The OIG has published their Work Plan for 2017, which summarizes new and ongoing projects the OIG plans to pursue with respect to HHS programs and operations. Why is that important to you? Because once the OIG identifies their areas of focus, audit contractors such as the Home Health and Hospice Medicare Administrative Contractors (HHH MACs), Supplemental Medical Review Contractor (SMRC), Comprehensive Error Rate Testing contractor (CERT), Recovery Audit Contractor (RAC), and the Zone/Unified Program Integrity Contractors (ZPICs/UPICs) typically follow suit and focus on similar topics or issues.
By having this knowledge, you can make a determination on the vulnerability of your business practices and then take the appropriate steps to identify your risk areas. Once you’ve identified areas of risk you will be better suited to implement the appropriate controls or corrective action plans needed to minimize the possibility of an extensive prepayment review (which ties up your cash flow) or a postpayment review (which could result in an extrapolated overpayment). Below, are the specific areas that the OIG will be reviewing for 2017, as it relates to Home Health Agencies.
Comparing HHA Survey Documents to Medicare Claims Data:
Home Health Agencies supply patient information (i.e. rosters and schedules) to State agencies during the recertification survey process, but State agencies do not have access to Medicare claims data to verify this information. Therefore, fraudulent HHAs might intentionally omit certain patients from information supplied to avoid scrutiny. Previous OIG work has shown that the home health program is prone to fraud, waste, and abuse. For 2017, the OIG plans to focus on whether the HHAs are accurately proving patient information to State agencies for recertification surveys.
Home Health Compliance with Medicare Requirements:
The Medicare home health benefit covers intermittent skilled nursing care, physical therapy, speech-language pathology services, continued occupational services, medical social worker services, and home health aide services. For CY2014, Medicare paid home health agencies (HHAs) about $18 billion for home health services. CMS’s Comprehensive Error Rate Testing (CERT) program determined that the 2014 improper payment error rate for home health claims was 51.4%, or about $9.4 billion. Recent OIG reports have similarly disclosed high error rates at individual HHAs. Improper payment rates identified in these OIG reports consisted primarily of beneficiaries who were not homebound or who did not require skilled services. The OIG will review compliance with various aspects of the home health prospective payment system and include medical review of the documentation required in support of the claims paid by Medicare with a goal of determining whether home health claims were paid in accordance with Federal requirements.
As always, being compliant in your billing practices to include having the appropriate documentation as to prove medical necessity can result in lesser scrutiny to your business, particularly in an audit. Being proactive in your processes, not only by ensuring your documentation meets policy requirements, but also through awareness of the services being reviewed by the OIG and other audit bodies allows you to prepare your files, as well as your office staff. The van Halem Group offers a wide array of audit services, including proactive, or prescreen claim reviews. If you want to be more prepared as we enter 2017 contact us. Since 2006 we have saved our clients over $30 million in claims denials and overpayments. Let us help you!