Home Health & Hospice Week

Watchdog agency finds inappropriate instances of respite care use, new report says.

Harsh scrutiny continues for the Medicare hospice benefit.

The HHS Office of Inspector General undertook a study of hospice respite care following a recent report comparing hospice for nursing home beneficiaries versus those in other settings (see Eli's HCW, Vol. XVII, No. 1). The report found that Medicare spent 25 percent more on hospice services for nursing home residents.

In 2005, only 2 percent of hospice beneficiaries received respite care, which is short-term inpatient care meant to give caregivers a break, the OIG notes in the report. "Most of these beneficiaries received the care for a total of [five] days or less," it adds.

But the watchdog agency still found a number of instances of potentially "inappropriate" care. Fifty-four beneficiaries received respite care longer than the five consecutive days allowed by Medicare, the OIG says. "And 62 beneficiaries received respite care while residing in nursing facilities, even though respite care is designed to relieve the beneficiary's caregiver."

The report is online at www.oig.hhs.gov/oei/reports/oei-02-06-00222.pdf.

• You may know a lot more about your future payment rates a month from now. Senate Finance Committee Chair Max Baucus (D-MT) says he will send Medicare legislation straight to the Senate floor rather than having the committee conduct a markup of the bill. That will happen in mid-May, observers predict.

What exactly the bill will contain is still up for grabs. But cuts for other Medicare providers still seem likely, since Congress is looking for funds to avoid the 10 percent cut to physicians' rates that hits July 1. And HHAs with their double-digit profit margins are at the top of the list for rate reductions.

Spreading the word: Scores of home care providers visited their elected representatives in Washington, D.C. and told their stories on April 8 as part of the National Association for Home Care & Hospice's annual March on Washington conference.

• Medicare is now receiving more than 98 percent of claims with a National Provider Identifier, CMS says in a message to providers. But providers need to focus on the next step--NPI-only claims, which CMS will require May 23.

After testing small batches of NPI-only claims and making sure those process smoothly, test other HIPAA transactions, the agency advises. Remember that providers must be able to accept NPI-only remittance advice transactions.

More NPI information is at www.cms.hhs.gov/NationalProvIdentStand and providers can apply for an NPI at https://nppes.cms.hhs.gov.

• Your state may pay for more home care now that CMS is making the rules to do so easier. CMS has proposed allowing state Medicaid programs to offer home- and community-based services (HCBS) without requiring a demonstration waiver.

"States will now be able to set their own eligibility or needs-based criteria for providing HCBS," CMS says in a release. "Previously ... beneficiaries were required to be at imminent risk of institutionalization."

"Thousands more Medicaid beneficiaries may now be able to opt for needed long-term support services in their homes rather than institutions," CMS Acting Administrator Kerry Weems says in the release. "Breaking the historic link between long-term care and institutions will level the playing field and give beneficiaries new choices for how they receive care."

The proposed rule is in the April 4 Federal Register and is online at www.cms.hhs.gov/MedicaidGenInfo/Downloads/CMS2249P.pdf. CMS will take comments on the rule until June 3.

• Get ready to fill out a whole new provider enrollment application if you need to change even minor information. One home health agency asked regional home health intermediary Cahaba GBA why it had to fill out an entirely new CMS 855 form when it just wanted to change the managing employee information, according to Cahaba's April provider newsletter.

"CMS requires that all enrollment information from the CMS-855 application be input into the Provider Enrollment Chain and Ownership System (PECOS)," Cahaba explains in the Newsline. Creating a PECOS record requires certain information from the 855.

"This information cannot be entered into PECOS unless it is verified to be current and correct," Cahaba says. "In order to determine this, the provider must submit the most current information via the CMS-855 application."

The April Newsline is online at https://www.cahabagba.com/part_a/education_and_outreach/newsletter/200804_rhhi.pdf.

• Out with the old, in with the new. RHHI Palmetto GBA has retired two local coverage determinations for hospice on pulmonary disease (97AH-009-M) and heart disease (97AH-015-M). A new hospice LCD on Cardiopulmonary Conditions took their place, Palmetto notes.

• Don't expect much help from the Quality Improvement Organizations starting in August, the National Association for Home Care & Hospice confirms. Home health agencies aren't mentioned specifically in the QIOs' 9th Scope of work, leading providers to wonder if they would continue to receive QI help from the organizations.

QIOs will work with as few as 450 HHAs under the contract with CMS, NAHC estimates. That's less than 5 percent of the 9,400 Medicare-certified agencies, the trade group observes.

• Seven nursing home residents backed by the AARP Foundation have filed a class-action lawsuit against the state of Florida demanding home care instead of institutional care, according to the Associated Press. The suit relies on the U. S. Supreme Court's 1999 Olmstead ruling regarding the Americans with Disabilities Act, which requires care provision in the community when possible.

Oregon lawmakers committed to a home care program twenty years ago and the state now has fewer nursing homes than it did in 1981, AP reports. It also spends about $24,000 per person on long-term care while Florida spends about $35,000 per person.

"Many states recognize it is both preferable and certainly more cost efficient to keep people at home," CMS' Mary Kahn told AP. "We encourage it, but we can't force states to do it."

Legislators worry that offering home care would bring lots more beneficiaries onto the long-term care rolls, raising LTC costs.

• More DME-related fraud convictions are coming out of Miami. In a recent case, Angel Castillo, Jr. was sentenced to a 235-month term in connection with his ownership of more than eight durable medical equipment companies in Miami during 2005 and 2006, according to a release from R. Alexander Acosta, U.S. Attorney for the South-ern District of Florida, and the Federal Bureau of Investigation's Miami Field Office.

Castillo's companies submitted more than $48 million in false claims when they never provided any Medicare patients with any type of equipment or service, Acosta says. Castillo received more than $7 million from the scheme and used family and friends to cash hundreds of checks to launder the money.

Castillo's co-conspirators, who served as straw owners of the companies, are receiving multi-year prison terms, the release notes.

• A Kentucky company that furnished home visits from nurse practitioners as well as services under the home care benefit has pled guilty to submitting false claims and agreed to a $120 million settlement of civil claims and criminal charges.

Louisville, KY-based HealthEssentials Solutions Inc.'s business grew from $15 million in revenues in 2001 to more than $53 million in 2003, notes U.S. Attorney David L. Huber of the Western District of Kentucky in a release. The government started investigating false claims allegations after four whistleblowers, who were former Health-Essentials employees, filed three qui tam lawsuits alleging upcoding of nurse practitioner billing.

The company submitted higher-paying NP evaluation and management codes for seeing a patient at home when the clinician really saw the patient in an assisted living facility or nursing home, the suits charged.

The company had to withdraw an initial public offering in 2004 after government agents executed search warrants on company locations, the release notes. And then it declared Chapter 11 bankruptcy in 2005. While HealthEssentials has agreed to a settlement, in actuality the bankruptcy will make it unlikely that the government--or the whistleblowers--will recover any funds, the release admits.