Home Health & Hospice Week

In an environment of increased scrutiny for  Medicare fraud and abuse, home care providers are taking center stage.

The HHS Office of Inspector General investigated durable medical equipment suppliers more than any other provider type in its last reporting period, according to the watchdog agency's latest semiannual report to Congress.

The OIG issued six reports about DME fraud and abuse in the last six months, on topics ranging from wheelchair reimbursement and coding to DME used during nursing home stays to negative pressure wound therapy pump pricing. Two more reports addressed inhalation drugs and albuterol.In comparison, the OIG issued two home health agency reports --one about overlap of Medicare and Medicaid payment and one about Medicaid personal care claims in New York City.

Hospices also were the subject of two OIG reports, both involving hospice care for nursing home residents. In contrast, hospitals and physicians saw four and three OIG reports in the period, respectively, according to the semiannual report.

Big bucks: The OIG racked up nearly $21 billion in fraud and abuse-related recoveries for fiscal year 2009, the agency notes in the report.

"We continue to make significant progress in our fight against fraud, waste, and abuse in HHS programs, particularly Medicaid and Medicare," Inspector General Daniel Levinson says in a release. "We're doing this by leveraging our audit, legal, evaluation, and investigative tools, as well as employing the latest in data analysis technology."

Home care providers should expect more

fraud scrutiny ahead. "We will remain aggressive in our mission to protect the integrity of these vital programs," Levinson says.

The report is online at www.oig.hhs.gov/publications/docs/semiannual/2009/semiannual_fall2009.pdf.

• The Senate may not have passed an amendment to strip home care cuts from the pending health care reform bill, but don't give up hope.

Sen. John McCain (R-Ariz.) introduced the amendment that would have eliminated about $500 billion in Medicare cuts, including home care reductions, as a funding source for health care reform. But the measure was defeated by a 42-to-58 vote.

More legislators plan to introduce amendments that would eliminate the home care cuts, the National Association for Home Care & Hospice reports. Senate Majority Leader Harry Reid (DNev.) has indicated a willingness to work through Christmas to produce a health care reform bill, according to press reports.

Background: The House of Representatives already passed its health care reform bill last month. It contains more than $60 billion in cuts to home health agency and hospice Medicare payment levels (see Eli's HCW, Vol. XVIII, No. 40, p. 308). Home care industry veterans hope the Senate bill will be kinder to the industry.

• The Centers for Medicare & Medicaid Services made some big mistakes in last year's aborted competitive bidding round, but that won't stop the program's current implementation.

"Problems occurred in round 1 because of poor communication by CMS and an inadequate bid submission system," the Government Accountability Office concludes in a new report analyzing the program.

"Poor timing and lack of clarity in bid submission information, a failure to inform all suppliers that losing bids could be reviewed, and an inadequate electronic bid submission system" made suppliers' idding difficult, the GAO continues.

This time around, CMS is notifying suppliers of missing financial documentation and requiring less of it, has installed a bidding ombudsman, clarified bidding instructions, and implemented a new bidding system --       the Durable Medical Equipment, Prosthetics, Orthotics, and Supplies bidding system (DBidS), the GAO notes.

Recommendation: The GAO wants CMS to "notify all suppliers of [the disqualified bid review] process, giving suppliers equal opportunity for such reviews and clearly indicate how to request them."

CMS agrees in its comments on the report."All suppliers should receive notice about all spects of the competitive bidding program," the agency says.

The report is online at www.gao.gov/new.items/d1027.pdf.

• Home health agencies' 2010 rates are official. CMS has sent contractors notice of the 1.75 percent increase to HHA rates in Dec. 4 Transmittal No. 1864 (CR 6747). See the rates online at www.cms.hhs.gov/transmittals/downloads/R1864CP.pdf and a related MLN Matters article at www.cms.hhs.gov/MLNMattersArticles/downloads/MM6747.pdf.

• If you submit hospice claims with 294.8 (Organic Brain Syndrome [OBS]) as the primary diagnosis, your documentation had better back them up. Reviewers at regional home health intermediary Cahaba GBA rejected about two-thirds of such claims in an edit targeting patients with that diagnosis and long stays (240 days or more), the RHHI says in its December newsletter for providers. The most common denial reason: "Six-month terminal prognosis not supported in the documentation."

"Patients with OBS may be appropriate for hospice, but it is the hospice agency's responsibility to ensure the documentation supports the six month prognosis," Cahaba stresses in the newsletter."Medical records should contain enough clinical factors and descriptive notes to show the illness is terminal and progressing in a manner that a physician would reasonably have concluded that the beneficiary'slife expectancy is six months or less."

Even if the beneficiary isn't declining from one benefit period to the next, the record still must clearly show the six-month terminal prognosis, Cahaba emphasizes.

• Medicare officials are sending out a stiff warning to suppliers participating in bidding: no price fixing.

Suppliers must adhere to all anti-trust laws,CMS's Joel Kaiser stressed in the Dec. 2 Open Door Forum for home care providers. That includes bans on price fixing or collusion. "If you are participating in such an act, there is a real and serious risk ... that you will have your bid rejected and ... possibly more serious repercussions," Kaiser said. "I can't stress enough how important it is."

CMS made the announcement because "we have heard concerns about acts of collusion that may be occurring during this round of bidding," Kaiser said. "We will be monitoring this situation."

• A fix for a nagging billing concern will finally come next month.

Beginning back in July, certain HHA claims have erroneously suspended to status/location SM8107 with reason code 38107, Medicare Administrative Contractor (MAC) National Heritage Insurance Corp. says in a message to providers. (NHIC took over from intermediary National Government Services.)

They suspend when a cancel fails to be removed from the request for anticipated payment (RAP) for the episode, NHIC explains.

• Suppliers and other providers receiving denials of enrollment may get more clarity on the issue. CMS has issued instructions requiring the denial letter to contain, among other things, "a clear explanation of why the application is being denied,including the facts or evidence used by the contractor in making their determination."

The same goes for letters about revocation of billing rights, according to Dec. 4 Transmittal No. 316 (CR 6487).

The letters must also contain "complete and accurate information about ... further appeal rights," the transmittal instructs.

More information about enrollment appeals,revocations, and corrective action plans is in the transmittal online at www.cms.hhs.gov/transmittals/downloads/R316PI.pdf.

• Recovery Audit Contractors are likely gearing up for home care reviews soon, so a new payment provision may come in handy. If your intermediary overpays you and a recovery audit contractor (RAC) asks for the money back, you could have 12 months to repay the overpayment via an extended repayment plan (ERP), according to CMS Transmittal No. 162, effective Dec. 15. If you request an ERP for a time period longer than 12 months, the RAC will request permission from its regional office, says the transmittal online at www.cms.hhs.gov/transmittals/downloads/R162FM.pdf.

• Medicare's "Care Transitions" project to reduce hospital readmissions is already starting  to see results, says CMS in a recent Associated Press article. Participating hospitals are seeing readmissions start to inch down, says physician Barry Straube, CMS chief medical officer.

CMS hopes to expand the program to all states eventually, Straube tells AP.

The government isn't the only one trying to reduce rehospitalizations. The American College of Cardiology began a "Hospital to Home" program this fall, signing up hundreds of hospitals to share solutions with the goal of cutting heart patients' readmissions by 20 percent within three years, the article notes.