Home Health & Hospice Week

Bulletproof your 1CGK claims.

Wondering where Medicare is going to put its resources for medical review and other oversight activities? A new data release may tell you. Before Christmas, the Centers for Medicare & Medicaid Servicesreleased a new data set, including information on 11,062 home health agencies, more than 6 million claims, and more than $18 billion in Medicare payments for 2013. The Home Health Agency Utilization and Payment Public Use File (Home Health Agency PUF), part of CMS’s Medicare Provider Utilization and Payment Data set, identifies individual home health agencies using their six-digit identification number but doesn’t reveal beneficiary-specific information.

The data set contains the total number of episodes that were provided by agency and by HHRG, distinct number of beneficiaries served, the HHAs’ total and average charges, the total and average Medicare payments, the total and average Medicare standardized payments, and information on low-utilization payment amount (LUPA) episodes and outlier payments, CMS says.

Data highlight #1: By far, the HHRG 1CGK (Early Episode, 0-13 therapies, Clinical Severity Level 3, Functional Severity Level 2, Service Severity Level 1) ranked as the top paying case mix category at $1.2 billion. The next-highest-paying HHRG was 3CGK (same as 1CGK but Late Episode) at $785 million, according to CMS’s website.

Data highlight #2: 1CGK also ranked as the most frequently occurring episode HHRG with more than 490,000 episodes, CMS says. 1BGK came in as the second-most-common HHRG with more than 328,000 episodes.

Data highlight #3: CMS also ran state comparisons of payment per episode, payments per beneficiary, and outlier payments. Florida was the only state to rank in the highest category for all three measures. Utah, Texas, and Idaho ranked in the highest category for two of the three measures.

You can bet that Medicare contractors ranging from HHH MACs to ZPICs will be using this data to target their oversight activities, experts warn. Make sure your claims for the most frequently used HHRGs are well supported, and expect extra review if you rank high in utilization.

Note: More information and a link to the PUF is at www.cms.gov/Newsroom/MediaReleaseDatabase/Fact-sheets/2015-Fact-sheets-items/2015-12-18.html.