The real reason your claim was denied.
Posts from the ‘medical review’ Category
Today’s post is written by John M. Reisinger, CPA (TN Licensed) of Innovative Financial Solutions for Home Health Publisher of the Home Health Care Resource Planner. His contact information follows this post.
John sent the following out in an email this morning so some of you may have already seen it but it is important enough that reading it twice is a good idea. It speaks to a new way that agencies can be denied without a lot of trouble. There are links to supporting information an this needs to be shared with your entire agency.
The CMS Medicare Learning Network (MLN) released a new article on March 24 regarding the denial of payment when a Claim is submitted when there is no (required) corresponding assessment in their system. This will have an effective date of April 1, 2017; so this is something that you want all your billers to be on top of, as well as those that manage the OASIS submission process. (Julianne’s note: often the OASIS is submitted but not included with ADR information when a recertification falls in the prior episode. Be sure that the person compiling the ADR knows to go back and retrieve the recert OASIS.)
PROVIDER TYPE AFFECTED
This MLN Matters Article is intended for Home Health Agencies (HHAs) submitting claims to Medicare Administrative Contractors (MACs) for home health services provided to Medicare beneficiaries.
PROVIDER ACTION NEEDED
In Change Request (CR) 9585, the Centers for Medicare & Medicaid Services (CMS) directed MACs to automate the denial of Home Health Prospective Payment System (HH PPS) claims when the condition of payment for submitting patient assessment data has not been met. CR9585 is effective on April 1, 2017. This article is a reminder of the upcoming change and provides further information to assist HHAs in avoiding problems with these Medicare requirements. Make sure that your billing staffs are aware of this change.
Don’t cost yourself money by not paying attention to the details. This has always been a requirement under PPS, just a loosely (if at all) enforced regulation. That is changing effective April 1st. Now is not the time to worry about the ‘way we have always done it’, now is the time to start doing it ‘the way it should be done’. Hopefully your software has systems in place to identify these instances when they occur, and your billers have an understanding of how to verify what is appropriate to be billed and what is not yet ready and why (and have processes in place to share that information with you immediately).
In fact, everyone should now be moving to and focusing on ‘the way it should be done’ in all aspects of their operations instead of the‘way we have always done it’, because if things we did in the past were so good, we wouldn’t be having the troubling relationship that we currently have with CMS, MedPac, Congress, et al, that we do have.
Ph. # (813) 994-1147
Fax # (866) 547-8553
What if I could tell you how likely you are to find your agency under intense scrutiny by Medicare? Would you want to know? What if I could tell you what Medicare expects you to do to address any risk areas? Would you do it?
Chances are the answer is a resounding, ‘No!’
You can have all this information within 15 minutes. All you need is your provider number and a patient ID number for a claim that has been paid prior to July 17, 2016. Both of these numbers are available on any 485.
Using these two numbers, any Medicare certified home health care agency can access the PEPPER portal. There you will find your agency specific reports that show where an agency falls compared to other agencies in areas that Medicare has identified as those being closely associated with Medicare fraud and abuse. Of all certified home health agencies, only 20 percent nationwide have bothered to look at their data.
One nurse asked me if maybe it was better not to download reports. Her rationale was that if Medicare would come down harder if they believed the agency was aware of any high risk areas as opposed to being unaware. To be clear, Medicare is not going to cut you a break if you didn’t know that your agency was meeting the threshold for any of the target groups reported.
Here’s what the PEPPER reports show:
Average Case Mix
Agencies with an average rate of 1.6 or higher may find themselves looked at for possible up-coding.
Average Number of Episodes
Nationwide, agencies in the 80th percentile provide an average of 2.78 episodes. Medicare believes there is a high chance of improper payments if you meet or exceed an average of 2.78 episodes per patient.
5 or 6 Visits
In order to get paid the full amount for an episode, an agency must provide at least five visits. Any nursing care over and above five visits adds to the cost of the episode but not to the payment. If your agency has more than 7.2 percent of their episodes with five or six visits, Medicare believes there is a chance that you are maximizing income without regard to patient care.
Medicare expects that agencies will have LUPA payments. When the number of LUPA payments is very low, Medicare suspects that an agency is avoiding LUPA costs by providing unnecessary visits to qualify for full payment.
Although some patients require 20 or more therapy visits per episode, the assumption is that agencies in which 2.9 percent or more of patients required 20 or more visits may be adding unnecessary visits to capitalize on the enhanced payment associated with high therapy.
The target for outliers is 7.6 of total payment. Note that this is less than 7.6 of total episodes. Anything over 10 percent will be adjusted quarterly.
These indicators of possible improper payments are only data. It is possible to hit the target in one more areas without doing anything improper. However, a prudent agency will be well aware of where they fall and document accordingly. Should questions arise, the agency should be able to provide an explanation as to the aberrancy. If you cannot arrive at a suitable answer, take a long and hard look at your charts.
The PEPPER reports that have been shared with us do not approach any level of concern. (Fraudulent agencies often eschew our services which focus on compliance.) My guess is that PEPPER Reports are effective at identifying improper payments. Agencies that routinely provide three episodes per patient and all the episodes have exactly 6 visits may not be assessing the patient and meeting their individual needs. If you are employed by an agency that has hit multiple targets and seems disinterested in addressing them, you may want to reconsider your current employment status.
If you decide to download your PEPPER reports, please let us know. If you feel like sharing them, we’d love to see them and promise to keep them confidential.