Medicare Compliance & Reimbursement

If you haven't seen extra scrutiny of your LUPA claims yet, that's likely to change. Home Health and Hospice Medicare Administrative Contractor NHIC has been performing medical reviews of low utilization payment adjustment LUPA claims, which have fewer than five visits, the MAC reports in a message to providers.

"Many denials have been identified in these reviews," NHIC says. The additional development requests (ADRs) on this issue are "driving people crazy" in New England, says consultant Betty Gordon with Simione Consultants in Westboro, Mass. Consultant Lynda Laff with Laff Associates in Hilton Head Island, S.C. sees this problem frequently when auditing, she says.

NHIC found three top reasons for denials:

1. No skilled observation. "The most common denial code for these claims was 55H3A, indicating that skilled nursing observation services were not reasonable and necessary," NHIC explains. Examples of denied services include administering oral medications, filling medication reminders, and finger-sticks for Prothrombin Time-International Normalized Ratio (INR).

"These services are not so complex that they require the skill of a nurse," NHIC tells providers. "These services could be safely performed by a nonmedical person or someone other than a nurse."

Remember: "The fact that the patient needs some assistance and is unable to perform the activity or has no care-giver does not make the non-skilled service skilled," NHIC reminds agencies. A lack of thorough documentation is often the culprit in these denials, Laff notes.

2. Homebound. "The second most common denial reason was 55H2B, indicating that the documentation did not show that the patient was homebound," NHIC reports. "The documentation must include information explaining that the person is homebound."

"Some records showed the patient was clearly not homebound," the HHH MAC says. Homebound status problems aren't limited to LUPA claims, Gordon observes. Homebound documentation is often lacking across the spectrum of home health agency claims.

3. Missing OASIS. "The third most common denial reason was 55H2C indicating that the Outcome and Assessment Information Set (OASIS) was not present," NHIC says. "With the advent of OASIS-C, CMS requires the reviewers to confirm the OASIS has been accepted by the state repository in a timely manner."

Sometimes agencies simply don't know or understand Medicare guidelines regarding the skilled need or homebound status of the patient, Laff points out. Other times clinicians just get sloppy with their documentation.

Either problem can result in a big expense to the HHA. Medical review is always costly, but it can be especially punishing when the reimbursement for the denied claim is low, Gordon notes. Agencies may have to spend significant time and resources defending or appealing a claim for only a few hundred dollars.

If HHAs fail to defend LUPA claims, they may land themselves on focused medical review (FMR), which brings a whole new world of reimbursement pain down on them.