RAC Audits -- What to do when they happen in Home Care and Hospice

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Many Home Care agencies are facing CMS RAC Audits.  Let's face it they are fishing for fraud.  That said the main thing to do is to NOT PANIC.  Just because you are under review does not mean you are doing anything wrong.

First thing to keep in mind is why you were selected.  The answer is not exactly clear, but can be described as that there is something about your utilizations which outside of average for your geographic area or Nationally.  So if you have a special Hip Replacement program you may well be targeted because that program requires more therapy than providers without it.  But as you can see, that program may well justify the additional therapy.

What to do?

1) As noted Don't Panic!

2) Budget in the lose of revenue for those cases that are under review.  CMS holds the money on these cases.   The money may well be held for 60-90 days from when you provide them the requested documentation.

3) Review the documentation before you send it... make sure you are thorough and there are no missing pieces.  Missing notes will be percieved as a fradulant omission so even a bad note is better than no note.  PROVIDE THE DOCUMENTATION IN A TIMELY MANNER.

4) Do not radically change your processes overnight.   Remember, you are not necessarily doing anything wrong.  Radical changes in process can be percieved as an admission of guilt.  Even if there is nothing wrong.

5) Hire a consultant to review your a) documentation processes b) your overall policies and procedures.  It is ok to change you business models.  But make educated decisions.

6) Did we mention dont panic.... well even if you are found at fault use your concultants to review the processes and come up with a plan of action to correct it.  Also know your rights.  You have the right to appeal any decision they make.

We at White Oak are dedicated to helping our customers and our community.  Please remember that Software like HomeRun can help you in situations like these, but that HomeRun is a tool and is only as good as how you use it.

Release 3087 - Home Care Therapy Alert Reports and Billing Edits

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White Oak Systems, released it's 3087 release yesterday.  This release corrects White Oaks existing Therapy Eval report and Billing edits to correspond to Clarifications provided by CMS with regard to the 13th and 19th visits and what to do in the event that a 13th or 19th visit re-eval/ reassessment does not occur.

The key to the Therapy Eval Alert report is that it.. scours the system looking for Therapy visits (Scheduling, Comprehensive Assessments, Timesheet and Billing).  All the visits are compiled to map out the current status of each patient.  Users can use this to determine and predict when the 13th and 19th visit take place and try to avoid errors.  As a daily report, providers are given constant real-time feedback as to where they stand at any moment.

In connection with this we have modified our billing edits to insure that if the therapy visits are not identified as being Eval/revaluations that Therapy visits will start to flag and corrective actions can be made.   Using the ability to mark visits as "Non-Covered Charges" providers can bill these missed visits and then get back into compliance.

The 3087 release is just another example of the strides White Oak Systems takes to make our customers compliant and prepared to deal with anything that Home Care Providers must face.

Clarification of 13th and 19th Home Care Regs and HomeRun Process

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Hi Everyone,

Happy Holidays!

We wanted to give you all a clarification of the process related to what you should do if the 13^th or 19^th Therapy re-evaluation/reassessment does not happen.

Before we provide this process, we wanted to give special thanks to the following people for helping is wade through this somewhat counter intuitive process:

Tim Sundberg, Empathy Care

Mary Tyler, Backus Home Health

Cheryl Leslie, HMS Healthcare Management Solutions

Mary St Pierre, NAHC

Here are the Steps.  Let’s say for the sake of argument that the re-eval/reassessment does not actually happen until the 16^th actual visit.  Here are the HomeRun Steps:

1)      The 13^th visit is to remain billable as a routine visit.

2)      The 14^th, 15^th and 16^th visits are to be marked non-billable as “Medicare Non-Covered Charges”.

3)      The 16^th visit is to be given the activity code of “THERAPY EVAL/ RE-EVAL” even though it is marked not billable!

4)      The 17^th visit becomes the de facto 14^th visit and it moves on from there.

As a result of these clarifications we will be making some adjustments to the Therapy Alert report as well as VDR164 “the 13^th and 19^th therapy visit warnings”.  Until we do please either turn off this edit or use the override function.

Thanks Everyone!

4 White Oak HomeRun Home Care Software users make Homecare Elite

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Hi everyone,

Just wanted to let you all know that a few of your fellow HomeRun  users have been noted in the 2011 Homecare Elite (attached).   Congratulations, are in order to

Backus Home Health

Bristol Hospital Home Care

Sightlineworks

For making the list!

And a special recognition is due to Welcome Home Care for being named a TOP 100 provider!

Nice Job Guys keep up the good work!!!!

Home Care Medicaid Billing for TPL States

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For those of you who live in TPL States such as Massachusetts and Connecticut you know that as of last year, your Medicaid Claims started failing on Dually Eligible patients.  That is Patient with both Medicare and Medicaid eligibility.  As of April 2010, Medicaid Changed their claim requirements for these payments to require a specific section of the electronic bill (837I) be modified so that the Medicare acknowledgement and denial be noted for each of these patients.  As many of you know, failure to put in this important information has resulting in denials by Medicaid.   Well, we are happy to announce that White Oak Systems, Has Successfully submitted these claims in both Connecticut and Massachusetts.  So if you has this billing issue, please contact us about how to get paid.

Home Care Therapy Eval does not take place until the 15th visit?

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I have had a number of customers mention that while they may try their best, due to the use of subcontractors etc, it is often very difficult to establish when the 13th and 19th Home Care therapy visit actually takes place.  As a result, it is possible that the actual re-evaluation does not occur until after the 13th (the 15th for example).  Medicare Guidelines state that you should mark the 13th and 14th visit as non-billable and they "recommend" you display them as non-covered charges on the claim.  This would make the 15th visit the 13th billable visit.  what are your thoughts on this? 

thanks to the folks at the Florida Association for Homecare who provided the following interpretation.

Attention Members,

Please review the communication below carefully. This update was sent from the National Organization which was based upon clarification they received directly from CMS. I have highlighted areas that you should pay particular attention to. CMS has previously stated that you only count billable visits in your overall therapy visit count when determining when the 13^th or 19^th reassessment should occur.  So as an example, if you did not complete the reassessment on visit #13 & the assessment was not completed until let’s say visit #16, according to the information below, visits 14,15, and 16 would then be non-billable. In addition under this principal visit #17 would resume your “billable” visit count but technically only count as the 14th visit in the total overall billable visits (working toward the next reassessment threshold of 19 visits). The link contained in the first paragraph below, takes you to the CMS Therapy Q&A page, which was last updated 5/5/11. It is also worth noting and passing this along to your billing department CMS’s clarification on how “non-billable” visits should be reported.

This requirement continues to become more and more confusing. Please do not hesitate to submit any questions you have and we will strive to obtain the answers we all need.  

Home Care PPS Final Rule Released November 1, 2011

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On November 1, CMS released the final rule for Home Care PPS Billing.  Despite  talking about changes to the Case Mix Ratios there is no evidence that any such change took place.   As you can see below the base rate was reduced but all of the visit, LUPA addon  and supply rates went up slightly.   Net is a -2.4 Percent change.

Based on the Site of Service for the Beneficiary

2. The per visit rates for LUPAs and the Non-Routine Supply rates are as follows:

HomeRun Home Care Software Release .3086 is coming

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docs/Release 3086.pdf

White Oaks Systems is proud to announce the release of our HomeRun Home Care 3086 Regualtory Release on Nov 1, 2011.  Key items include the 5010 837, the ability to bill Non-Covered Charges to CMS and a new Therapy Tracking report to provide agencies the ability to manage therapy utilization under the new 13/19 30 day regulations.

Contents:

White Oak Systems Release Manifest Version for HomeRun Home Care Software:

 3.10.00.3086 The 2012 Regulatory Release

Date of Release: November 1, 2011

Prerequisites:  3.10.00.3085, and all subsequent releases are required

Contents:  Oct  2011

Purpose:  5010 Electronic Billing, F2F Report, HHABN Report, Therapy Eval / Re Eval Alert Report,  New Homebound assessment, Medicare Non-Covered Charge, Updates for MSP, “Medicare episodes with missing or invalid OASIS”, 837P processing, and OASIS Haven edits.

New and Terminated ICD-9's and impact on Home Care PPS Billing

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With the onset of new and terminated ICD9 codes.  We begin the yearly ritual related to their use on episode that cross Oct 1.  The impact on Home Care Billing is clear with denials and/or suspensions likely.  The rule of thumb here is for PPS episodes that cross Oct 1, NEVER use a new or terminated diagnosis PERIOD.   If you have one in there, you must remove it as it will cause an issue.  The reasons are quite simple.  RAPS and FINALS do not follow the same rules.  Basically CMS edits look at diagnosis codes at the beginning of the Episode for RAPS and at the END for FINALS.  Therefore an code which is perfectly valid on day 1 but is terminated prior to day 60 will lead to a denied FINAL.  Therefore if you have one.  Back out the orders.  Cancel the RAP and find a suitable replacement that is NOT one of the new ones.

Copays for Home Care Billing by 2017?

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Read an article from NAHC which said that the President's Budget plan proposes that Home Care Billing include a co-pay by 2017.  Now that is really easy to say but what do Home Care Providers plan on doing about it?  I don't mean the protest thing, which we all should support, but rather how would we implement this?  Now most of us are used to paying co-pays at a doctors office and most cases we use a credit/debit card to pay this amount.   So let's think about this from 2 seperate angles. 

1) The effect on the Home Care Provider:  Home Care Software will need to facilitate the capture of that payment.  Do we use cellular based credit card scanners synced with software?  Perhaps...

2) The effect on patients:  Most of us pay $10, $20, $30, etc for a doctors visit... but most of us who are well enough to stay home, don't see a doctor every day.  But in Home Care we sometimes do provide daily service if not multiple visits on a single day.   So the looming question is how much is this copay going to be and how quickly does the amount become too much for the patient to bear.

The thing is that Home Care is by far the most cost effective health care option in the market place and we have to wonder whether or not co-pays will push patients away from Home Care, which may ultimately lead to more hospitalizations and greater cost...