The Patient Protection and Affordable Care Act (PPACA), pronounced ‘PAKA’ by the folks with CMS, will have a transforming impact on healthcare. One of the more immediate challenges agencies is more layers of oversight. The current administration has allocated millions of dollars for fiscal intermediaries and subcontractors to look harder at home health claims and payments.
This oversight has started in neighboring Texas, where it is reported by Home Health Line that on March 10, 2010, a multi office provider received a letter “asking for $2.9 million in overpayments based on extrapolation from a 49 claim sample.” Lucian Bernard, the agency’s attorney, of Pearson and Bernard of Covington, KY, indicated that therapy claims and patients recertified at least twice, were the primary areas of focus.
Turn the timeline back to BBA ’97 and you will recall that rampant denials led to overpayments, and recoupment of overpayments pushed providers out of the home health program. This increased scrutiny, and eventual reduction in payments, will achieve what BBA ’97 did when it shrank the industry from nearly 10,000 home health agencies down to around 6,000.
I spoke with Lucian Bernard by phone this week, and he agreed that providers are in for significant challenges. Bernard indicated administrative law judges have a history of overturning a high percentage of denials. But providers who have not had a meticulous program of documentation review over the past years may find themselves in a very difficult position if asked for claims documentation as far back as 2006.
Jan Spears, of MJS & Associates in Nacogdoches, TX, indicated in the article that 15 of her clients had claims denied based on a ZPIC phone call that simply asked patients about their homebound status. She indicated one client had purchased an agency recently, and got denials from the previous owner that recouped large sums from the new owner, who had cleaned up the claims and documentation since his purchase.
With this news in the May 3rd edition of Home Health Line, HCLA has engaged Lucian Bernard and Jan Spears to speak in the coming months. In the short-term, Arnie Cisneros, PT, will be in Louisiana addressing these types of denials via RACs, and now ZPICs. Knowing what to expect and how to respond may well determine the fate of your agency as this new era of increased scrutiny revisits Medicare home health. Go to www.hclanet.org for more information or call HCLA at 800-283-4252.
If you have questions or comments on this piece please join the conversation.
Warren Hebert
CEO – HCLA
