Home Health & Hospice Week

NPI edits cause billing headaches.

Warning: Don't remove all of your legacy numbers from the National Provider Identifier database. If you do, Medicare and other payors may have a hard time finding you and that could delay your payments.

When the NPI database comes out on Sept. 4, payors will be looking up their providers according to those legacy numbers, officials from the Centers for Medicare & Medicaid Services told an Aug.14 physician Open Door Forum.

"If you remove your legacy numbers from the 'Other Provider Identifier/Other Provider Identifier Type Code' fields, linkages that Medicare has established using the reported Medicare legacy numbers will be broken and your Medicare claims could be rejected," CMS warns in a message to providers.

The old problem: Providers had until Aug. 20 to remove sensitive data like Social Security Numbers from the NPI database. Some providers wrote their SSNs in the NPI database in the "other provider numbers" field. You're supposed to use this field to list your legacy numbers.

The new problem: CMS advised providers to remove SSNs from those fields to avoid their public release in the NPI database. But then some providers just erased all numbers from that field.

"The reporting of legacy numbers ... will assist Medicare in successfully creating linkages between providers' NPIs and the identifiers that Medicare has assigned to them," CMS says in the release.

But even correct NPIs can cause you billing headaches. Claims submitted after Aug. 17 with valid NPIs were going to Return To Provider (RTP) locations in error, report regional home health intermediaries National Government Services and Cahaba GBA. "Several provider records that originally matched with our provider file became unmatched, causing claims to go to RTP incorrectly with reason codes 32103, 32104 or 32105," Cahaba explains in an email to providers.

Do this: The problem has been resolved, Cahaba says. But if you submitted claims via file batch transfer that were rejected with those codes, you need to resubmit them, Cahaba instructs.

About 30 percent of NGS providers saw rejected claims due to the NPI problem, the RHHI says.

• Two operators of a New York home health agency have pled guilty to Medicaid fraud in an industry-wide crackdown in that state. Nachem Singer and Ervin Rubenstein of Immediate Home Care Inc. in Brooklyn bilked the program of $12 million, alleges New York Attorney General Andrew Cuomo in a release.

The pleas are the first from HHA owners in "Operation Home Alone," the probe of fraudulent home care aide certifications. Immediate's revenues increased from $3 million to $52 million from 2003 to 2006, the release notes. Immediate employed uncertified aides, recruited aides from training facilities where false certifications could simply be purchased, billed for services never rendered, and billed for services rendered to aides' relatives.

Mary Smalls of Brooklyn-based Smalls Training and Counseling School and Laurette Escarment of Queens-based On-Time Home Care Agency have pled guilty to supplying hundreds of home health aides with false training certificates, Cuomo says. And at least 10 aides have been convicted of operating with phony certifications.

New York HHAs can expect more scrutiny ahead. "The investigation of fraud in the home health care industry... is ongoing," the release pledges.

Bad press about these fraudulent activities is negatively affecting legitimate home care providers, protests the Home Care Association of New York State. "The vast majority of our hardworking home health care providers and their caregivers are delivering invaluable quality home-based health care," the trade group says in a release. HHAs and aides "have been unfairly labeled through overzealous hyperbole."

• The HHS Office of Inspector General has issued more examples of its crackdown on DME suppliers. In Florida, a supplier was sentenced to 63 months in jail and his wife received six months of home confinement over a scheme in which the owner paid Medicare beneficiaries for the use of their numbers to bill medically unnecessary DME. The owner also paid a physician to furnish the prescriptions for the DME, according to the OIG's Web site. The physician received 36 months in jail and all three subjects were ordered to repay $1.3 million.

In Pennsylvania, a DME supplier was sentenced to six months in home detention and ordered to repay $31,000 for billing Medicare for prosthetic limbs and other DME that was never furnished.

• Corporate HHA owners and executives should take note of a recent statement from the OIG. The OIG spoke out Aug. 27 on a recent court decision that could affect the imposition of civil monetary penalties (CMPs) against HHAs.

The case--against Thomas Horras, owner of Hawkeye Health Services Inc. in Knoxville, IA--is the first reported decision by an appellate court upholding the OIG administrative sanctions under the CMP law against a corporate owner and executive for Medicare fraud. (see Eli's HCW, Vol. XVI, No. 29)
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"This decision is an important affirmation of the OIG's use of our administrative enforcement tools against corporate owners and executives who are responsible for Medicare and Medicaid fraud," warned Inspector General Daniel Levinson in a statement.

• Don't be surprised if your hospice must provide a corrective action plan for exceeding the hospice cap--three years ago. CMS asked RHHI Palmetto GBA to conduct a hospice cap project in which Mississippi and Oklahoma hospices that exceeded the cap in 2004 submit a corrective plan, Palmetto says in its August Hospice Coalition Questions and Answers.

Watch out: Exceeding the cap may now result in a post-pay review or a referral to the CMS Regional Office for possible suspension of Medicare payments, according to the Q&As.

Disagreement: The project aims to help hospices avoid cap-related overpayments, Palmetto says. But hospices argue that it creates barriers to hospice care for long-stay patients.

• Home care providers served by National Government Services have one more change to get used to as part of the intermediary's switch to the HIGLAS accounting system.

Instead of automatically reissuing a check when a payment is voided (for example, when a check gets mutilated in the mail), NGS will run the reissued check through HIGLAS to again look for any withholdings that may apply against the reimbursement, the intermediary notes in a message to providers. Confusion may arise as NGS may add claim payments to the check as well, and the new check won't come with a copy of the original RA as it used to.

• Pediatric Services of America Inc. is one step closer to becoming a private company. PSA shareholders voted to approve the proposed merger with private equity firm Portfolio Logic, the Norcross, GA-based chain says in a release. More than 77 percent of shares voted in favor of the merger. The deal was slated to close Aug. 31.