HHAs brace for wave of Medicare appeals
HHAs brace for wave of Medicare appeals
Home health agencies (HHAs) facing implementation of the Medicare home health prospective payment system (PPS) in two months should brace for even more Medicare appeals than they now confront. "Home health is going to be vulnerable every day in every way," warns Ann Howard, executive director of the Washington, DC-based American Federation of HomeCare Providers.
Medicare will not only have its fiscal intermediaries scrutinizing providers, it will also have its new Medicare Integrity Program contractors closely watching reimbursement, says Howard. "Agencies will also be vulnerable through the state survey process because they will have to reduce services to some patients," she adds.
According to Howard, Medicare will continue to look at claims filed until Sept. 30 on a retroactive basis. "They are still going to be looking at the same types of issues such as medical necessity," she adds. "There are still going to be massive numbers of appeals on both pre-PPS and post-PPS allowances."
Likewise, HHAs will still face reimbursement on a per-visit basis and the question of whether beneficiaries are deemed eligible for home care in the first place, notes Howard. For example, Medicare recently determined that wound care patients are not supposed to continue receiving home care services if their wounds are not healing. "I can see that opening up a Pandora’s box of all kinds of trouble," she asserts. "The agency will argue the patients needed the services, the fiscal intermediary will disallow the care, and the agency will have to appeal to the administrative law judge."
The focus of Medicare home health audits used to be on high-utilization providers. Since the interim payment system was implemented, the focus has shifted to discrepancies over billing, documentation, and coverage, according to Denise Bond, of the Washington, DC-based firm Schmeltzer, Aptaker & Shepherd.
Bond reports that some fiscal intermediaries have demanded payment for extrapolated amounts. She adds that many HHAs have challenged their methodology, but to no avail.
In other instances, Bond says intermediaries have claimed they are simply following up on a review by surveyors who uncovered problems. "In other cases, we saw variations where the periods didn’t match," she reports. "The intermediaries looked at one time period, the surveyors looked at a different time period, and it caused problems for the providers."
Bond says that HHAs confronted with a situation like that should immediately review their claims and look at the medical charts even if the intermediary says they have no right to reconsideration. "Don’t give up your appeals rights," she warns. Instead, she says that if intermediaries are doing an extrapolation, HHAs should review their overpayment calculations and point out any errors or inconsistencies. "A number of providers uncovered all kinds of problems with the calculations and the extrapolations, and were able to get revised overpayments," she reports.
Bond says an overpayment letter would be issued notifying the provider of the number of claims denied, number of visits denied, and what was not paid under waiver. That amount would then be extrapolated over the entire fiscal year, and HHAs would be required to make a repayment within 30 days. "It was terrifying to a lot of providers because the figures were in the millions of dollars in many cases," Bond asserts.
The first thing HHAs confronted with this situation should do is file for an extended repayment plan, according to Bond. "It is very unlikely that you are going to otherwise be able to pay back the money," she warns. "You want to do this very quickly before the intermediaries begin an offset, which is generally within 30 days of the overpayment letter."
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