For two years, we have been reporting that the giant collection agencies that won government contracts to recover Medicare overpayments were entirely focused on lucrative bounties available when they audit hospitals and large physician practices. That may be changing. (more…)
Stamford, CONN. – August 1, 2011 – IVANS, Inc., a national health information exchange, announced Monday that 73 percent of hospitals agree that the Recovery Audit Contractor (RAC) Program helps to reduce Medicare fraud and errors.
However, more than 60 percent do not think the audit process is fair. (more…)
On February 17, Secretary Kathleen Sebelius held a joint press conference with Attorney General Eric Holder and FBI Director Robert Mueller to announce the largest mass arrest of alleged Medicare fraud perpetrators in history. In her remarks, Secretary Sebelius described the H.E.A.T. task force as overwhelmingly successful so far, returning more than six times as much money to federal coffers than it cost taxpayers to operate it. She also disclosed the cities where two new H.E.A.T. offices have set up shop. Here is her prepared speech from that press conference. (more…)
“More frequently than chance would dictate, denial letters dispose of just enough visits to kick a full-pay episode down to a LUPA. When there were seven visits, they deny three; when there were five visits, they deny one. Rarely if ever do agencies see a seven- or ten-visit episode reduced to five.”
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by Michael McGowan
My phone began to ring off the hook in early August and has not stopped yet. Over a three-week period, Medicare certified home health care providers in California and Nevada had begun to receive letters from Trust Solutions, LLC, requesting documentation of Medicare services they had provided and long since paid for. The letters politely demanded charts for specific patients and imposed a very short deadline. (more…)
If home health care providers sometimes feel that government agencies treat the industry like a pre-ball Cinderella when it comes to payment rates, a new report from the Office of Inspector General (OIG) will not make them feel any better. Though CMS continues to look for reasons to reduce payment rates to home care agencies, it apparently resists efforts to cut rates for insurance companies participating in the Medicare Advantage program. (more…)
Even before President Obama’s promise to hire bounty hunters to eliminate waste and fraud from Medicare, Regional Home Health Intermediaries had been stepping up their rate of payment denials. Most often, justifications to withhold payments for already provided nursing or therapy services center around “lack of medical necessity.” In case after case, attorneys and appeals consultants argue that medical necessity was certainly in place. In case after case, Administrative Law Judges retort, “Then why didn’t the nurse or therapist write it down?” (more…)
Dear Ms. Smith,
After our long relationship as consultant and client, please know that I care for you and Mr. Smith and your business. Otherwise, I would not have gone through this much effort to draw your attention to a situation that I consider critical to your agency’s survival. I would ask that you examine this document very carefully, try to separate facts from feelings, and take action.
I am deeply concerned for the well being of your home care agency. I have been representing you before your RHHI and the ALJ but I can no longer do so if your slow, progressively terminal condition is left unchecked. (more…)
In our previous story, we reprinted a letter from a payment denials and appeals consultant who told a client he would stop representing their appeals until they improved their staff’s clinical documentation skills. At the end of the letter, he offered some examples of what kind of documentation they were giving him when he argued their case before the Administrative Law Judge. First, comments about Physical Therapy documentation. Below, his critique of skilled nursing. (more…)
On January 1, 2010, The Centers for Medicare and Medicaid Services (CMS) closed a loophole in its home health PPS regulations with a rule that is likely to harm more legitimate providers than shady characters, the group the rule supposedly targets. Responding to a known abusive practice, the federal agency applied a sledge hammer where a scalpel was needed, potentially damaging or closing more than 2,000 home care agencies. If buying or selling a Medicare certified home health agency is in your plans, learn — better yet, memorize — 42 CFR 424.550(b). (more…)
