Home Health & Hospice Week

Watchdog agency audits three HHAs based on Medicare payment error rate.

How would you like to face a $2.9 million Medicare repayment based on 10 claims? That, and worse, are facing three home health agencies recently audited by the HHS Office of Inspector General.

The OIG undertook the reviews due to the high 2016 Medicare payment error rate for HHA claims found by the Comprehensive Error Rate Testing program. “Although Medicare spending for home health care accounts only for about 5 percent of fee-for-service spending, improper payments to HHAs account for more than 18 percent of the total 2016 fee-for-service improper payments ($41 billion),” the OIG notes in one report. “Using computer matching, data mining, and data analysis techniques, we identified HHAs at risk for noncom­pliance with Medicare billing requirements.”

All three audited home health agencies maintain that their claims were valid and that they will pursue appeals. Interestingly, when faced with the HHAs’ assertions about their claims, the OIG reversed some of its own findings — sometimes a big portion of them.

Case #1: The OIG found 41 claims out of a 100-claim sample noncompliant for Excella HomeCare, the watchdog agency says in a report about the audit. The beneficiaries for which Excella billed were not homebound or did not require skilled services, the OIG claims. However, the OIG reviewer originally found 70 claims incorrect. “Our medical reviewer overturned, in part or full, 35 claims that it initially found in error” when it conducted a second review of the 70 claims it originally dinged. The agency submitted a 27-page comment letter on the OIG’s original report, drafted by its attorneys at Washington, D.C. law firm Alston Bird.

Even with the claims determinations that it took back, the OIG still declared 41 claims noncom­pliant. Those claims paid $129,520. The OIG extrap­olated the overpayment to the agency’s universe of claims to calculate a $6.6 million overpayment for 2013 and 2014.

Case #2: The OIG found 35 out of 100 claims it reviewed incorrect for EHS Home Health Care Service Inc., the agency says in a report about the audit. The determinations were for the same homebound and skilled service shortfalls. In this audit, the OIG reviewer originally found 41 claims incorrect, but reversed six of those determinations upon a second review. The 35 incorrect claims led to a $55,303 overpayment, which the OIG extrap­olated to a $7.5 million overpayment in 2014 and 2015. EHS submitted comments via its attorneys at Washington, D.C. law firm Bass Berry & Sims.

Case #3: The OIG found 11 out of 100 claims it reviewed incorrect for Metropolitan Jewish Home Care Inc. due to the homebound and skilled service reasons. In this audit, the OIG reviewer originally “questioned” 19 claims and eliminated two of its findings upon a second review, according to the report about the audit. The noncompliant claims led to a $34,514 overpayment, which the OIG extrapolated to a $2.9 million overpayment in 2013 and 2014. MJHC’s comments were submitted by counsel for its parent, Metropolitan Jewish Health System in Brooklyn, New York.

“It looks like OIG applied the wrong homebound definition in several cases and supple­mental documentation saved some others,” notes attorney Robert Markette Jr. with Hall Render in Indianapolis. “It is important for providers to be aware of the standards CMS uses in these reviews and to provide all documentation that may support the claim,” Markette stresses.

However: “This does appear to show OIG reviewers just getting some of these audits flat out wrong by applying the wrong standards,” Markette tells Eli. “This would appear to be a risk in face-to-face [documentation], given how many times those requirements have changed.”

Note: The reports are at https://oig.hhs.gov/oas/reports/region1/11600500.pdf, https://oig.hhs.gov/oas/reports/region2/21601001.pdf, and https://oig.hhs.gov/oas/reports/region5/51600055.pdf.