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. Make sure nursing and therapy team members communicate, either by phone or in person, and document that communication in the chart, she advises. Making these steps part of your agency's routine practice "will go a long way to eliminate these discrepancies," she assures.

6. Keep therapy goals realistic. Therapists shouldn't make goals so specific to a timeline that the agency runs into trouble if the goal isn't met on one specific visit. "There are too many variables involved for this to be a useful or accurate practice," McNamara cautions.

7. Beware the OASIS trap. While the OIG is focusing on therapy visits, about $33,000 of Red Oak's overpayment was due to denied skilled nursing visits, McNamara notes. "Agencies cannot be too careful in ensuring that care is at skilled level and documentation supports this," she emphasizes.

Don't make the common pitfall of claiming a skilled nursing visit to fill out OASIS if the nurse does not furnish any other covered skilled service during the visit. "Unless there is a specific nursing skill required by the patient, these visits ... are administrative visits, not billable," McNamara reminds HHAs.

8. Monitor therapists' stats. You should monitor "both the total number of visits per patient as well as the amount of time spent by therapists on each visit," McNamara counsels. If therapists' utilization is high or visit duration is low, it may be time to review Medicare and agency requirements. "If mentoring, inservice training and coaching do not change their practice patterns, they may not be the best therapists for the home care setting," she says.

9. Encourage communication between billers and clinicians. Billers often are the last line of defense against incorrectly billed claims.

"While in most cases the biller cannot be responsible for making OASIS corrections or making clinical determinations, the biller is the key person in identifying the issue and helping resolve the issue prior to billing," Little explains. "The best way to ensure accurate payments and billing compliance is for the biller to be able to lead communication with agency clinicians and leadership and follow through with any necessary billing corrections."

10. Include therapy in compliance efforts. "Serious fraud issues" await agencies accused of pumping up therapy visits, says Burtonsville, MD-based health care attorney Elizabeth Hogue. "Agencies should be taking a hard look at therapy utilization as part of their corporate compliance plans and quality assurance efforts."