Subscribe to RSSThe last RAC Assistance for Hospice Newsletter alerted hospices to the fact that HealthDataInsights, the RAC for Region D, has received approval from CMS to review two hospice-related issues. Given that we are all new at this and don’t know how it will impact hospices, here are some thoughts…
These two issues most likely fall into the category of automated reviews. Given that the RACs have only just started getting some issues approved for complex reviews, it is a fair assumption that the two hospice-related issues fall under the automated category of review. That means that the RAC believes this audit can be done without reviewing the medical record (as opposed to a complex review that requires the medical record) and also that this is a “slam-dunk,” meaning that the RACs believe it is a black and white issue (for example, not submitting a claim for services after the patient has died).
Here is how it might work… HDI will run its proprietary software on all the data it has available to it from CMS and will identify all the Medicare recipients in its region who received hospice care and the dates of that care. Then, with that information in hand, it will run the computers again and identify DME and other Part A and Part B providers who submitted claims for care, services, and/or equipment provided to those beneficiaries while they were on hospice. When it gets a “hit”, a demand letter will be sent to the provider to recoup the money that was paid to the provider because the RAC determined (somehow) that it was related to the patient’s terminal diagnosis and therefore included in the hospice’s per diem. In this scenario it is not going to be the hospice that is hit with the overpayment demand but instead its DME supplier or another provider of services to the hospice’s patients.
This whole scenario is disconcerting and raises lots of issues and questions. How is the RAC going to determine if whatever was provided was related or not related to the terminal illness without a deeper review of the circumstances than can be provided by an automated review? Will DME suppliers and other providers come after the hospice for payment? Has the hospice adequately and acurately determined and documented what services provided to the patient were and were not related to the terminal illness? It is obvious to hospices that figuring out related vs. non-related is a gray area at best (and by NO means a “slam dunk”) - do the RACs understand this?
So this is the first area of RAC scrutiny we can chew on to try to determine how all of this is going to play out. But we still don’t really know. If anyone has other ideas or, better yet, experiences this audit, please let us know.
In the meantime, the lesson of the day is to clearly and carefully document all services, supplies, equipment, etc. provided to each patient and whether they were related or not related to the patient’s terminal illness. Everything provided to the patient that is related to the terminal illness should be in his or her plan of care.
We provide care to patient’s in the long term care setting,the nursing home has contracted with a providor to provide wound care for all their patients and they bill medicare part B,since our patients are seen by this providor under the contract of the nursing home are we responsible?
Your hospice would be responsible for payment if the wound care provided is related to the patient’s terminal illness.
And how will the RAC know if care provided is related to the terminal illness unless they do a complex review? Claim data will not elicit the information needed. I am thinking that it would be highly recommended, at least at first, for the hospice to challenge any of these types of issues when they arise.
Somehow, I do not think the RACs are up to speed on the nuances of hospice- both coding wise and care wise as the RAC conference call this week identified.
This was an excellent report. It really makes me wonder if we are all ready for the challenges. Thanks so much