Home Health News

We may not always have a Medically Unbelievable Denial story to offer every week but this one could not wait until next month. This episode was denied, in part, because “home health care agencies are paid more when they provide more therapy services.”

Read the following carefully before forming your own opinion. Presented are two of the reasons offered by Field Manager Betsy Lulf, of CAHABA Government Benefit Administrators, LLC, for denying payment for services to a patient confined to his home for multiple conditions requiring IV hydration and physical therapy and a host of other treatments.

Reason 1: “The Medicare health insurance number (HIICN) has been identified as being utilized in questionable billing practices. Based upon this, it appears services were not provided as billed. The beneficiary is not responsible for payment of this claim.”

Reason 2: “…home health providers are paid at a significantly higher rate…when more than five therapy visits are covered.”

With regard to Reason #1, the agency responded within 120 days, as required, demanding to know the reasons CAHABA believes the patient’s Medicare number had been used fraudulently in the past. Though CMS PUB 100 -4, paragraph 310.4 (D.) requires that such evidence be made available for inspection by the appellant agency, CAHABA has ignored the request, even though it was made through the Freedom of Information Act.

The agency’s appeals consultant also noted that it is impermissible for a RHHI to withhold payment or even mention other reasons for payment denial without first addressing the evidence for its initial accusation regarding questionable billing practices. Informing CAHABA of this federal requirement garnered no reply.

Reason #2, a mere statement of a general observation about PPS, was not the only statement of its kind in the denial statement. The letter was filled with quotations from Medicare manuals and Social Security legislation, a practice in which RHHIs are specifically requested not to engage.

“The rest of the appeal is full of the customary ramblings, freely citing esoteric sections of the Social Security Act and the Code of Federal Regulations, as if the recipient ought to be fully fluent in the jargon listed,” he said. “The CMS manuals specifically spell out issues that should not be included in a denial letter to a provider, and these are included on that list.”

“I am seeing this more and more often,” the consultant told a RAC Assistance reporter. “I believe the intent is to intimidate with legal language and multiple irrelevant citations from Medicare manuals. If they can scare the small business person out of appealing, their job becomes easier.” CMS instructions to write in colloquial language, aimed at an 8^th grade level, are routinely ignored, he stated.

The appeals consultant also sees in this denial what can only be identified as a “bait and switch” practice. “What will happen in this case, as it does in so many others, is that our appeal will kick the case to the QIC. There, the denial will be confirmed but for completely new and different reasons.”

Over and over again, he explained, the QIC invents clinical reasons to support a denial that was originally administrative. “Then I have to start all over, writing my next appeal on a completely different basis for the same exact case,” he added, with no attempt to hide his exasperation.

If they succeed in this type of intimidation, the consultant explained, the RHHI wins one more denial notch on its belt. “Is this to protect the Medicare Trust Fund or the RHHI’s government contract?” he wonders.

According to NAHC attorney Denise Bonn, the Office of the Inspector General (OIG) and Department of Health and Human Services (HSS) have stated recently that the current 1.4% average denial rate is too low, hinting that if current contractors cannot raise the rate they will find others who can. Certainly, they have the incentive to increase denial activity.

The current environment, of which this case is but one example among thousands, leads some to believe, including the consultant appealing this case, that RHHI tactics are designed to get as much money out of providers with the least amount of fight, regardless of the legitimacy of the claim. “The multiple words and pages are rarely an indication of increased substance in their denial report,” he advises his clients. “Ignore the fluff, go to the heart of the issue, and you often find there is nothing there and the appeal is easily won.”

As a matter of fact, his track record since the recent upsurge in denial activity is nearly 90% success in overturning denials. “Most of them are weak arguments, which the Administrative Law Judges immediately recognize,” the expert stated.

CAHABA Field Manager Betsy Lulf did not identified herself as a clinician in her denial statement, but as an “appeals manager.” Nor did she list the name of any clinical reviewers who may have helped write this review. She did, however, cite a Local Coverage Determination (LCD) to support her denial decision. The problem was that she used an LCD that only applies to CMS region VII providers, yet she was denying payment to a provider in region IX.

Result:
Following the first appeal level, CAHABA decided to down-code the claim and pay it at a lower rate, now citing clinical documentation issues rather than the original reasons. The agency is currently deciding whether the remaining amount is worth further appeals effort. “These down-codes work in the RHHI appeals manager’s favor,” the consultant concluded. “It takes so many resources to appeal claims that in most cases an agency will just take the loss. RHHI goals met.”

In this case, the agency has decided to continue the appeal. The appeals consultant believes the chart has excellent documentation and a strong, measurable physical therapy evaluation. The documenting therapist used industry standard measurements, such as Tinetti Gait and balance, combined with the use of goniometric measurements of the affected leg and made a clear demonstration of progress towards goals in each follow up note.

“The chart paints a clear and compelling story of progress toward goals set on the initial plan of treatment,” he concluded. “Winning back these seven visits will be arduous but quite achievable for the client.”

In an effort to maintain fair and balanced reporting, it is imperative that “Clear as M.U.D.” include RHHI decisions, such as this week’s, from time to time. In future reports, we will shine our light on QIC, ALJ and MAC appeals while waiting for Recovery Audit Contractors, our primary target, to arrive in home care.

We ask all of you who are experiencing payment denials to keep track of the names that arise during these articles as the denials are nationwide. When patterns arise from different judges and review managers, we can come together as a community and learn from each other, we can use our collective voice. If we lock ourselves in silos, we will be overrun, one by one.