Medicare Compliance & Reimbursement

Beware denials that result in LUPAs

Congress should expand national coverage for off-label uses of cancer drugs, the American Society of Clinical Oncology argues in the July 1 Journal of Clinical Oncology.
 
Congress should require Medicare contractors to consider peer-reviewed literature as they make coverage decisions about off-label cancer drugs, ASCO says. Non-Medicare insurers should follow Medicare rules on off-label cancer drug use, ASCO adds.

RHHI Denies 75 Percent Of Claims With 1 Nursing, 4 Therapy Visits

When you submit a claim with one nursing and four therapy visits, you'd better be ready to defend it.
 
Regional home health intermediary (RHHI) Cahaba GBA has been reviewing claims with that visit mix for nearly a year, it notes in a June 27 posting to its Web site. And in the quarter spanning January through March, Cahaba denied 239 of 313 such reviewed claims.
 
Top denial reason: For 132 claims, the intermediary denied the skilled nursing visit as medically unnecessary due to lack of documentation.
 
Beware: Denying just one visit in a five-visit episode pushes the claim into the rock-bottom per-visit low utilization payment adjustment (LUPA) rate.
 
"Generally, if the skilled need for the nurse is observation and assessment, there is greater need than a one-time visit," Cahaba says in the notice at www.cahabagba.com/part_a/whats_new/20060627_denials.htm.

Fill Out 855 Forms Online To Save Time In Future

CMS is offering pdf files of the 855 enrollment form, it says. The forms "can be filled out online and saved for future reference or to notify CMS of any future changes," a CMS spokesperson says. "This presents a significant savings in terms of time and energy for the practitioner."
 
Download the forms at www.cms.hhs.gov/CMSForms/CMSForms/list.asp -- search for "855".

In Other News...

 • Missouri is wrong to deny coverage of medical equipment under Medicaid, a federal appeals court says in a June 22 ruling.
 
The decision by the 8th U.S. Circuit Court of Appeals gives new life to a lawsuit over last year's Medicaid cuts in Missouri. It was unreasonable of Missouri to deny coverage of certain equipment to most low-income adults, the court suggests. Specifically, the appeals court says Missouri's policy of covering some DME items but not others appears unreasonable under federal Medicaid rules and court precedent.
 
States have discretion to determine the optional services in their Medicaid plans, the ruling says. But "failure to provide Medicaid coverage for non-experimental, medically necessary services" within a Medicaid category is both "unreasonable and inconsistent with the stated goals of Medicaid," according to the decision.

 • Prosecutors accused the owners of Leonza Health Management Group Clinic of billing Medicare for injected drugs that they didn't administer, administered in smaller quantities than billed, or administered in return for kickbacks. They billed $7.5 million for the injections, prosecutors say.

 • New legislation approved by the Senate Budget Committee could lead to home care cuts. The Stop Overspending Act of 2006 (S. 3521) calls for across-the-board spending cuts in Medicare if certain spending levels are reached and other mechanisms for cutting Medicare and Medicaid spending.
 
The SOS bill may not have much chance of passage in this election year but could be "a harbinger of things to come," warns the National Association for Home Care & Hospice (NAHC). Consideration of "dramatic cuts in Medicare underscores the continuing need for grassroots action by the home care community to protect the Medicare market basket inflation update for home health care and hospice," NAHC warns.

 • A lawsuit by House Democrats that seeks to nullify the Deficit Reduction Act should be dismissed, the U.S. Justice Department says.
 
The lawsuit rests on the fact that the House and Senate failed to approve identical versions of the bill. The Senate version stipulated that Medicare could pay to rent some items of medical equipment for 13 months, while the House passed a version that erroneously stated "36 months" for the capped rental period.

 • Dearborn, MI physician Ali Makki allegedly overbilled $500,000 for unnecessary medical tests, faked medical records in response to a Medicare audit, and provided false medical records for more than 500 green-card applicants. He allegedly prescribed controlled substances without a medical purpose for two immigrants who had syphilis "negative" test results.

 • Providers completing an electronic National Provider Identifier (NPI) application should be able to obtain their new NPI number within 10 days, expects RHHI Palmetto GBA. However, "we cannot predict the amount of time it will take to obtain [an NPI] because several factors come into play," including how many applications are being processed at the time and whether the application is completed correctly, Palmetto says in a posting on its Web site.

 • A federal judge dismissed a group of doctors' class action suit against a variety of managed care insurers. All of the defendants except Coventry Healthcare and United HealthCare had already paid large amounts to settle the suit, which accused the insurers of using claims processing software to delay, reduce and deny physicians' payments.

 • A health plan had the right to withhold a physician's payments to recoup past overpayments, the U.S. Court of Appeals for the Second Circuit found in a recent case (05-6096-cv).
 
An audit found New York internal medicine doctor Clinton Sewell upcoded his office visits in claims to the 1199 National Benefit Fund for Health and Human Services, which provides medical services to union members. Sewell billed 99.7 percent of his new patient visits at the highest level evaluation & management (E/M) code, compared with 30.2 percent for other doctors.
 
Instead of choosing his E/M levels based on history, physical exam and decision-making, Sewell assigned himself "units" based on the amount of time he spent with the patient and the complexity of the patient's problems. For each "unit," Sewell gave himself five dollars. Then he billed the code that matched the dollar amount he felt he deserved.
 
The health plan downcoded all of Sewell's new claims one level to recoup the $200,000 it said Sewell upcoded. Sewell argued that this was "arbitrary and capricious" behavior, but the court ruled that the plan had the right to recoup the payments, and downcoding all his visits was a reasonable alternative to investigating each incoming claim.

 • A home health agency is heading to federal court to fight CMS for its rightful therapy reimbursement. As expected, the CMS Administrator overturned the Provider Reimbursement Review Board's (PRRB) favorable ruling for The Medical Team in Reston, VA, according to the recent Administrator's decision.
 
The agency plans to appeal the reversal in federal court, confirms attorney John Jansak with Harriman & Jansak in Towson, MD. The decision is the latest in a string where the CMS Administrator reverses the PRRB's stance on compensation for therapists paid per visit.

 • You can expect some close scrutiny of claims including a diagnosis of 344.61 (Cauda equina syndrome with neurogenic bladder). RHHI Cahaba GBA is initiating a widespread probe review of such home health prospective payment system claims, it says in a June 22 posting to its Web site. The topic code for this medical review will be 5THCZ.

 • Non-physician practitioners can't sign a home health plan of care, but they can bill for home health care plan oversight (CPO) services, CMS says in Transmittal 993, dated June 23.

 • Lumbar artificial disk replacement (LADR) with the Charite lumbar artificial disk is non-covered for Medicare patients over 60, CMS said in Transmittal 60, dated June 23.