Home Health & Hospice Week

Florida isn’t the only hot spot for insulin injection assistance abuse.

The Centers for Medicare & Medicaid Services used these facts about insulin-injection-based claims when formulating a potential list of eligibility-proving diagnosis codes, according to the 2015 prospective payment system proposed rule published in the July 7 Federal Register:

• Analysis of 2012 claims found episodes that qualify for outlier payments in excess of $10,000 had, on average, 160 skilled nursing visits in a 60-day episode of care with 95 percent of the episodes listing a primary diagnosis of diabetes or long-term use of insulin.

• The 2012 claims analysis found nearly 44 percent of episodes that would qualify for outlier payments had a primary diagnosis of diabetes.

• Sixteen percent of episodes that would qualify for outlier payments had a primary diagnosis of Diabetes mellitus without mention of complication, type II or unspecified type, not stated as uncontrolled. “Qualifying for outlier payments should indicate an increased resource and service need. However, uncomplicated and controlled diabetes typically would be viewed as stable without clinical complications and would not warrant increased resource and service needs nor would it appear to warrant outlier payments,” CMS notes in the rule.

• CMS estimates about 81 percent of outlier payments would be paid to proprietary HHAs.

• About two-thirds of outlier payments would be paid to HHAs located in Florida (27 percent), Texas (24 percent) and California (15 percent), CMS estimates.

• For outlier payments of more than $10,000, 95 percent of episodes were for patients with a primary diagnosis of diabetes or long-term use of insulin, and most were concentrated in Florida, Texas, New York, California, and Oklahoma.

• In analysis of 2013 and 2014 claims likely to include insulin injections, the average length of a skilled nursing visit for episodes between the 90th and 95th percentiles was 37 minutes, less than half the length of visits for episodes between the 75th and 90th percentiles. 

Source: 2015 HH PPS proposed rule, July 7 Federal Register.