![\"\"](\"https:\/\/advantagehcconsulting.com\/blog\/wp-content\/uploads\/2018\/06\/PEPPER.png\")
<\/p>\n<\/p>\n
Your PEPPER report could come in handy.<\/em><\/strong><\/span><\/p>\n With attention on low-visit episodes heating up, now\u2019s the time to make sure your related claims can stand up to reviewer examination.<\/p>\n In light of the\u00a0HHS Office of Inspector General\u2019s\u00a0<\/strong>new Work Plan item, \u201cReview of Home Health Claims for Services With 5 to 10 Skilled Visits,\u201d consider the following expert advice on dealing with Low Utilization Payment Adjustment issues:<\/p>\n 1. Know your risk.<\/span>\u00a0<\/strong>Reviewers realize that no home health agency will have zero episodes with five to 10 visits. But they will likely be looking at agencies whose barely-exceeding-LUPA-rate episodes are higher than their peers\u2019. Take a look at your stats for episodes containing five to 10 visits to know where you stand, advises attorney\u00a0Robert Markette Jr.\u00a0<\/strong>with\u00a0Hall Render\u00a0<\/strong>in Indianapolis. Particularly focus on those episodes that exceed the LUPA threshold by only a visit or two.<\/p>\n The problem:<\/span> The Centers for Medicare & Medicaid Services\u00a0<\/strong>and the HHH Medicare Administrative Contractors haven\u2019t issued readily available data on episodes containing five to 10 visits, notes\u00a0Joe Osentoski<\/strong>, Reimbursement Recovery & Appeals Director with\u00a0QIRT\u00a0<\/strong>in Troy, Michigan.<\/p>\n The solution:<\/span>\u00a0<\/strong>You can look to your free PEPPER report from Medicare for a few stats that may help, Osentoski says\u00a0The PEPPER report includes metrics on \u201cEpisodes with 5 or 6 Visits\u201d as well as \u201cNon-LUPA Payments,\u201d Medicare\u2019s PEPPER contractor notes.<\/p>\n PEPPER data puts the national 5-to-6 visit episode occurrence around 7 percent. And data from 2016 cost reports analyzed by\u00a0BKD\u00a0<\/strong>put the median LUPA rate at 6.6 percent and the upper quartile at 10.3 percent, says the Springfield, Missouri-based firm\u2019s\u00a0M. Aaron Little<\/strong>.<\/p>\n Figures above those benchmarks \u201ccould put an agency at risk,\u201d Osentoski cautions. However, keep in mind when looking at episodes with five to 10 visits, that the average would increase, he adds.<\/p>\n 2. Boost your low-visit episode documentation.<\/span>\u00a0<\/strong>There are many good reasons that a patient\u2019s episode will exceed the LUPA threshold, Markette points out (see story, p. 178<\/em>). The key will be making sure your documentation supports those visits by illustrating the reasons.<\/p>\n \u201cThe OIG is saying, \u2018we\u2019re skeptical\u2019\u201d of episodes with five to 10 visits, Markette says. \u201cWhen the OIG is skeptical, you need to make sure you\u2019re compliant.\u201d This is where sloppy documentation can come back to haunt you, he warns. Documentation must prove the medical necessity for every single visit.<\/p>\n 3. Reconsider your low-episode billing.\u00a0<\/strong><\/span>Be prepared to look at your low-visit episodes with new eyes, urges Washington, D.C.-based regulatory attorney\u00a0Elizabeth Hogue<\/strong>. \u201cAgencies with a high number of five to 10 visits during an episode should take a hard look at the appropriateness of these visits,\u201d Hogue counsels. \u201cIf agencies identify instances when the fifth visit and above were not medically necessary or patients did not meet eligibility criteria, they should take action. Agencies may decide to back those claims out of the system electronically and resubmit them as LUPAs, if they are within the one-year timely filing period.\u201d<\/p>\n 4. Prepare for increased scrutiny.\u00a0<\/strong><\/span>With the OIG focusing on episodes barely exceeding LUPA thresholds, don\u2019t be surprised to see other Medicare contractors pick up the issue too, experts say. That focus may intensify once the\u00a0Centers for Medicare & Medicaid Services\u00a0<\/strong>issues its next payment reform proposal, particularly if the pay reform model rejiggers the LUPA as HHGM did.<\/p>\n Remember: \u201cIn last year\u2019s proposed HHGM model, CMS built a major behavioral adjustment into that model that assumed providers would make extra visits to avoid LUPAs,\u201d Little points out.<\/p>\n Source- SuperCoder<\/span><\/i><\/a><\/p>\n","protected":false},"excerpt":{"rendered":"