Home Health & Hospice Week

Medical reviewers deny therapy visits on new grounds.

A new federal report on home health agency therapy utilization is bound to turn up the heat even higher on an already hot topic.

The HHS Office of Inspector General has released the third in its string of audits of HHAs' claims with 10 to 12 therapy visits. Through regional home health intermediary Palmetto GBA, the OIG determined that 22 of 100 such claims were inappropriately paid, according to the report (A-04-05-02000).

Total Patient Care Home Health in Jackson-ville, FL actually had 407 claims in fiscal year 2003 that included at least one therapy visit, and 200 of those claims contained between 10 and 12 therapy visits. When Palmetto examined a 100-sample claim at the OIG's request, reviewers denied visits for a variety of technical and regulatory reasons.

The inappropriate payments total $43,088, the OIG says. Applied to Total Patient Care's universe of claims for FY 2003, the overpayment reaches $63,425.

This newest audit is unlike the first two audits in the series (see Eli's HCW, Vol. XIV, No. 21,and Vol. XIV, No. 28). That's because the earlier audits shot down therapy visits based on medical necessity, while this audit rejects visits for technical errors, lack of physician orders, and lack of appropriate documentation, notes the National Association for Home Care & Hospice.

"All services reviewed in the claims were found to be reasonable and necessary," NAHC points out.

Unsigned, Undated Orders Plague HHA

Medical reviewers nixed 10 claims because services weren't properly authorized, the report notes.

That includes six claims where physicians didn't date plans of care or orders, two claims where physicians dated orders after Total Patient Care already submitted the final claim, one claim where the physician didn't sign the orders, and one claim where the orders were undated and failed to specify frequency or duration for the therapy visits.

Reviewers deemed 11 claims inappropriately paid because Total Patient Care didn't furnish services as ordered. That included an instance where the patient went into the hospital for two weeks and then resumed occupational therapy after returning home. Total Patient Care exceeded the duration of the orders and the reviewers rejected two of the 11 therapy visits provided, setting up a $2,291 recoupment.

Example: In another case, reviewers knocked down a patient's high-therapy episode because the agency furnished three therapy visits in a week instead of the specified two visits. That means all three visits for the week were denied, the report explains.

Reviewers downcoded three claims because Total Patient Care incorrectly calculated the HIPPS code and downcoded or denied four claims due to incomplete medical records, including missing visit notes.

Agency Admits Billing Errors, Strengthens Controls

Total Patient Care could have warded off these overpayments. "It's a shame that each of these denials could have been avoided with better pre-billing audit procedures," notes consultant M. Aaron Little with BKD in Springfield, MO.

Also unlike the earlier two audits, the HHA admits it made all the mistakes the reviewers propose. "We are disappointed in our lack of billing controls that led to this result," Total Patient Care Administrator Ronald R. Arrington says in a response letter included in the report.

The audit period was right after the agency was acquired, Arrington says. The HHA has tightened pre-billing audits and revamped personnel since receiving the audit results, he notes in the letter.

Gray areas: All three audits' findings "underscore [NAHC's] concern over a lack of objective standards for determining medical necessity of therapy services," the association protests.

And the audit results "support NAHC's contention that claims often are denied based on technical errors--such as a date missing on signed orders--that should be open for resubmission," the trade group argues.

The OIG recommends that Total Patient Care refund the projected $63,425 overpayment, identify and submit adjusted claims for overpayments received subsequent to the audit period, and strengthen billing controls.

Total Patient Care did not respond to inquiries for this story.

Editor's Note: The report is at http://oig.hhs.gov/oas/reports/region4/40502000.pdf.