Medicare Compliance & Reimbursement

Rise in utilization sparks scrutiny.

Increased utilization of costly continuous home care is drawing unwanted attention to the service--and to hospices that provide it.

Regional home health intermediary Palmetto GBA is launching a probe review of continuous home care (CHC), the RHHI says in a recent Web site posting. The probe will sample 100 claims each from California, Florida, Illinois, Ohio and Texas.

If the probe turns up high denial rates, hospices everywhere can bet on increased scrutiny of continuous home care going forward.

Palmetto will select claims using bill type 81x and 82x and revenue code 0652 for prepayment review, it says in the posting. "These services have been identified due to significant increase in use, beneficiary count and revenue code charges," the intermediary explains.

CHC Basics

Medicare covers CHC "only during periods of crisis and only as necessary to maintain the terminally ill individual at home," the Centers for Medicare & Medicaid Services says in a Feb. 28, 2003 memo (A-03-016). Hospices must furnish at least eight hours of care, with at least half of that time by an RN or LPN.

CHC has a base reimbursement rate of $738.26 ($30.76 hourly), compared to the hospice routine home care rate of $126.49 per day and the hospice general inpatient care rate of $562.69.

This is the first time in recent memory hospice attorney Mary Michal with Reinhart Boerner Van Deuren in Madison, WI has seen CHC targeted for a probe edit, she says.

But the move isn't exactly unexpected. Monitoring and auditing of the service is no surprise, "as it is a fast-growing segment of a fast-growing Medicare benefit," notes consultant Beth Carpenter with Beth Carpenter and Associates in Lake Barrington, IL.
The additional development requests this review will generate will prove expensive to hospices that receive them, Michal cautions. "A probe edit, usually involving 20 to 40 claims, creates a significant administrative cost."

And hospices may be ripe for CHC denials, worries consultant Sharon Litwin with 5 Star Consultants in Ballwin, MO. Litwin sees many hospices that use the service either too much or not enough. "Neither is good," she notes.

Hospices on the low side write off the service altogether as too complicated or staff-intensive to furnish, while hospices on the high side set inappropriate goals for high percentages of CHC, Litwin tells Eli.

CHC Growth Legitimate

There are many reasons for the legitimate growth in CHC utilization, Michal maintains. Hospices often underutilized the service in the past because of nurse staffing shortages and the problems with administering and tracking it under Medicare's complicated rules.

Now increased competition is motivating hospices to furnish this service more often, Carpenter believes. Patients would usually rather stay in their own homes and receive CHC than go to the hospital for general inpatient care.

Authorities should really look at target hospices' provision of CHC in conjunction with their utilization of inpatient care, Michal argues. Under the probe's narrow focus, determining whether "the outlier hospices chosen for the probe edit are simply doing a better job of keeping patients at home and out of the hospital" will be impossible.