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Home Health & Hospice Week

Managed Care Appeals Burden Gets Heavier Next Month

Published on Fri Dec 19, 2003

Your relationship with Medicare+Choice payors could be in for a shake-up in the new year.

Beginning Jan. 1, M+C plan enrollees will have the right to an expedited review by a Quality Improvement Organization when they disagree with their M+C plan's decision that Medicare coverage of their home health agency, skilled nursing facility or comprehensive outpatient rehabilitation facility services should end, the Centers for Medicare & Medicaid Services pointed out in a recent notice to providers.

HHAs, SNFs and CORFs will be responsible for delivering the first of the two termination notices required in the new process, and may be on the hook for many other appeals-related duties as well (see Eli's HCW, Vol. XII, No. 20, pp. 154-157).

More information about the new process, which stems from the high-profile Grijalva lawsuit, is at www.cms.hhs.gov/medlearn/mcprogram.pdf.

  • The Data Assessment and Verification (DAVE) project will begin to assess the accuracy and reliability of OASIS assessment data in 2004, CMS says. Until now, it's been used in nursing homes only (see Eli's HCW, Vol. XII, No. 13, p. 99).

    DAVE will be implemented nationally in January, CMS has announced. The project also aims to support quality improvement efforts, CMS integrity initiatives addressing payment accuracy, and payment policy development, the agency says.

    CMS has said it plans to share problems found via DAVE with surveyors. More information is at www.cms.hhs.gov/providers/psc/dave.

  • A new HCPCS code for combinations of albuterol sulfate and ipratropium bromide inhalation solutions goes into effect Jan. 1, durable medical equipment regional carrier Palmetto GBA says. Suppliers should use J7621 for both manufactured (non-compounded) preparations as well as compounded preparations, the DMERC says in a notice on its Web site.

    Suppliers should use the code instead of billing separately for albuterol (J7618, J7619) and ipratropium (J7644), Palmetto explains.

  • You can give your two cents to the HHS Office of Inspector General on new or changed safe harbors to the anti-kickback statute. In its annual Federal Register solicitation of proposals to protect innocuous business arrangements from the extremely broad anti-kickback law, the OIG also welcomes suggestions for topics to be addressed in future special fraud alerts.

    The request is at www.access.gpo.gov/su_docs/fedreg/a031212c.html.

  • On the heels of CMS Administrator Tom Scully's departure, Department of Health and Human Services Secretary Tommy Thompson has announced he won't stay on in his position if President Bush wins a second term in office.

    Meanwhile, Thompson named Dennis Smith as CMS Acting Administrator to temporarily replace Scully. Smith is Director of CMS' Center for Medicaid and State Operations.

    Deputy Administrator and Chief Operating Officer Leslie Norwalk will "continue to be the CMS lead in carrying out the Medicare legislation signed into law by the President last week," according to a CMS release.

  • Home care does reduce state expenditures, as one recent report shows. The Connecticut Home Care Program for Elders generated savings of $63.6 million due to the reduced utilization of nursing facility beds in 2002, according to an annual report published by the state's Department of Social Services, reports the Connecticut Association for Home Care.

  • Nurses topped Gallup's 2003 annual survey on the honesty and ethics of various professions. Americans, in the Nov. 14-16 CNN/USA Today/Gallup poll, were asked to rate the honesty and ethical standards of people in 23 different professions. This year's list focused on medical professions, and nurses topped doctors, pharmacists and dentists, with 83 percent of respondents rating their honesty and ethics as "high" or "very high." Politicians ranked at the bottom of the list.

  • Gentiva Health Services, Inc. has extended its national home care contract with CIGNA HealthCare - Gentiva's largest single customer - for three years through Dec. 31, 2006, the home health giant says.

    "Gentiva's CareCentrix unit will continue to coordinate and administer home care services for a substantial number of CIGNA HealthCare members, under capitated and fee-for-service arrangements" for an undisclosed sum, the Melville, NY-based company says. The services cover traditional home nursing, chronic and acute infusion therapies, and durable medical and respiratory equipment.

  • Praxair Inc. plans to use its market presence in hospitals to beef up its home care market share. Praxair is number one in the hospital services sector and fifth in home care, it told Business First of Buffalo.

    The company's Hospital-to-Home program places a Praxair rep in the hospital to supply oxygen to patients who will be discharged needing home oxygen. If the patient chooses Praxair as its home oxygen provider, she doesn't have to repeat much of the administrative work done in the hospital, Mark Weise, director of Praxair's health care research and development, told the newspaper. "This is a way for us to take advantage of our stronger position in the hospitals and leverage in home care," Weise said.

    The fragmentation of the home care industry, with more than 2,000 oxygen providers nationwide, makes expansion via acquisitions attractive, Weise told the paper. The company is researching potential purchases.

  • Former National Century Financial Enterprises Director of Compliance Brian Stucke is the second NCFE official to plead guilty to securities fraud in relation to the financing company's meltdown last year (see Eli's HCW, Vol. XI, No. 40, p. 322). Stucke pled guilty Dec. 11 and faces a maximum penalty of five years in jail, a $250,000 fine and three years of supervised release, reports Business First of Columbus. The Securities and Exchange Commission has filed a civil suit against him.

    A number of home care companies, including Baton Rouge, LA-based Amedisys Inc., were left high and dry when their receivables were caught up in NCFE's collapse.

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