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Our address is
8930 SW Gemini Drive,
Beaverton, OR 97008.
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Last Updated on:
07/09/08
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Appealing
Medicare HHA Cost Limits
As
a result of the Balanced Budget Act of 1997, Home Health Agency (HHA) costs are
now subject to three limits: 1) a lower of cost or charges limit; 2) per visit
limits by discipline; and 3) a per beneficiary limit.
It is possible to appeal Medicare limitations to HHA costs by filing a request for exception to cost limits based on atypical services.
This
process is very well established for nursing homes.
However, successful HHA appeals have been more difficult because the
exception request process for HHAs is not as clearly defined by Medicare
regulations. For example, it has
been difficult to provide a comparison to a peer group because HCFA never
established peer group norms for HHAs as it did for SNFs.
In
a recent Provider Reimbursement Review Board (PRRB) case, a HHA was able to gain
approval for an exception to the per-visit limits.
The significance of this case is that the PRRB provided specific guidance
on the documentation needed for HHAs to file a successful exception request.
In general, a provider must demonstrate that a high acuity level of its
patients necessitated provision of atypical services, which in turn increased
costs. The PRRB determined that the
following items would demonstrate high acuity:
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Minutes per visit (including transportation and in home care) that
are higher than industry norms. HCFA
has established norms of 60 minutes for skilled nursing and 114 minutes
for home health aides.
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Costs
per skilled visit that are higher than those of similar providers in the
area. This information can be
obtained from the Medicare cost reports of other area providers, which are
accessible through the Freedom of Information Act.
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High
average age of patients.
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High
average number of secondary diagnoses per patient.
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High
percentage of patients requiring lab procedures, special dietary
preparations, ancillary procedures, or procedures that must legally be
performed by RNs.
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High
number of functionally impaired patients.
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High
number of new medications requiring patient education and monitoring.
If
your HHA's Medicare costs were limited, it may be possible to recover some or
all of the denied costs by filing an exception request within 180 days of the
date your Medicare cost report was finalized. Please contact our office if
you are interested in exploring this option.
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