Between 2014 and 2023, personal care services accounted for at least 34% of fraud convictions in some years and as much as 48% in other years.

That’s according to a new report from OIG that detailed the findings from Medicaid Fraud Control Units (MFCUs). MFCUs are mandated by the Social Security Act to investigate and prosecute Medicaid provider fraud and patient abuse or neglect.

MFCUs are in all 50 states and are jointly funded by the federal and state governments.

In fiscal year 2023, these units reported 1,143 convictions, which, while higher than in FY 2020, remained lower than pre-pandemic levels. The number of convictions had steadily declined during FY 2020 — aligning with the onset of the COVID-19 pandemic — which indicates a “sustained impact on enforcement activities,” OIG wrote in its report.

However, there seems to be ongoing issues related to fraud in personal care.

While personal care attendants made up a significant amount of convictions, they also represented a higher percentage than all other provider types.

In FY 2023, OIG found personal care services accounted for 279 convictions compared to 66 for nurses, 43 for home health agencies, 33 for ophthalmologists and 36 for mental health facilities.

The OIG report cited 43 criminal convictions from home health agencies and 26 civil settlements in 2023.

Of the dozens of provider types listed in the report, home health fraud convictions totaled the highest in recoveries at $34.6 million. Other notable provider types near the top of the list were surgeons ($26.8 million), personal care service agencies ($26.4 million) and suppliers of durable medical equipment ($23.6 million).

The 1,143 criminal convictions totaled $272 million in recoveries and the 436 civil settlements totaled about $962 million.

This week, Family First Home Health Care, a personal care agency based in North Carolina, reached a settlement of $600,000 to settle accusations of submitting fraudulent Medicaid claims from 2015 to 2020, which violated both federal and North Carolina False Claims Acts.

The government alleged that Family First and its owner Marion James billed Medicaid for in-home personal care services that were never performed on days when patients were hospitalized.

As for the federal government’s crackdown of these cases, the crime units seem to be paying off.

“The amount of civil recoveries reached a 4-year high in 2023 and the combined criminal and civil recoveries were $1.2 billion, resulting in an ROI of $3.35 for every $1 spent,” the OIG reported.

The post OIG Report Highlights Personal Care’s Outsized Role In Medicaid Fraud appeared first on Home Health Care News.

In 2018, the Centers for Medicare & Medicaid Services (CMS) implemented a rural add-on payment, or a percentage increase, at the request of Congress. That is added to the standardized home health payment.

Lawmakers created the rural add-on to give higher percentages to rural counties with low population density.

According to a new report from the Office of Inspector General (OIG), the rural add-on did shift payments to those low population density areas. However, there were some issues in reporting those utilization figures, due to possible record-keeping errors.

“We determined that the methodology shifted the distribution of add-on payments from the ‘high-utilization’ category to the ‘low-population density’ and ‘all other’ categories,” the OIG summary read. “We originally planned to use Federal Information Processing Standards (FIPS) data to analyze utilization, but were unable to do so because the FIPS data was incomplete.”

High-utilization counties are those in the highest quartile of counties based on the number of Medicare home health episodes served per 100 people. About 25% of rural counties fall into this category, according to the OIG.

Low population density areas are the counties with a population density of six people or fewer per square mile. About 17% of rural counties fall into this category, with the remaining 58% being “all other.”

The OIG report found that from 2016 to 2021, the number of home health beneficiaries served fell by more than 13% in urban counties, more than 20% in the “high utilization” rural category and more than 10% in the “all other” rural category.

In that same time period, the number of beneficiaries served in the “low population density” rural category increased by less than 1%.

Rural add-on payments will stop at the end of 2022.

In the 2023 home health final rule, CMS requested comments on future approaches to health equity in the expanded Home Health Value-Based Purchasing Model (HHVBP) to remedy inequities in outcomes caused by several factors, including living in a rural area.

OIG findings, recommendations

While conducting the audit, the OIG found that home health providers were either not always applying FIPS codes to claims or the codes that were used were invalid.

The OIG also found Medicare administrative contractors (MACs) did not always return claims with missing or invalid FIPS codes to providers. Because of that, the errors were never corrected.

However, that trend seems to be improving.

Despite the improvements, the federal watchdog group believes CMS should take steps to improve the reporting of FIPS codes for home health claims and update its pricing logic to check for missing and invalid FIPS codes on all home health claims.

In response, CMS agreed that the FIPS requirements apply to all claims, but it did not concur with OIG’s recommendation that the home health pricer check for a FIPS code on all claims.

“Enforcing such an edit on all claims, and not just those claims where the rural add-on payment is impacted, may delay prompt payment for eligible home health services and would not affect the payment amount,” CMS wrote in response.

The second recommendation from OIG, which was agreed upon by CMS, was to work with MACs to ensure that these claims are returned to providers for correction.

The post How The Rural Add-On Payments Changed Where Home Health Services Were Delivered appeared first on Home Health Care News.

That’s one major takeaway from a recent report from the Office of Inspector General (OIG).

The report examines the use of telehealth among Medicare providers during the first year of the pandemic. The report is based on the analysis of Medicare fee-for-service claims data, and Medicare Advantage encounter data of the 742,000 providers who billed for a telehealth service from March 1, 2020, to February 28, 2021.

As a response to the COVID-19 emergency, the Centers for Medicare & Medicaid Services (CMS) rolled out a number of measures to expand access to telehealth for Medicare beneficiaries on a temporary basis.

During this time, CMS also temporarily paused various program integrity activities, including medical reviews of claims.

OIG saw telehealth use spike dramatically during the first year of the COVID-19 emergency. Specifically, over 28 million Medicare beneficiaries used telehealth services that first year.

In other words, Medicare beneficiaries used 88 times more telehealth services during the first year of the COVID-19 emergency than in the previous year.

“The changes to Medicare telehealth policies, along with the dramatic increase in the use of telehealth, underscore the importance of determining whether providers are billing for telehealth services appropriately and how to best protect Medicare and beneficiaries against fraud, waste, and abuse,” OIG wrote in the report.

Overall, the report found that 1,714 providers who billed for telehealth services during this time period posed “a high risk to Medicare.”

The 1,714 providers were flagged for at least 1 of 7 measures that OIG developed indicating possible fraud, waste or abuse of telehealth services, according to the report.

Additionally, these providers nabbed $127.7 million in Medicare fee-for-service payments and billed for telehealth services for roughly half of a million beneficiaries.

Though home health providers are exempt from these findings — as they don’t have the ability to receive reimbursement under Medicare for telehealth services — it doesn’t bode well for their future.

The legislative efforts around home health telehealth have, largely, been stalled and unsuccessful.

What’s more, home health is already viewed as a site of rampant fraud. In July, the Health & Human Services Office of Inspector General’s (HHS-OIG) annual report zero-ed in on a handful of home health-related cases.

Despite the lack of reimbursement, that hasn’t stopped home health providers from utilizing telehealth services to increase access to care and deliver services.

In fact, providers have even delivered telehealth without receiving full pay for these services, which have become a lasting problem for them, according to National Association for Home Care & Hospice (NAHC) President William A. Dombi.

“Both in home health and in hospice, [agencies] delivered telehealth services quite robustly during the pandemic for free,” Dombi previously said. “And so now the next expectation is [they’ll] always do it for free.”

Ultimately, OIG believes that the findings in its report underscore the importance of telehealth oversight.

The post Why OIG Telehealth Fraud Findings May Mean Further Roadblocks For Home Health appeared first on Home Health Care News.

And after a slower audit period during the COVID-19 pandemic, experts told Home Health Care News that providers should expect a ramp-up in audits over the next year.

Battling that element of surprise will be key to getting through a successful audit process.

“Having a very healthy, robust compliance program that really challenges the health of a home health agency internally is a good way to be ready for when an outside entity, like the government, does the same,” Bryan Nowicki, a partner at Husch Blackwell, told HHCN.

Home health agencies should be at a place where they aren’t just prepared for audits, but also expect them.

“Don’t be surprised if and when you get an audit,” Husch Blackwell Associate Erin Burns told HHCN. “It’s likely going to happen, and knowing that should help you be more prepared in the long run.”

What federal government audits are looking for

The audit process can be a long and arduous one.

“The audit process itself is — as we tell our clients — a marathon, not a sprint,” Burns said.

Knowing that audits are coming is part of the battle, Burns said. But knowing what OIG or other federal agencies are looking for is another piece to the puzzle.

Historically, audits done by OIG include the office taking 100 claims at random, evaluating those claims and then coming to an error rate. OIG will then extrapolate that error rate and assess it over the industry.

Other audits — like the ones done by unified program integrity contractors (UPICs) hired by the U.S. Centers for Medicare & Medicaid Services (CMS) — are used to investigate home health agencies for potential fraud.

“We have seen an uptick in UPIC activity across the board for home health this year and I think that relates, in part, to the government relaxing some of the COVID restrictions,” Nowicki said. “I think the audits will focus on the time periods when COVID was an issue and I think that’s something home health agencies will have to address.”

Many in the industry have expected OIG audits to proliferate in home health, like they have in hospice over the last few years. The home health industry could also see an uptick in audits from OIG on provider relief funds as well, Burns said.

Generally, both audit processes will look at financial data for home health agencies, homebound statuses, OASIS compliance and other factors that impact payment.

OIG is likely going to refine what exactly they are looking for on the other side of the pandemic, Nowicki said. However, what that looks like won’t be known for another year or so.

“We do know from the OIG audit we’ve been working on that the fundamentals are still there and they’re getting a little more precise in certain details that they’re looking into,” Nowicki said. “They’re also reserving their ability to change the focus of the audit if they find something that interests them.”

One of the first issues that comes to mind for Katie Wehri, the director of regulatory affairs for the National Association for Home Care & Hospice (NAHC), is the lack of understanding by the general public and home health consumers about the OIG audit process.

Wehri also said it’s important for home health providers to know that the routine “Work Plan” audits from OIG are not targeted audits.

“Home health agencies need to remember if they receive a request for a record from one of the audits being conducted from the OIG’s Work Plan, that the audit is not targeting the provider,” Wehri said in an email. “The audit is targeting all home health services and the OIG usually includes 100 claims as part of the review.”

If everything on the books is in good shape, home health agencies shouldn’t fret much about those.

“Documentation is key in compliance programs,” Burns said. “Hopefully they are keeping up with their compliance program, documenting their efforts, doing internal reviews on policies and procedures and making sure those mirror and support their internal processes.”

Being compliant is one step. Having a prepared team in place is the next.

“Being ready to deal with requests when they come in and knowing who is going to be on the team that’s going to address that,” Nowicki said. “How does that group get together? And if you have that infrastructure – the audit response infrastructure in place before you even get that letter – then you’re going to be better served in responding to what are often pretty short turnaround times.”

Wehri agreed, and said that ensuring staff members are on the same page and abreast with the latest information is key to getting through the process scot-free.

“Home health providers need to ensure that the agency staff recognizes and knows the internal processes for handling an audit request from the OIG,” she said.

The post Why Home Health Insiders Expect Uptick In Audits, Inquiries From Federal Watchdogs appeared first on Home Health Care News.

As the home health space continues to grow, federal oversight and the scrutiny attached to the industry have grown with it.

Experts at Husch Blackwell have followed this trend through the hospice industry, and have gleaned knowledge from that.

“As we have been following and reporting on those hospice audits, the OIG has been looking at the home health space as well,” Bryan Nowicki said this week on a podcast episode of Hospice Insights. “They’re very similar in overall structure with what we have been working on with hospice. They’re looking for certain kinds of errors that they’ve identified as being recurring or ‘top of mind’ in the home health field.”

When the OIG first began its hospice audits in 2021, the office was looking for things like whether beneficiaries met the definition of being confined to a home; whether they were truly in need of skilled services; whether the OASIS information was being submitted in a timely fashion; and whether services were properly documented.

Those were the four priorities being reviewed by the OIG, Nowicki said. Now the OIG is cranking up those efforts and focus areas, this time for home health agencies.

“Frankly, those are pretty recurring issues in home health,” Nowicki said. “We would expect more of the same, but [the audit process] is going to be guided by what they actually find. Audits are happening now and the OIG’s goal is to begin issuing final audit reports and publishing them on their website in 2023.”

Unlike many audits, results from the OIG audits are made public, which creates even more anxiety from the industry, according to Husch Blackwell attorney Meg Pekarske.

Another difference between home health and hospice is the dollar amounts. Payment levels for home health in the audits are lower on a per-claim basis.

Hospice claims in OIG reports could range from $6 million to as much as $40 million.

“What we see in the home health area is less than $5 million,” Nowicki said. “The OIG takes 100 claims, randomly selected, evaluates them, arrives at an error rate and extrapolates it. But the end result number, historically, has been significantly lower than what the hospice industry has encountered.”

The audit process is not complaint-driven, Nowicki said. The OIG isn’t going after specific providers, but instead after the industry itself.

“They don’t look at the provider, they just look at the claims data,” Nowicki said. “From that, red flags are identified and they’d never tell what the exact red flags are. But that’s how they develop this pool of potential home health agencies to audit and then, from that, they select a certain number to go ahead and audit.”

Home health agencies should be aware the audits are happening now, Husch Blackwell Associate Erin Burns said.

But it’s likely that results from these audits won’t be clear until much later dates.

“We probably won’t see any sort of final reports published until next year because the OIG audit process is pretty long,” Burns said. “Once those come out, take a look, see what kinds of things they’re denying, then consider whether those are points that you should look at for your own agency. There may be some internal review, or beefing up your compliance on those particular issues, that might be worth your time.”

The post What Home Health Providers Can Learn from Hospice OIG Audits appeared first on Home Health Care News.

That’s according to a May report from the U.S. Department of Health and Human Services Office of Inspector General (HHS-OIG). The findings throw further support for facility-based care alternatives, including the types of hospital-at-home models that lean heavily on home health and home care agencies.

“Given the scale and persistence of patient harm in hospitals in the decade since our last report, HHS leadership and agencies must work with urgency to reduce patient harm in hospitals,” stated the report.

As part of their work, OIG investigators examined medical records for a random sample of 770 Medicare patients discharged from acute care hospitals during October 2018 – a period of relative normalcy long before the COVID-19 crisis. The examination included a preliminary review where nurses screened records for possible patient harm, as well as a physician-led review to further assess the severity of adverse health events.

Among their findings, investigators determined that one in four hospitalized Medicare patients experienced harm during their stay.

For nearly 25% of those individuals, the “harm events” resulted in additional costs to Medicare. Additionally, physician-reviewers determined that 43% of the harm events could have been prevented if patients had been provided better care.

A similar OIG effort in 2010 found that 27% of hospitalized Medicare patients experienced harm during stays in October 2008, with nearly half of those events preventable. While the earlier investigation has led to an increase in federal oversight and internal efforts from hospitals to strengthen clinical practices, there are clearly still problems.

“Addressing patient harm and promoting patient safety takes on added urgency in light of the ongoing pandemic and its effects on hospital operations,” the report continued. “Despite substantial action by HHS agencies and success in reducing certain types of events, patient harm remains pervasive, is often preventable, and continues to cost the Medicare program and patients.”

The most common type of harm event was related to medication, such as patients experiencing delirium or other changes in mental status. Other common events included hospital-acquired infections, pressure injuries and problems that arose during procedures.

In October 2018 alone, OIG estimated that medicare spent $520 million on costs associated with patient harm events. Two-thirds of patients received care that was paid under the Medicare Inpatient Prospective Payment System (IPPS).

“We found that 20% of patients covered by IPPS who experienced harm events incurred additional costs to the Medicare program and potentially to the patients themselves as a result,” the report noted.

To combat systemic problems, OIG broadly recommended more checks and balances, with further federal oversight. Yet long-term investment in hospital-at-home models that shift higher-acuity care into the home – or prevent hospitalization in the first place – could also make a major difference.

A 2012 analysis, for example, found that hospital-at-home patients had a 19% lower six-month mortality rate compared to hospitalized patients. A more recent study found that hospital-at-home patients also had a lower risk of long-term care admission, with lower rates of depression and anxiety.

Other studies have suggested hospital-at-home patients recover quicker and have a lower risk of outside infection due to a more controlled environment.

New York-based Mount Sinai Health System launched its own hospital-at-home program in 2014 as part of a three-year grant from the Center for Medicare & Medicaid Innovation (CMMI). Since then, the Mount Sinai team has repeatedly observed outcomes that surpass traditional hospital care.

“Outcomes were better and we were able to reduce complications,” Dr. Al Siu, director of Mount Sinai at Home, previously told Home Health Care News. “We were able to show we could do this safely, and that there was another option for patients and their families.”

The hospital-at-home concept isn’t new, but programs have dramatically increased since the start of the pandemic, partly thanks to the temporary Centers for Medicare & Medicaid Services (CMS) “Acute Hospital Care at Home” waiver. As of May 17, 97 systems and 225 hospitals in 35 states had been approved for the waiver, which will end when the public health emergency expires.

The OIG report suggests that policymakers consider a more permanent replacement, ensuring that hospital-at-home programs can continue thriving moving forward. That’s something hospital-at-home stakeholders are certainly pushing for, specifically in the form of the ​​Hospital Inpatient Services Modernization Act.

“There’s a lot of interest and support for the waiver,” Jeremiah McCoy, director of policy and government relations at Moving Health Home, previously told HHCN. “We just need to continue to build on that and make sure that the Hill is hearing what everyone’s saying, not only for what the opportunity has been during the pandemic, but what this means for a future iteration of the acute care home model in Medicare.”

In addition to hospital-at-home models, the OIG report also suggests that policymakers consider further investments in home health and home care.

Home health and home care agencies often enable hospital-at-home programs by being the “eyes and ears” in the home. But home-based care agencies themselves have repeatedly been found to prevent hospitalizations.

The post A ‘Persistence of Patient Harm’: Hospital Failures Highlight Need for Home-Based Care Investments appeared first on Home Health Care News.

A recently published budget report from the House Appropriations Committee obtained by Home Health Care News offers further insight into that call to action.

Each year, Congress publishes reports with its enacted federal budget outlining how and where federal dollars should be spent. This year’s budget report related to the U.S. Department of Health and Human Services (HHS) is noteworthy for its several passages with language strongly supporting home-based care and a shift away from institutional settings.

“I’ve never seen so many references to home-based care before and keeping people in their own homes,” one longtime industry advocate told HHCN.

For starters, the Appropriations Committee budget report urges the U.S. Centers for Medicare & Medicaid Services (CMS) to avoid any payment policies that could “risk patient access to home health providers” in rural areas. That could potentially include the agency’s ongoing adjustments to the home health rural add-on, which is currently being phased out despite its history of bipartisan support.

Broadly, rural add-on payments have given certain home health providers a small reimbursement boost to continue delivering services while dealing with costly travel demands and often smaller patient populations.

“Aging in place is beneficial to the patients that we serve, as well as appropriate utilization of Medicare resources,” Tonya Hopper, vice president of home health operations at Interim HealthCare of Texas & New Mexico, told HHCN in 2018. “Without the rural add-on, there would not be any ability to care for rural Americans in their homes, which would force patients into an institutional setting.”

The House budget report — a roadmap to future spending — also generally urges Congress to allocate more money to home- and community-based supportive services at large. Specifically, it calls for an additional $10 million above the 2021 budget request to further fund “a wide range of social services that enable seniors to remain independent in their homes for as long as possible.”

“This language is important because it shows what [lawmakers] are concerned about,” the advocate said. “It’s instructional to the enacted budget.”

The spending roadmap additionally includes language urging Congress to “maximize access to health care through technology with equitable payment and reimbursement policies.” That message comes during a time when the HHS Office of Inspector General is actively auditing telehealth utilization by Medicare-certified home health agencies.

Outside of the home health field but related to aging in place, the House budget report similarly encourages Congress to beef up its support of Programs of All-Inclusive Care for the Elderly (PACE). As of November, there were at least 272 PACE centers in 31 states, according to the National PACE Association.

PACE organizations offer comprehensive medical and social services to certain frail, community-dwelling elderly individuals to keep them out of long-term care facilities.

“The Committee acknowledges the important role of [PACE] in the lives of over 52,000 participants, by allowing these highly medically complex Medicare or Medicaid beneficiaries to live at home, instead of in a nursing facility,” the report states. “The Committee urges CMS to move forward expeditiously on PACE-specific pilots, authorized by the PACE Innovation Act of 2015, specifically testing the innovative, comprehensive, integrated and fully risk-bearing PACE model of care with new Medicare or Medicaid beneficiaries.”

Rebalancing Medicare

Beyond keeping seniors healthy and happy at home, the House Appropriations Committee budget report also hints at lawmakers’ views toward the rebalancing of Medicare.

Health care policymakers accelerated the development of Medicare Advantage (MA) and did everything possible to encourage beneficiary enrollment under the Trump administration. That mission is perhaps best illustrated by the MA hospice carve-in and CMS’s multiple moves to expand what supplemental benefits MA plans can offer.

There were nearly 25.4 million MA beneficiaries nationwide for the month of October, with an overall Medicare-eligible population of about 62.5 million individuals, according to statistics from the Better Medicare Alliance. That comes out to an MA penetration rate of roughly 40% — an all-time.

The future of MA has been murky after the election of President Joe Biden and key Democrat victories in the Senate, however. Republicans have naturally been more supportive of the MA program.

The budget report directs CMS to “avoid taking any action that actively promotes one form of Medicare coverage over another, particularly with respect to the choice between traditional Medicare and Medicare Advantage.”

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In an audit report published last week, the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) found that stronger oversight of Low Utilization Payment Adjustments (LUPAs) in home health care could have saved the government roughly $192 million in fiscal year 2017.

Instead, the Centers for Medicare & Medicaid Services (CMS) and the Medicare administrative contractors (MACs) it worked with allowed some agencies to shirk LUPA thresholds, receiving full reimbursement when they should have received a lesser, standardized per visit payment, according to OIG investigators.

To conduct its audit, OIG’s team looked at $1.25 billion in Medicare payments to home health agencies in 2017. It then selected a stratified, random sample of claims from 120 agencies that delivered just enough visits to avoid triggering a LUPA.

OIG’s audit occurred when the old Prospective Payment System (PPS) was in place. Under that now outdated payment methodology, a home health agency triggered a LUPA if it delivered four or fewer visits during an episode of care.

For any agency, being hit with a LUPA claim could mean hundreds or even thousands of dollars less in Medicare reimbursement.

“Because of the large payment increase starting with the fifth visit, [home health agencies] have an incentive to improperly bill claims with visits slightly above the LUPA threshold,” investigators wrote in their report.

That remains true under the new Patient-Driven Groupings Model (PDGM), which created a more complex framework for how LUPAs are handled.

While the old PPS included a universal threshold of “four or fewer visits,” PDGM moves the LUPA goalposts around depending on patient characteristics, referral sources and a variety of other factors. Today, every one of PDGM’s 432 case-mix groups has its own LUPA threshold, ranging from two to six visits.

Despite the change in payment methodology, OIG believes its findings that home health agencies are improper billing to avoid LUPAs would likely remain true under PDGM.

“The majority of the claims in our sample that did not comply with Medicare requirements under the previous PPS methodology would also have not complied with those requirements under the new methodology,” investigators observed.

OIG’s random sample of 120 claims all included five, six or seven visits in a payment episode — the bare minimum needed to avoid a LUPA in 2017. To determine whether those extra visits were actually needed, OIG enlisted an independent medical-review contractor to look at medical necessity and coding requirements.

Of the 120 sampled claims, 91 complied with Medicare requirements, meaning a full episodic payment was warranted.

But another 25 claims did not comply with requirements, according to the medical-review contractor. The remaining four claims did not have documentation available to make a compliance determination.

In one example, a home health agency was paid $3,131 for an episode of care that included seven visits. However, five of the seven visits did not meet Medicare requirements, meaning the agency should have been hit with a LUPA and only paid $389.

Delivering services to beneficiaries “who were not confined to the home” was the most common reason for agencies not meeting Medicare requirements, OIG investigators found.

OIG recommendations

In part, the alleged improper payments occurred because the MACs CMS worked with in 2017 did not aggressively look into home health agencies that delivered just enough visits to avoid a LUPA.

One MAC that did conduct reviews was instructed by CMS to instead focus on the Targeted Probe and Educate (TPE) program.

Moving forward, OIG recommends that CMS first direct MACs to recover all perceived overpayments made to home health agencies in its sampled claims — $41,613 in total. Additionally, OIG believes CMS should require all MACs to perform data analysis and risk assessments of claims with visits slightly above the applicable LUPA threshold and target these claims for further review.

More generally, MACs should also start educating home health agencies on properly billing for home health services with visits slightly above the applicable LUPA threshold.

CMS concurred with those recommendations.

Red flags and contradictions

There are multiple red flags and apparent contradictions within OIG’s LUPA report.

On a basic level, the OIG report does not take into consideration CMS’s messaging on LUPAs during the transition to PDGM.

In putting the payment overhaul together, CMS anticipated that home health agencies would do everything possible to “upcode” and avoid LUPAs whenever possible, for instance.

“CMS is almost giving people a license to add visits and code upwards — and that’s not conduct that should be encouraged,” National Association for Home Care & Hospice President William A. Dombi previously told Home Health Care News. “I think the message has been pretty clear to agencies.”

Moreover, a major issue OIG had in its audit was the “homebound requirement” in home health care — or the stipulation that home health patients need to be stuck at home and unable to leave unassisted to be eligible for service. For years, home health insiders viewed that homebound requirement as inherently flawed, hurting patients and providers alike by diminishing access to care.

Maine Senator Susan, a Republican, is among those who have criticized the homebound requirement.

“Right now under Medicare, the definition of homebound is extremely strict,” Collins told HHCN in March 2019. “It says that the patient cannot leave home without — I believe the phrase is — a considerable and taxing effort. There are other beneficiaries who could benefit from home health care if we did not apply such an onerous restriction.”

CMS loosened Medicare homebound requirements toward the start of the COVID-19 public health emergency.

Lastly, OIG’s report makes no mention of the fact many home health agencies have been financially devastated by skyrocketing LUPA rates since the start of the emergency.

A NAHC survey released in April suggested that more than 67% of all home health agencies have seen their LUPA rates double as a result of the coronavirus.

The post OIG: CMS Could Have Saved $192M with Stronger LUPA Oversight appeared first on Home Health Care News.

The Medicaid health home care option allows states flexibility in creating programs that produce care coordination and care management plans for beneficiaries with chronic health issues.

The OIG — a part of the U.S. Department of Health and Human Services (HHS) — was alerted by Iowa’s unusually high reimbursement claims rate in 2016. That year, Iowa’s Medicaid home health claims accounted for 3% of the entire federal total.

Even if all states were created equal, Iowa’s 3% piece of the pie would be high. But for a state that accounts for less than 1% of the country’s population, it was especially alarming.

That led to the OIG investigation, which consisted of an audit that covered 795,000 payments made to Medicaid-backed home health providers in Iowa from 2013 to 2016. The OIG decided to randomly pick 130 payments out of that bunch to sample, seeing if providers followed state and federal requirements.

In the sample, the OIG found that 62 of the 130 payments were improper claims for federal Medicaid reimbursement by the state of Iowa. The improper payments primarily had deficiencies in regard to documentation, including Iowa home health providers not documenting core services, integrated home health outreach services, diagnoses and enrollment correctly.

“In addition, Iowa’s providers did not maintain documentation to support higher payments for intense integrated health home services and did not ensure that beneficiaries had full Medicaid benefits,” the OIG report read.

Therefore, the OIG ruled that the mishap was due to Iowa not adequately monitoring providers for compliance with both state and federal requirements.

The state improperly claimed at least $37.1 million in federal Medicaid reimbursement for payments made to home health providers, the report said.

While the OIG recommended that Iowa refund the $37.1 million, Iowa disagreed with most of the watchdog’s findings and has not yet agreed to pay that amount.

The state did agree, however, that it needed to improve its monitoring of the health home program and said that it was revising its state plan.

The post OIG: Iowa Overpaid Medicaid-Reimbursed Home Health Providers by $37.1M appeared first on Home Health Care News.

Many of the recommendations were tied to home health, hospice and personal care services, in addition to how Medicare Advantage (MA) plans operate.

OIG’s recommendations — 25 in total — come from several years of audits and evaluations, performed under the Inspector General Act of 1978.

On the home health care front, OIG doubled down on its stance that the Centers for Medicare & Medicaid Services (CMS) should implement the statutory mandate requiring surety bonds for home health agencies that enroll in Medicare — and consider implementing the requirement for other providers as well.

CMS could have recovered at least $39 million in uncollected overpayments between 2007 and 2011 if it had required home health agencies to obtain $50,000 in surety bonds, according to OIG.

In fiscal year 2018, Medicare paid an estimated $3.2 billion in improper payments for home health services, though that figure has plummeted dramatically over the past several years. In general, improper payments are most commonly linked to improper documentation — not eligibility issues or intentional fraud. 

“While there’s more to be done, the work of CMS and the industry since 2015 now has us swiftly and aggressively moving in the right direction,” Amedisys Inc. (Nasdaq: AMED) CEO Paul Kusserow wrote in an April letter to the editor published by Home Health Care News.

When it comes to hospice, OIG reaffirmed its belief that CMS should seek statutory authority to establish additional remedies for hospices with poor performance. Currently, the agency’s primary means of recourse when a hospice is found to have serious deficiencies is to terminate the hospice from the Medicare program.

Failure to make home visits, failure to manage patients’ pain and maggots infesting a patient’s feeding tube were just a few of the safety deficiencies noted in a recent hospice report from OIG. Overall, about 20% of hospices surveyed by regulators or accreditors between 2012 and 2016 had a deficiency that posed a serious safety risk, OIG watchdogs found.

Meanwhile, OIG also called attention to its unimplemented recommendation that CMS requires states to either enroll personal care services (PCS) attendants as providers or require such attendants to register with their state Medicaid agencies, assigning each attendant a unique identifier.

“PCS are subject to persistent fraud and beneficiary harm,” OIG wrote in its Monday report. “Furthermore, OIG has raised concerns about the varying standards, and in some cases minimal vetting, for PCS attendants.”

Internally, CMS continues to discuss the feasibility of requiring unique identifiers for PCS attendants. Carrying out the recommendation may soon be a moot point, however, as the 21st Century Cures Act mandates that states implement an electronic visit verification (EVV) system for all Medicaid personal care service providers by Jan. 1, 2020. 

Along Medicare Advantage lines, OIG once again pointed out that CMS should require MA plans to include ordering and referring provider identifiers to their encounter data.

“Ordering and referring provider identifiers are not required in, and were frequently absent from, encounter data,” OIG wrote. “This limits the use of these data for vital program oversight and enforcement activities. It is important that quality of patient care can be tracked by National Provider Identifiers to assess whether ordering or referring providers have determined that services were appropriate for patients.”

CMS has made no progress on that particularly recommendation, according to OIG.

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