Home Health & Hospice Week

Are you waving a red flag at medical reviewers?

If you can't prove the therapy visits you're furnishing are medically reasonable and necessary, you could stand to lose thousands of dollars per episode.

Scrutiny of therapy visits and high-therapy episodes will be at an all-time high after two harsh HHS Office of Inspector General reports on the subject. You need to be ready to defend your rightful reimbursement, which includes a roughly $2,500 increase for episodes that meet the high-therapy threshold of at least 10 visits.

To protect your therapy-related reimbursement, heed these tips from the experts: 1. Perfect your documentation skills. "Everyone gets sick of hearing about the importance of documentation, but I believe it is key to surviving these therapy audits," stresses reimbursement consultant M. Aaron Little with BKD in Springfield, MO.

"The real answer to questions about medical necessity of the services rendered, either nursing or therapy, is documentation and more documentation," agrees Abilene, TX-based reimbursement consultant Bobby Dusek. And agencies must have "an understanding of the regulations covering home care services," Dusek adds.

2. Don't require therapy numbers. While financial incentives in a payment system are bound to influence utilization patterns, don't make the mistake of requiring across-the-board threshold-meeting therapy visits in your agency, instructs consultant Regina McNamara with LW Consulting Home Health and Hospice Division in Harrisburg, PA.

"Administrators need to be careful that they do not consistently and publicly require their therapists to ensure that all patients receive 10 to 12 visits," McNa-mara tells Eli. "This sort of direction, documented in records of staff meetings or monitored in [performance improvement] activities, can work against the agency with regulators." 3. Monitor your red flag episodes. Episodes that just barely exceed the 10-visit therapy threshold are both suspicious and easy financial targets for medical reviewers, experts observe.

"Any agency that has a relatively high percentage of therapy visits that are in the 10- to 12-visit range will certainly be on OIG's screen," McNamara warns. The target of the OIG's latest audit, Los Angeles-based Red Oak Home Health Services, had 67 percent of claims with therapy in this range, McNamara notes. 4. Review risky episodes closely. "With the OIG taking such a strong position, we are advising that agencies critically examine documentation in episodes where 10 to 12 therapies are provided," Little says. If you can't review every single claim in this category, at least sample them, he counsels.

Put your claims through a pre-billing audit "to make certain the services are medically necessary and reasonable and that all signed orders and other documentation fully support the services provided," Little advises. 5. Encourage communication between therapists and nurses. The nursing assessment and OASIS coding can often be in conflict with the therapy assessment, McNamara cautions. [...]