Hospice and Home Health Agency (“HHA”) Providers Subject to RAC Audits
Hospices and home health agency (“HHA”) providers were excluded from Recovery Audit Contractor (“RAC”) auditing activity during the RAC demonstration program, which ended in 2008. However, in the nationwide RAC permanent program, RACs are authorized to conduct audits of hospices and home health providers.
Hospice
Hospice providers should begin to prepare for increased Medicare scrutiny. Areas of compliance risk for hospice providers include the following:
- Patients with certain diagnoses prone to longer hospice stays (e.g., patients with Alzheimer’s disease, Parkinson’s disease, chronic obstructive pulmonary disease (“COPD”), heart disease, etc.).
- Technical reasons for Medicare denials (e.g., hospice election statements, certifications, plans of care, etc.).
Our firm has extensive experience representing hospice organizations with respect to Medicare audits and pre-payment review. For example:
- Our firm represented a hospice entity, which had been subject to an audit of its services provided to 17 beneficiaries. In that case, we received 14 favorable decisions on the record, without even the need for a hearing.
- Our firm currently represents a hospice entity that was subject to pre-payment review. To date, our law firm has returned over $4 million to the entity, with a high success rate. As a result of these successes, the hospice was removed from pre-payment review.
Home Health Agency (“HHA”) Providers
Significantly for HHAs, the Centers for Medicare and Medicaid Services (“CMS”) recently has announced its intention to focus auditing activities upon HHAs and durable medical equipment (“DME”) suppliers. Areas of compliance risk for HHAs include the following:
- Whether the Home Health Resource Group (“HHRG”) assigned to determine payment to the HHA is accurate and supported by documentation in the records.
- Whether the services provided were medically necessary.
- Certification deficiencies.
At Wachler & Associates, P.C., we have been providing strong and knowledgeable legal counsel and advocacy to hospices, HHAs and other healthcare providers, suppliers and entities for over 20 years.
Pre-Payment Review Representation
Hospices and HHAs can be targets for medical review for many reasons. New hospices and HHAs may be placed on pre-payment review. In addition, if your hospice or HHA experiences a sudden or significant increase in utilization, your agency may be placed on pre-payment review.
Although the RACs are not authorized to initiate pre-payment review, Medicare intermediaries are authorized to initiate pre-payment review, which can interrupt cash flow and result in a significant financial burden.
Our attorneys have experience negotiating successfully on behalf of hospices and HHAs to assist these agencies in being removed from pre-payment review.
Publications and Speaking Engagements
Attorneys from our law firm are often asked to write and speak to hospice and home health organizations. Recent writing and speaking engagements include the following:
Publications
"Audit Impact: Expanded Liability for Overpayments," Andrew B. Wachler, Esq. and Jennifer Colagiovanni, Esq.,The RAC Monitor, July 2011.
"Weathering a Medicare Audit: Overview of the Medicare Appeals Process," Andrew B. Wachler, Esq. and Jennifer Colagiovanni, Esq., MGIS Talking Points Newsletter, Vol.2 No. 3, June 23, 2011.
"Contractor Involvement in the Medicare Appeals Process," Andrew B. Wachler, Esq. and Jennifer Colagiovanni, Esq., The RAC Monitor, June 13, 2011.
"One Year Later The Impact of Health Care Reform on Health Care Provider Audits and Compliance Programs," Andrew B. Wachler, Esq., Jennifer Colagiovanni, Esq., and Christopher J. Laney, Esq., Michigan Bar Journal, June 2011.
"RAC Medical Necessity Denials of Inpatient Services - Fair & Equitable Reimbursement," Andrew B. Wachler, Esq., The RAC Monitor, April 21, 2011.
"The Use of Payment Suspensions in the Audit Landscape," Amy K. Fehn, Esq. and Jennifer Colagiovanni, Esq., The RAC Monitor, March 24, 2011.
"New Audit Risk for Home Health Agencies: Face to Face Certification Requirements," Amy K. Fehn, Esq. and Jennifer Colagiovanni, Esq., The RAC Monitor, March 14, 2011.
"Providers Need to Be Aware of Key Hospice Risk Areas," Andrew B. Wachler, Esq. and Jennifer Colagiovanni, Esq., Wachler & Associates, P.C., The RAC Monitor, March 1, 2011.
"Prepare for Increased RAC Activity in 2011," Andrew B. Wachler, Esq. and Jennifer Colagiovanni, Esq., Wachler & Associates, The RAC Monitor, December 7, 2010.
Speaking Engagements
"RACs, ZPICs, and More - The Latest Improper Payment Initiatives for Governing Audits," MGMA Webinar regarding Recent Proper Payment Initiatives, May 12, 2011.
"Preparing for and Surviving a Third Party Payor Audit," Indiana Medical Society in Merrillville, IN, April 27, 2011.
"The New Landscape of Audits: MICs, MACs, RACs and ZPICs" co-presented with Susan Emanuel, System RAC Coordinator, Catholic Healthcare West, Phoenix, AZ; and Dawn Crump Network Director of Compliance, SSM Health Care St. Louis, Orlando, FL, HCCA's 15th Annual Compliance Institute, April 13, 2011.
"Medicaid RAC Appeals - Similarities and Differences with Medicare RAC Requirements and Processes," 5th Annual Medicare RAC Summit, Washington, D.C., March 9-11, 2011.
"Full Steam Ahead: Latest Developments in Medicare and Medicaid," co-presented with James G. Sheehan, Office of the New York State Medicaid Inspector General, American Bar Association (ABA) Emerging Issues Conference, New Orleans, LA, February 23-25, 2011.
"Medicare and Medicaid Audits: A Year in Review," American Health Lawyers Association (AHLA) Hospital and Health Systems Law Institute, Las Vegas, NV, February 11, 2011.
Please click here for a more complete listing of our attorneys' publications and speaking engagements.
Contact Us
Call us at 248-544-0888 or send us an e-mail to schedule a meeting to discuss your concerns with RACs or to address your other healthcare law-related needs.
