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…)
Analysis by Editor Tim Rowan
As we have emphasized over the last few months, too much attention is focused on the Recovery Audit Contractor program and too little on other contractors that have the power to reduce home care and hospice revenue today rather than on some unknown date in the future. For the contractors themselves, however, there is ample reason to pay attention. In fact, the reason so much time passed between demonstration and implementation is that several insurance companies and collection agencies whose bids to become RACs were not initially accepted sued to force CMS to reconsider their choices.
Obviously, the expectation is that these contracts will be quite lucrative for the contractors. But are they actually lucrative for Medicare and taxpayers? A quick look at the monies involved in the three-year RAC demonstration is quite revealing. It is clear why losing bidders put up such a fight. It is not clear, however, that Medicare and taxpayers will be significant winners. (more…)
File this one under “lesson learned…the hard way.” Incorporate it into your next staff training. This agency properly followed the government’s appeal procedure after receiving a notice of payment denial. Excerpts below show that the administrative law judge did not find the provider’s care lacking, just its paperwork. That is correct, it is not merely an old cliché. The job is still not finished until the paperwork is done…and submitted.
Some healthcare providers are concerned they may not know how to proceed if their organization is audited by a Recovery Audit Contractor (RAC) and receives a payment recoupment notice. Fortunately, there is a way to learn the RAC appeal process in advance and be completely prepared. (more…)
Since the inception of Medicare Fraud Strike Force operations in March 2007, the Strike Force has obtained indictments of more than 460 individuals and organizations that collectively have falsely billed the Medicare program for more than one billion dollars. In addition to the fraud hotbeds in Los Angeles, Houston, Detroit and — the one that dwarfs all three of them combined — Miami, the Department of Justice (DOJ) and the Department of Health and Human Services will soon target three additional cities, establishing strike force offices in Baton Rouge, Tampa and Brooklyn. Enforcement teams that include these two agencies plus the FBI and DEA are housed in strike force centers. (more…)
Attorney General Holder and Health and Human Services (HHS) Secretary Kathleen Sebelius recently announced the creation of a new interagency effort, the Health Care Fraud Prevention and Enforcement Action Team (HEAT), to combat Medicare fraud. Holder and Sebelius also announced the expansion of Strike Force team operations to Detroit and Houston. Medicare Fraud Strike Forces, currently in operation in South Florida and Los Angeles, fight Medicare fraud on a targeted local level. (more…)
