Home Health & Hospice Week

Overlapping Medicare, Medicaid claims suspect, says report targeting dual eligibles.

Home health agencies serving Medicare and Medicaid patients may see tighter scrutiny of their payments for patients dually eligible for both programs, thanks to a new report.

Connecticut's Medicaid program could have paid HHAs in that state $1.8 million for services already covered under Medicare payment in fiscal years 2002 and 2003, a report from the HHS Office of Inspector General says. Agencies discharged patients prematurely from their Medicare episodes to start Medicaid services and delivered fewer visits than called for in patients' Medicare plans of care, the OIG charges.

The OIG stops short of saying the $1.8 million definitely was in error. But it casts the overlapping Medicare and Medicaid services as highly suspect.

The watchdog agency recommends that Connecticut educate providers on Medicare and Medicaid coverage criteria, implement prepayment edits for Medicaid claims and recoup the "potential" overpayments.

PPS Heightens Double Dipping Concerns

The report highlights a huge gray area for many providers--where Medicare coverage ends and Medicaid coverage begins for home care services, notes William Dombi, vice president for law with the National Association for Home Care & Hospice's Center for Health Care Law. "It's an age-old problem," Dombi says. "It's a very fuzzy line."

Appropriately separating Medicare and Medicaid home health responsibility is a "long-standing and difficult problem," observes Bob Wardwell with the Visiting Nurse Associations of America. "The dual eligibility problem ... is simply one of the more vexing examples inherent in having two payers with divergent interests, different payment systems and coverage rules dealing with one patient," notes Wardwell, a former Centers for Medicare & Medicaid Services top official.

Concern about double dipping has increased since the Medicare prospective payment system took effect in October 2000. Before that, HHAs received payment either from Medicare or Medicaid for visits and Medicare usually was a much better payer.

Now under PPS, agencies can receive a full PPS episode payment, discharge the patient before the 60-day episode limit, and start receiving per-visit Medicaid payments, Dombi explains. "Anything over zero" adds to the bottom line, he notes.

That's the concern the OIG targets in the report. But Brian Ellsworth of the Connecticut Association for Home Care doubts most of the premature discharge scenarios the OIG describes are fraud or abuse. Rather, they are likely legitimate reasons for switching payers--such as homebound status--that HHA clinicians failed to document well, he believes.

Other overlap problems may come from different interpretations of Medicare coverage, especially regarding custodial care, Ellsworth notes. "We think what we've done is correct," he tells Eli. If not, CMS needs to clarify coverage criteria, he urges.

Demo Fails in Coverage Education

Hunger for such clarification is what has driven a four-year demonstration project on third party liability for dual eligibles in Connecticut, New York and Massachusetts. Now the TPL demo is about to wrap up and participating HHAs are still searching for coverage answers for this patient population.

"Our major concern at this point is that barring an extension, the [demo] is scheduled to end without any of the coverage decision-making education ... having taken place," laments Pat Kelleher of the Home & Health Care Association of Massachusetts.

Without such education occurring, the demo shouldn't end, Ellsworth maintains.

"I am not sure that this [OIG] report sheds light on the key issue of lack of clarity around coverage rules for dual eligibles around issues of custodial care, skilled care and homebound status," Kelleher says. But it at least calls for the coverage education that providers need, she notes.

The demo should resolve the dual eligible problem "in a way that puts the patient first and allows agencies to collect appropriately from Medicare or Medicaid with some measure of efficiency," Wardwell urges.

Upshot: If Connecticut's Medicaid program moves to initiate overpayments based on the OIG's recommendations, Connecticut agencies will fight them, Ellsworth says. But he expects the state to have a tough time recouping dual eligible overpayments when the coverage rules surrounding them are so muddy. 

Note: The OIG report is online at www.oig.hhs.gov/oas/reports/region1/10400011.pdf.