By: Valery Bond
As many home health providers are aware, four or less skilled nursing visits are reimbursed a standardized per-visit payment based on the type of visit billed instead of the standard 60-day episodic payment. These payments are known as Low Utilization Payment Adjustments (LUPAs) and they’re on the OIG’s radar, (see their June 2018 workplan). Planned for fiscal year 2019, the Office of Inspector General will be reviewing claims submitted to CMS with 5 or more visits to ensure that they should not have been billed as a LUPA. The OIG has not reviewed LUPA payments in the past so providers and case managers have a very narrow 6-month window to review charts, review billing, and prepare.
Though some LUPAs cannot be avoided understanding why LUPAs occur may help in reducing them in future episodes. Examples of inevitable LUPAs include instances where a patient is transferred to Hospice, readmitted to the hospital before a Plan of Care is complete, or a patient is recertified but attains their goals within the following four visits. Other than making sure the Hospice transfer or hospital readmission happens after the 5th visit, there’s not much an agency can do to prevent a LUPA of this sort.
Certain diagnoses can pull also the LUPA trigger. A seasoned case manager should be able to recognize the LUPA potential on things like B12 shots, catheter changes and mental health patients. Additionally, the industry wide challenge of missing visits is not only an operational challenge but a LUPA magnet as well.
To prepare for this new OIG initiative, providers should begin reviewing supporting documentation with the following tips in mind:
- Verify all scheduled visits were completed and correctly documented
- Conditions of coverage were supported
- Remainder of the episode is appropriately scheduled
- Develop a consistent strategy for periodic chart and utilization reviews
As with other OIG enforcement, the likely consequences of an adverse finding when an agency billed between 5 and 10 visits but should have billed 4 or less (LUPA) include financial offset (reduction) of future reimbursement, clearing house recoupment, state and accrediting agency survey or worse.
