Home Health & Hospice Week

If you're lax about checking the credentials of your referring physicians, you may soon pay a big price. Sixty-nine home health agencies in the Houston area are already paying it, thanks to submittingclaims that listed a physician who was ineligible to enroll in Medicare, according to the Centers for Medicare & Medicaid Services.

Under its new predictive modeling fraud data program, CMS identified claims with 86 such ineligible physicians, a CMS rep tells Eli. And in late August, CMS sent letters to 69 HHAs telling them claims from just one such ineligible physician would be denied starting Sept. 2. After starting with this one case, there are "about 85 similar circumstances that we will also be addressing," the CMS source pledges.

More to come: Since its initial run, CMS's Center for Program Integrity has also found more ineligible physicians, the rep adds. CMS can't release the names of the physicians due to HIPAA concerns. Watch for a "second batch" of letters on this topic to go out, the CMS rep says. But CMS will consult with the industry before sending them out.

Important distinction: This program targets physicians who are not eligible to enroll in Medicare, not just those who are eligible but have neglected to enroll in the online Provider Enrollment, Chain, and Ownership System (PECOS).

Denials for claims that have ineligible physicians can have a big financial impact, warns consultant Judy Adams with Adams Home Care Consulting in Chapel Hill, N.C. That's because "agencies stand to have all reimbursement for episodes certified by a non-enrolled physician denied, since the MD was not qualified to certify a home health patient," Adams says.

HHAs have a longstanding requirement to check physicians' eligibility, reminds Chicago-based regulatory consultant Rebecca Friedman Zuber. For many years, "agencies have been responsible for insuring that the physicians from whom they accept referrals and orders are appropriately licensed and have not been excluded from Medicare," Zuber says.

When agencies fail to make the checks or a physician slips through the cracks, HHAs have to eat the costs of the related episodes, says consultant Tom Boyd with Rohnert Park, Calif.-based Boyd & Nicholas.

Red flag: CMS is starting its claim denials with one ineligible physician who referred patients to 69 different HHAs. This indicates that CMS may be targeting "ordering services above and beyond what should be considered reasonable, in terms of volume, coming from a responsible practice," Zuber suggests.

The PECOS edits that CMS originally scheduled to begin earlier this year should help home care providers check on their referring physicians' Medicare enrollment status, Zuber notes. But CMS has delayed those edits (see Eli's HCW, Vol. XX, No. 23, p. 183).

In fact, providers may not see the PECOS edits, which will reject HHA claims when the listed referring physician doesn't have a valid PECOS record, until fall of next year, predicts the National Association for Home Care & Hospice.

And PECOS will not be a sure-fire way to confirm physicians' enrollment anyway, Boyd suggests. CMS could lag in entering physicians' information in PECOS, and docs could tell agencies their enrollment application is pending when it's really not.