Medicare Compliance & Reimbursement

Legitimate home health agencies (HHAs) in the Miami area that serve patients with high aide needs have been slapped with a major burden.

As of March 1, the Medicare claims system started denying claims that contain three or more aide visits per week and qualify for outlier payments, according to a letter Medicare's home health Program Safeguard Contractor (PSC) in Florida, TriCenturion, faxed agencies in Miami-Dade County in mid-February.

HHAs can appeal denied claims for more aide visits, says TriCenturion in the letter. But "TriCenturion may interview beneficiaries for whom appeals are filed as part of its normal review process," the PSC warns.

And TriCenturion will red flag "patterns of fraudulent appeals" for the HHS Office of Inspector General and Federal Bureau of Investigation, it says.

Good guys: "Honest [providers] are somewhat frustrated because they have patients who really need more visits," says Gene Tischer of the trade group Associated Home Health Industries of Florida. "They will continue to provide the care, and then appeal the denials to the extent their finances allow."

The industry generally applauds efforts to combat fraud and abuse, notes Burtonsville, MD-based health care attorney Elizabeth Hogue. But "automatic denials are always problematic because they penalize both those who are behaving appropriately and those who are not," Hogue says.

Post-pay reviews would be more fair, observers argue. "It is hard to understand why automatic denials are necessary," Hogue adds. Why wouldn't it work "at least as well to do retrospective reviews that result in denials when they are warranted?" Hogue asks.

Beneficiary advocacy group the Center for Medicare Advocacy is looking into the measure's impact on patients who need daily aide care, reports Mary St. Pierre with the National Association for Home Care & Hospice.

Automatic denials will require extra resources to appeal. "What a shame for those agencies that are serving patients appropriately," Hogue laments.

Bad guys: Meanwhile, the limit probably won't make much of a dent in the processes of fraudsters, Tischer worries. "The crooks, I imagine, will just adjust their visit frequencies and make a little less profit," Tischer tells Eli.

Coming your way? HHAs in other areas may see this kind of enforcement imposed on them in the future, observers warn. "I suspect that if it is happening in one home health abuse hot spot, it is happening in others as well," points out Bob Wardwell with the Visiting Nurse Associations of America.

CMS alerted the industry to outlier problems in Miami-Dade County when it raised the fixed dollar loss (FDL) outlier ratio from 0.67 to 0.89 in the prospective payment system final rule late last summer.

But CMS did not include Miami-Dade HHAs in the fraud demonstration that requires reenrollment of all providers. That demo is running for HHAs in Southern California and Texas and for durable medical equipment suppliers only in Miami.

Nevertheless, CMS and TriCenturion have uncovered some startling statistics about outliers in South Florida, the letter notes. "Home health payments in Miami-Dade County have increased from $71 million in 2001 to over $532 million in 2006, and almost $521 million for the first seven months of 2007," TriCenturion says. "The outlier portion of claims alone has increased from $11.6 million in 2001 (16 percent) to $279 million (52 percent) in 2006 and to $296 million (57 percent) for the first seven months of 2007."

Out of whack: Medicare payments to HHAs in the area increased about seven-and-a-half times from 2001 to 2007, but outlier payments increased a whopping 24 times, the letter says. "In the first 7 months of 2007, Miami-Dade County claims data shows that the total number of aide visits billed has already exceeded the total aide visits billed in 2006 by over 300,000."

CMS intimates that the excess aide services that cause the outliers might be due to unethical kickback and marketing practices. "Daily aide services ... should not be offered as a matter of convenience to the beneficiary for de facto maid services or used as a marketing tool," TriCenturion chides.

Providers should furnish daily aides only "in rare cases, such as for a home health qualified quadriplegic without a caregiver," the PSC maintains.

HHAs can't give in to beneficiary or referral source demands for daily aide services, TriCenturion tells agencies. "It is the agency's responsibility to determine if any aide services are appropriate, and if so, at what frequency."

Agencies should focus on the requirement that the services be both reasonable and necessary, the letter urges. "The standard to establish that aide visits occurring one or more times daily are reasonable and necessary is extremely high."

And a physician's stamp of approval doesn't automatically make it OK. "Having the signature of a physician on a Plan of Care ordering a specific number of aide visits does not make the visits reasonable and necessary," TriCenturion stresses.