues Web site.

And there isn't any good news yet. "We are aware and researching," Palmetto says.

• If you don't listen to your employees' complaints, the authorities may be all too happy to do so. That's one lesson learned by the Tucson, Ariz.location of Evercare Hospice, a 15-location hospice chain run by managed care company UnitedHealth Group.

Two former Tucson Evercare employees have filed suit against the company for wrongful termination after they complained to state authorities about care lapses at the hospice, reports The Zonie Report, a multimedia news outlet in Arizona.

Former director Marlene H. Deakins and case manager Terri L. McCormick claim that nine violations occurred at Evercare in late 2007, including new nurses doing patient visits without sufficient training; nurses missing patient visits altogether; wound care not being administered; and a patient's blood clot going unaddressed by staff, according to the lawsuit filed in Pima County Superior Court.

After McCormick filed a complaint with the state Department of Health Services on December 27, 2007, she claims Evercare's executive director Richard Lomas threatened to fire her, according to the Report. Four days later, the lawsuit claims she was written up with no explanation. Deakins had since been fired.

After state investigators contacted Evercare to check out McCormick's complaint in January, she claims she received a second write-up and then was fired in late February. Hospice officials also filed a complaint against her nursing license, according to the Report.

• Lafayette, La.-based LHC Group Inc.has entered into a joint venture with Southeast Alabama Medical Center to provide home nursing services,the regional chain says in a release.

The joint venture has two locations in Dothan and Eufaula and covers 16 counties in the certificate of need (CON) state, LHC says. The agencies' annual net revenue is about $1.4 million.

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