Home Health & Hospice Week

A pre-billing audit is key to accurate therapy claims.

In the wake of the feds' intense scrutiny of therapy, home health agencies should do all they can now to protect their therapy reimbursement later.

"Home health agencies [should] prepare for increased M0825-related oversight," warns the National Association for Home Care & Hospice, referring to the OASIS item recording the number of therapy visits. The HHS Office of Inspector General's string of audits on the topic will put therapy visits even higher on reviewers' hit lists.

Reimbursement consultant Rose Kimball with Med-Care Administrative Services in Dallas reports that her clients are examining their therapy utilization with the expectation that medical reviewers may go over therapy claims with a fine-toothed comb.

Heed these expert tips on how to protect your therapy reimbursement:

1. Institute a thorough pre-billing audit. The review should include verification that all orders are signed and dated and that all services were provided within order limitations, advises consultant M. Aaron Little with BKD in Springfield, MO.

Examine an actual claim as part of the prebilling audit to ensure services are accurately represented on the claim, Little urges. "This is one of the best ways to ensure compliance and payment accuracy."

2. Don't let software lull you into complacency. Just because your agency uses a sophisticated software system doesn't mean you can assume the information in it is correct. "A software system ... is only as good as the users controlling it," Little cautions. "I've seen numerous occasions where the information in the system was not accurately reflected on the claim due to user or system errors."

3. Foster communication. "Make certain those individuals performing the pre-billing audits communicate with the billers so that claims are not billed prematurely," Little stresses. Communication between clinical and billing staff is essential to correctly submitting claims.

4. Monitor therapy utilization. If too many of your claims fall into the profitable 10 to 12 therapy visit range, you're going to stick out like a sore thumb to the HHS Office of Inspector General and reviewers, Kimball warns. Just like with nursing visits, therapy visit utilization should vary depending on clients' needs, she reminds.

5. Document thoroughly. The old saw that if it isn't documented, it isn't done proves just as true with therapy billing. Your clinical documentation must prove why the patient needs therapy services and record their delivery, Kimball counsels.

6. Pursue appeals. Agencies "should seek review of claims denied for technical reasons and administrative appeals when inappropriate denials are issued," NAHC exhorts. NAHC plans to address the issue of inappropriate therapy service denials with Centers for Medicare & Medicaid Services medical review staff.