RAC ‘n Rehab© Series Does this sound familiar? A patient comes into your outpatient therapy clinic and states they are not receiving any home health. You are checking because you know if that the patient is receiving home health therapy, that they can’t also receive outpatient therapy, right? STOP right there. Even if a patient has stopped therapy under a home health plan of care but is still receiving other home health services (such as nursing services), the home health is being paid under a Part A consolidated billing payment. So even if the beneficiary had never received therapy (perhaps just wound care by nursing), the home health agency that receives the payment is responsible for therapy, and CMS will not separately pay an outpatient provider for services covered under the consolidated billing rule. Many clinics know this and try their best to quiz the patient on this, and even check with family. Most Medicare Administrative Contractors have their system programmed with edits that will prevent the payment, so at least you have not received payment that you will have to refund.
However, not is all that easy…… Performat, the Region A Recovery Auditor (RAC) has a CMS approved issue for automated review that involves payment to private practice for outpatient therapy while a beneficiary is under a home health plan of care and subject to consolidated billing rules. If you are a provider in DC, DE, MD, NJ, PA, and have received payments for outpatient therapy under the Part B outpatient therapy benefit, and the patient was currently receiving home health under a Home Health Plan of Care (a Part A benefit), the money will be recouped via a demand letter. This is an issue that is an automated review, meaning that no medical records will be requested and/or reviewed. You may receive a recoupment letter even if you did not know that the patient was under a home health plan of care, even if therapy was not part of the HH POC, or therapy had been discharge but the patient was still receiving other HH service. It was the unfortunate mistake of the Medicare Contractor who paid a claim that should not have been paid, however if you received payment, you were not entitled to it and it will be recouped.
Oh – and by the way – even if the patient wants to come to your clinic, the only way you get paid is to negotiate for payment with the home health agency that is receiving the consolidated payment for the episode. If you provide services and your claim is denied, you cannot hold the beneficiary liable.
Moving forward, all outpatient therapy clinics should double check their admission procedures to ensure that beneficiaries are not currently under a home health plan of care, and additionally ensure that any home health episode has been discharged.