Home Health & Hospice Week

The HHS Office of Inspector General’s string of home health agency audits keeps getting longer. Don’t expect the OIG to stop adding to it any time soon.

The OIG is “back to scrutinizing home health,” observes attorney Robert Markette Jr. with Hall Render in Indianapolis. While the OIG has always focused heavily on HHAs, its concentration on the industry is more pronounced than ever. The watchdog agency has issued reports about a dozen HHA audits in the last year.

Nearly all of the audits have a common pattern: the reviewer determines a steep percentage of sampled claims is improperly billed and extrapolates an alarmingly high overpayment for the audited agency; the agency pushes back on the review findings; and the OIG walks back a portion of its unfavorable claims determinations — but still assesses a hefty overpayment amount using statistical sampling.

This isn’t exactly a shock. “In every home health audit I have been involved with, the auditors seemed to be aggressive and engaged in overreach,” Markette tells AAPC.

But it is taking its toll on HHAs that are under heavy pressure from the Patient-Driven Groupings Model, the COVID-19 public health emergency, staffing shortages, skyrocketing costs, and more.

The OIG conducted the latest such audit on Southeastern Home Health Services’ Bristol, Pennsylvania location. Southeastern, which has 11 offices in Pennsylvania and 2 in Virginia, is served by HHH Medicare Administrative Contractor CGS Administrators, the report notes.

The OIG reviewer found that 28 of 100 sampled claims from 2015 and 2016 didn’t comply with Medicare billing requirements, based on homebound and skilled need criteria, as well as incorrect HIPPS codes.

Southeastern, through its attorney Lorraine Rosado with Liles Parker, submitted a 33-page letter in response to the OIG’s initial findings. Among many challenges, Southeastern said the OIG reviewer used an “illegal ‘rule of thumb’ and ‘numerical utilization screen’” related to ambulation, according to the report.

The OIG reconsidered, coming back with a count of 18 claims that were not compliant. The agency estimated that Southeastern received overpayments of at least $1.8 million for the period and urged the agency to “identify, report, and return any overpayments.”

This audit shows how important homebound documen­tation is, Markette maintains. “The key for agencies is to understand, you need to document homebound status very well,” he stresses. “This provider appears to have done that, but not necessarily connected the dots between the clinical record and ‘severe and taxing.’ This OIG report shows that reviewers will rely upon tests that may not be obvious from the text of the statute, regulation, or manuals.”

Addressing the “severe and taxing effort” standard can be tricky. Although it “alone does not prove homebound status, providers must make the case that the patient cannot leave the home without a severe and taxing effort,” Markette stresses.

On the other hand: “Agencies should not just repeat those words as if it is a magic phrase,” Markette urges. “They must paint the picture in their documentation of a patient who is homebound. Reviewers do not give providers the benefit of the doubt,” he adds.

Don’t forget: “The manual guidance does allow for a patient to leave the home for certain limited reasons and still maintain homebound status,” Markette reminds agencies. “The occasional absence from the home to attend church or go to a hair appointment should not undercut homebound status, by itself.”

Note: The 69-page audit report is at https://oig.hhs.gov/oas/reports/region3/31700004.pdf.