Home Health & Hospice Week

Tip: When in doubt, resubmit claims.

With federal authorities getting more comfortable with the idea of suspending Medicare payments without formal charges or indictments, more and more home care providers may find themselves blindsided by the powerful anti-fraud tool.

Background: The Affordable Care Act of 2010 gave the Centers for Medicare & Medicaid Services broader authority to impose payment suspensions, but CMS didn’t really start using the tool until last year. In addition to the 78 home health agencies that underwent payment suspensions in relation to the Dr. Jacques Roy case, CMS suspended payments for 30 providers in a big fraud bust last fall "following a data-driven analysis and based upon credible allegations of fraud," according to a Department of Justice release. (For more details of those cases, see Eli’s HCW, Vol. XXI, No. 36.)

Having payments suspended without corresponding legal action is fairly unusual, and providers who are now coming off suspension in the Roy case are unsure of how to handle it (see related story, this page).

Take heed: With the feds’ increasing reliance on data mining and questionable referrals to home care and hospice, more HHAs could be next on the suspension list. Then they will face the same daunting climb the suspended agencies in Texas are experiencing.

Unsuspended HHAs should consider the following steps, advises Lynn Olson, owner of Corpus Christi, Texas-based billing company Astrid Medical Services:

1. Resubmit all RAPs starting 60 days before the suspension.

2. Submit end-of-episode (EOE) claims for the RAPs four to five days after the RAP submission, or if an initial episode 10 to 15 days. You can also monitor online and submit EOEs as soon as the RAP goes to a paid status, Olson adds.

3. Check payment status of all EOEs that were submitted 20 days before the suspension.

4. If you are unsure of claim status, submit everything. If a claim is previously paid or there is not a RAP, for EOE, you will get a denial.

5. Do not count on reimbursement for any referrals from an indicted source.