Home Health & Hospice Week

With at least one HHH MAC focusing on LUPA claims for medical review, you should take a critical look at your own LUPA billing practices. Head off medical review problems with your low utilization payment adjustment claims by heeding this expert advice:

• Document, document, document. Under the prospective payment system, the intensity of medical review has diminished. Some experts argue that that has led to lower quality documentation on the part of clinicians.

"Every note has to stand on its own," emphasizes consultant Betty Gordon with Simione Consultants in Westboro, Mass. You need to clearly show what skilled service you are providing and why it is necessary.

For example: Teaching can be very important when a patient begins new meds, Gordon offers. Say a person with congestive heart failure is put on a diuretic, but doesn't like the side effects. "Nobody wants to be up going to the bathroom all night," she observes. Education from a home care nurse about why the medication is necessary and how it will prevent fluid build-up, and a CHF relapse, is key to keeping the patient healthy and out of a hospital readmission.

• Benchmark. Take a look at your LUPA claims figures to determine if you will stand out from your peers -- and potentially catch medical reviewers' eye. Above-average volume for LUPA claims can certainly be legitimate, but you'd better be prepared to back up your claims with solid documentation.
• Consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. uses a 10 to 12 percent figure as a rule of thumb for a LUPA percentage ceiling, she tells Eli.
• Maintain consistent management. Avoid LUPA problems by employing consistent management practices, Laff urges. That means overseeing clinicians via routine case conferences to validate that patient care is skilled.
• Submit OASIS. One of the most common reasons for denial was agencies simply neglecting to include proof of OASIS in the ADR response, HHH MAC NHIC explains in its message to providers about the LUPA edits (see related story, p. 256).

Do this: "Home Health providers must be sure the OASIS is accepted by the state repository," NHIC instructs HHAs. "Providers may submit a copy of the transmission record or the OASIS tracking sheet. This is especially helpful if the patient's Medicare number is different than their Social Security number."

• Use an appeal cover letter. If your preventive efforts have been for naught and you need to appeal a LUPAclaim denial, don't just stuff an envelope full of paperwork and send it in.

"Agencies have better success [with an appeal] when they use a cover letter," Gordon advises. Medical reviewers tend to be short on time and won't necessarily see all the details in the paperwork you submit. Using a cover letter to present your argument and point out the relevant portions of the documentation you submit is helpful.