Home Health & Hospice Week

OIG walks back adverse determinations on 6 claims after challenge.

Home health agencies continue to challenge federal auditors’ claims determinations — and succeed, at least in part.

In its latest released audit of a home health agency, the HHS Office of Inspector General found 32 of 100 sampled claims from Total Patient Care Home Health in Richardson, Texas “did not comply with Medicare billing requirements.” Problems ranged from lack of homebound status to medical necessity.

Based on the sample, the OIG estimates that TPC “received overpayments of at least $1.7 million for our audit period” that ran from 2014 to 2016.

TPN challenged the OIG’s findings in the report. “OIG’s claim determinations are flawed because they do not account for all of the relevant clinical information in the records and resulted from application of the wrong coverage standards,” TPN’s attorney, Adam Bird with Calhoun Bhella & Sechrest, says in a 24-page letter commenting on the report.

“The reviewers have clearly applied an improper ‘rule of thumb’ to determine many beneficiaries were not homebound, seemingly created a presumption that beneficiaries residing in congregate living facilities do not qualify for the Medicare home health benefit, and failed to consider examples of homebound beneficiaries given in CMS guidance,” TPC’s letter says. “In other cases, OIG’s reviewers simply stated in conclusory fashion that services were ‘excessive’ or ‘not medically necessary.’”

The OIG “had our medical reviewer again review all 38 of the claims originally found in error” after TPC’s response, the agency says in the audit report. “Based on the results of that review, we revised our determinations, reducing the total number of sampled claims incorrectly billed from 38 to 32, and adjusted the findings for 13 of the 32 claims.”

TPC also takes aim at the OIG’s extrapolation techniques, noting it “will challenge the validity of OIG’s sampling methodology” if necessary.

Note: The 62-page audit report is at https://oig.hhs.gov/oas/ reports/region6/61605005.pdf.