Well, it has taken some time, but the Recovery Audit Contractors have finally started posting issues that relate to home health and hospice.
Health Data Insights, the Region D Recovery Audit Contractor (Region D covers: "Alaska, Arizona, California, Hawaii, Iowa, Idaho, Kansas, Missouri, Montana, North Dakota, Nebraska, Nevada, Oregon, South Dakota, Utah, Washington, Wyoming, Guam, American Samoa, and Northern Marianas). Has posted three issues related to hospice and home health. One issue (Hospice Related services) was approved last September, the other two issue have been approved since December 22, 2009. They all apply to claims billed after October 1, 2009
HDI has added two hospice related issues: DME while in hospice and Hospice Related Services - B. For both of these, Health Data Insights explains that:"Services related to a Hospice terminal diagnosis provided during a Hospice period are included in the Hospice payment and are not paid separately." The RAC will be looking at claims for DME and "Related Services" paid for separately by Medicare during a hospice admission. Obviously, if it is equipment and services related to the terminal illness and was paid for outside of the hospice reimbursement, Medicare should not have paid for it again.
This audit will likely be triggered by an automated review. They can churn through the numbers and identify claims submitted by non-hospice providers during a hospice episode. Whether or not a repayment is owed depends upon whether the claim is for DME or services related to the terminal illness. The RAC cannot determine that simply by an automated review. I say this, because, as anyone who has dealt with a hospice patient in a nursing home realizes, the question of what is and is not related to a terminal illness can often be disputed. It requires looking at the documentation for the additional services and comparing to the terminally ill patient's diagnosis and needs. Of course, if the hospice and the DME or other service provider both list the same illness, the issue becomes much simpler.
Health Data Insights has also added issues related to home health. This issue is titled "Medical Supplies and Consolidated Billing". Like the Hospice issue, this is an effort to identify services or supplies covered by the PPS episodic payment that were paid for separately. For example, a patient receives physical therapy during a home health episode from a provider other than the home health provider - that is covered under the episodic payment and should not be billed separately. This is another issue where the RAC can churn through the numbers and identify overlapping claims. This is one that is actually easier for the RAC, because certain supplies and services are covered by the episodic payment, without much room to quibble. (It's not like hospice where hospice patients can have other medical issues.)
Home health and hospice providers should be looking at their claims and trying to identify situations where other providers claims overlap for services that are covered under the payment they receive. The RAC may pursue the entity that provided the additional service (which seems like the correct response to me), but they may come after the HHA or Hospice. The best course of conduct is to attempt to avoid these overlapping claims.
Now that one RAC has identified home health and hospice issue, the others won't be too far behind. You may expect to start seeing letters form the RAC (in region D at least for now). When you receive a request for information, be sure to respond promptly. One of my favorite statistics from the RAC demonstration was the percentage of claims recouped simply because the provider failed to provide documentation. You should never have to pay back money because you just did not respond in time. The government already pays you too little and routinely asks for more back - don't help them out by not being ready for the RACs.