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Posts tagged ‘RAC’s’

New Kids on the Block


Strategic Health Solutions is a Medicare Supplemental Review Contractor.  If you haven’t heard of them yet, chances are you will.  They have been ‘encouraging’ agencies to send them clinical records with letters that read as follows:

Effective April 1, 2011 , Section 6407 of the Patient Protection and Affordable Care Act (ACA) established a face-to-face encounter requirement for certification of eligibility for Medicare Home Health services, by requiring the certifying physician to document that he or she, or a non-physician practitioner working with the physician, has seen the patient. CMS implemented the face-to-face encounter requirement of the ACA via the Home Health Prospective Payment System (HHPPS) Calendar Year rulemaking. The Final Rule states that documentation of the face-to-face encounter must be present on certifications for patients with starts of care on or after January 1, 2011 .

Office of Inspector General (OIG) work conducted, before the ACA mandate went into effect, found that only 30 percent of beneficiaries had at least one face-to-face visit with the physicians who ordered their home health care. This constitutes new and material evidence that establishes good cause for reopening as required under 42 CFR 405.980(b). Based on this information CMS has directed Strategic to perform postpayment review of Medicare Part A Claims billed for home health services.

As you well know, it is most unlike me to be argumentative but I googled ‘home health referral sources’.  As it turns out, the CDC information from 2010 is in stark contrast to the information provided by the OIG via Strategic Health Solutions.

referral sources

This graph states that providers who only offer home health services have 40 percent of their admissions from a hospital.  It says that 30 percent were from physicians but not that they were the outcome of actual physician visits so lets assume none of them were.  Sadly, the CDC’s 2010 report references 2007 data.

Lets move on to MedPac.  They write reports twice a year for the Congress about how much we are overpaid.  They increase our confusion by writing about how many episodes are preceded by a hospital stay but their data reflects 2010 so that’s a plus.  They say that 27 percent of initial episodes are preceded by a hospital stay and the average length of stay for those patients was 1.4 episodes.  That means that 38 percent of patients come from a hospital.

Neither MedPac or the CDC differentiate between patients  who were in the hospital seen by physicians who did not order their home health and those that did.  If a patient was from out of state, it might be that their personal doctor ordered home health or that a hospitalist saved that special joy for the primary physician.   This is important because it shows how accurate data could potentially be manipulated to paint an inaccurate picture of our industry.

In any event, I can say with confidence that at least 38 percent of patients were seen by a physician because that’s what happens in hospitals.  Doctors come write orders, nurses carry out the orders and the cafeteria always closes five minutes before you can get away to lunch.

So, we have huge discrepancies between the CDC, the OIG/SHS and MedPac.  Who are you going to believe?  My money is on the OIG because the CDC and MedPac do not have the authority to arrest me or monitor my email or phone calls.

So, after that long and rambling trip through the unfamiliar territory of numbers, we are back at the 30 percent mark referenced in the letter reproduced above sent by the OIG/SHS.  That leaves us with some disturbing facts.

We have an entity that looks like a RAC, walks like a RAC and quacks like a RAC but is really a Medicare Supplemental Review Contractor.

The RAC lookalike has noted that in 2010 providers did not adhere to guidance that was effective in 2011.

This non-adherence from 2010 constitutes NEW AND MATERIAL evidence that is being used as grounds to investigate home health care agencies for fraud.

And they will find it.   And it will not in any way, shape or form improve the care that our patients receive.

Note:   Pre-Nursing was the only curriculum that did not require math when I was in college which is why I chose nursing as a career.  Please feel free to correct any mathematical errors – politely, of course.

If I Were a Recovery Audit Contractor

If I were a Recovery Audit Contractor, I know pretty much exactly how I would choose my targets for review. After all, we know that that the RACs can use statistical information from electronic sources to select agencies to review. By looking at aberrancies in data, I would choose the following triggers to guide me in my work:

  1. High case mix weights. This is pretty much a given since agencies with very low case mix weights may be under-billing.
  2. High therapy utilization. Nothing brings up a case mix weight more than therapy! Prior to 2008, there were many patients who needed 10 or 11 visits to meet the therapy threshold. Now the same patient might be assessed as needing seven or 14 visits! Very few patients receive 12 visits anymore.
  3. I would look for a lot of technical stuff. If I wanted to prove a diagnosis wasn’t appropriate, I would have a lot of clinical record review to get through. Then, when I adjusted the case mix weight based on diagnosis coding, I might find a couple of hundred dollars. On the other hand, if a physician didn’t date his or her signature, I get back the entire HHRG.
  4. All things being equal, I would choose agencies with very long lengths of stay. While it is true that a Medicare Beneficiary is entitled to unlimited episodes of home health as long as they have a qualifying need, documentation tends to become stale after a while. Homebound status is a little more difficult to discern by clinical record review but when I am reviewing clinical records, I can’t help but wonder about patients with multiple missed visit reports.

Does this mean that you should avoid patients who need therapy and have a high case mix weight. I do not see that as a valid answer. But when time is limited and you must pick and choose clinical records to review for completeness, these are the types of patients I would choose. I would also keep all these factors in mind at case conference. Front end protection in a RAC situation is most certainly better than trying to address problems after the record has been requested.

If you have comments or questions, please post below or email them. If you have any other ideas of what you would do if you were a RAC auditor, please share!

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