Tuesday, July 12, 2016

OIG Places 562 Home Health Agencies and 4,500 Physicians on Red Flag List - 7-12-2016

In June the Office of Inspector General of the Department of Health and Human Services issued a nationwide analysis of common characteristics in OIG home health fraud cases.  470 home health agencies had an unusually high percentage of home health episodes for which the beneficiary had no recent visits with the supervising physician.  483 home health agencies had an unusually high percentage of home health episodes with primary diagnosis of diabetes or hypertension.  770 home health agencies were outliers on the percentage of beneficiaries who received home health care from 3 or home health agencies over the course of 2 years.  778 home health agencies had an unusually high percentage of beneficiaries with multiple home health readmissions in a short period of time.  Listed below two tables of home health information:

Home Health Agencies Outlier Characteristics
# of Agencies
Outliers on 2 characteristics
Outliers on 3 characteristics
Outliers on 4 characteristics

Home Health National Medians and Outlier Thresholds
Outliers as a
of Total
No recent visit with the supervision physician




Diabetes of hypertension diagnosis




Beneficiaries with claims from multiple HHAs




shortly after discharge





Where does your agency stand with these Characteristics?

For more information, please go to:


Friday, July 8, 2016

Proposed Home Health LUPA Payment Rates 2017

Home Health episodes that have four or less visits are paid a LUPA rate instead of an episode rate.  Listed below are the National LUPA Payment Rates.  Remember these rates will be adjusted for each home health agencies wage index.

Listed below are the LUPA Payment Rates Per Discipline

Urban Agencies
Quality Data
Urban Agencies
Not Submitted
Quality Data

Rural Agencies
Quality Data
Rural Agencies
Not Submitted
Quality Data

LUPA Episodes are paid a higher rate for the first visit of the episode.  Listed below are the payment rates for the first visit of LUPA episodes

Urban Agencies
Quality Data
Urban Agencies
Not Submitted
Quality Data

Rural Agencies
Quality Data
Rural Agencies
Not Submitted
Quality Data

To view the rule please go to:


Proposed Home Health PPS Rules & Rates for 2017 - 7/5/2016

CMS has issued the Proposed Home Health PPS Rules & Rates for 2017 late Tuesday July 5th.  The overall impact is to reduce home health payment by 1% or $180 million in 2017.  This is the first of several email alerts that we will publish this week on the information contained in the proposed rules & rates for 2017. 
2017 National Standardized 60-Day Episode Rate   $2,936.68

The national standard 60-day episode rate is the basis for all home health payments.  Home health agency patients living in a rural area have the 3 percent add on which is scheduled to expire on January 1, 2018.  Home health agencies that do not submit quality data will have the above rates reduced by an additional 2 percent. 

Proposed National Urban Agency Rate                                               $2,936.68
Proposed Urban Agency Rate That Do Not Submit Quality Data      $2,879.27
Proposed Rural Agency Rate                                                               $3,024.78
Proposed Rural Agency Rate That Do Not Submit Quality Data        $2,965.65

Your individual home health agency rate will also be adjusted by location wage index. 

Other items included in the proposed rule:

1.       Changes to the outlier program computations
2.       New payment measures to meet (IMPACT) 2014
3.       Changes in the HHVBP Model
4.       Changes in Case-Mix Weights



Friday, June 17, 2016

How to Stop Pre-Claim Demonstration for Home Health Services - 6/17/2016

We know we all feel CMS has lost their mind trying to implement the Pre-Claim Demonstration for Home Health Services.  This program can only be stopped by the 46 million senior citizens in the country and other concerned citizens.  Congress and the President do not really care about the home health industry’s opinion of the program.  But they do care about the opinion of the 46 million senior citizens and other concerned citizens that will be voting in November. 

If you really want to stop the program listed below is a simple but effective game plan:

  1. Have all of your patients, family members of your patients and friends of your patients contact their two US Senators, their Congressman, and the President of the United States.
  2. Have all of your employees, family members of your employees and friends of your employees contact their two US Senators, their Congressman, and the President of the United States.
  3. Notify your local TV, Radio, Newspapers, community leaders, elderly spokesman, churches and synagogues.  

What do the above people need to say about the Pre-Claim Demonstration for Home Health Services? 

  1.  It will put patient care at risk if home health providers have to wait for approval of care.
  2. At a time when we try to reduce the cost of Medicare, it will cause longer hospitalizations and nursing home stays and reduce lower cost home health stays.
  3.  It will be a huge raise to the administrative cost of the Medicare program at a time when we need to focus on providing patient care.
  4. The Medicare Administrative Contractors do not have the staff needed to implement the program.
  5. It will waste administrative dollars targeting all home health agencies, instead of the potential abusers in the industry.
  6. While the Medicare coverage of home health will appear to the beneficiaries to be unchanged the reality is it will be another barrier the administration is placing on home care benefits. 

We believe that if we can get the public to raise the above to their Congressman, Senators, and the President of the United States that we have an opportunity to stop this program.

Thursday, June 16, 2016

Know Your Provider Enrollment Revalidation Due Date - 6/15/2016

Every Medicare Provider, Supplier and Physician has to revalidate their enrollment in the Medicare program periodically.  We found a great tool that will help you determine when your Home Health Agency or Hospice revalidation is due.  Over the last year we have had several clients call us about their referring physician’s failure to revalidate their enrollment.  We believe you can utilize this same tool to determine if all of your referring physicians have revalidations due. 

Please utilize the link below:


CMS Prior Authorization Could Gut the Home Health Benefit - 6/9/2016

For some reason the people who run the Center for Medicare and Medicaid Services (CMS) have decided to move forward with a Prior Authorization Demonstration for Home Health Agencies in five states.  Over 100 members of Congress have written letters to CMS in opposition of the Home Health Prior Authorization Demonstration.  But CMS “the all knowing all for the greater good of Medicare”  has decided to move forward anyway. 

The rule published on June 8, 2016 sets up a three-year Home Heath Prior Authorization Demonstration that impacts the state of Illinois beginning no earlier than August 1, 2016, Florida no earlier than October 1, 2016, Texas no earlier than December 1, 2016, and Michigan & Massachusetts no earlier than January 1, 2017.

Under this demonstration, a home health agency will be encouraged (Required To Get Paid) to submit the relevant MAC a request for pre-claim review, along with all relevant documentation to support Medicare coverage of the applicable home health level of service.  After receipt of all relevant documentation, the MAC will review the pre-claim request to determine whether the services level complies with applicable Medicare coverage and clinical documentation requirements.  The home health agency should submit the Request for Anticipated Payment (RAP) before submitting the pre-claim review request and begin provided the services while waiting for the decision from the MAC.

The MAC will communicate to the home health agency and beneficiary a decision provisionally approving (or Disapproving) payment after a submission of a request for pre-claim review.  For the initial submission of a pre-claim review request, the MAC will make all reasonable efforts to make a determination and issue a notice of a decision within 10 business days. (This is a 100% Medical Review for all home health claims in five states. How can we believe they can do this in 10 days?)  While you wait for approval you continue to provide services without knowing you will get the authorization.

After the first three months of the demonstration in a particular state, CMS will apply a payment reduction for claims that, after such prepayment review, are deemed payable, but did not first receive a pre-claim review decision.  As evidence of compliance, the home health agency must submit the pre-claim review number on the claim in order to avoid a 25 percent payment reduction.  The 25 percent payment reduction cannot be recouped or charged to the beneficiary and is not subject to appeal.

This must be stopped.  My recommendation is that you have all of your patients and employees call their members of Congress and Senators and tell them do not to let Medicare go the way of the VA.  I would contact every person in your local community, church members, family and friends and have them call their Congressman and tell them to “Stop the Home Health Prior Authorization Demonstration Program - Do Not Restrict My Medicare Home Health Benefits by Adding More Red Tape Like The VA”.

Temporary Link (Permanente Line Will Be Sent In Future Email)


DOL Strikes Again - 6/8/2016

The US Department of Labor has set new rules and regulations defining the exemption for Executive, Administrative and Professional employees.  The key part of the rule that could impact our home health and hospice clients concerns raising the standard salary level that could exempt some employees from overtime from the current pay of $455 per week to $913 per week (Annualized rate from $23,660 to $47,476).  This means if an employee was salaried and makes less than the $913 per week or $47,476 per year, you will also have to pay overtime at 1.5 times their hourly rate for any hours worked in excess of 40 hours per week.  

They have added for the first time that employers will be able to use nondiscretionary bonuses and incentive payments including commissions to satisfy up to 10 percent of the standard salary level.  To be allowed as part of the standardized salary level the bonuses must be paid at least quarterly. 
The net effect of the rule is that employees who meet all other duties and requirements to be salaried employees and make less than $913 per week or $47,476 per year will be subject to overtime rules.  This rule goes into effect December 1st 2016.