Home Health & Hospice Week

Watchdog agency serves up its long string of HHA, hospice audits to Congress in latest semiannual report.

If you thought the OIG would lay off home health agency audits now that its number of audit reports for the provider type in the last year have entered double digits, think again.

On May 28, the HHS Office of Inspector General issued one such report targeting Caretenders of Jacksonville in Florida. The OIG-contracted reviewer originally determined that 55 of 100 sampled claims from 2014 and 2015 “did not comply with Medicare billing requirements,” the report notes. Namely, patients were not homebound or did not require skilled services, and HIPPS codes were incorrect, the OIG charges.

After Caretenders pushed back on those results, the OIG scaled down the noncompliance rate to 39 of the 100 claims, according to the report.

Medicare paid this Caretenders agency about $25 million for 8,570 claims in the audit period. Caretenders received overpayments of $92,345 for the 39 claims the OIG-contracted reviewer determined were noncompliant. Using extrapolation, the OIG estimates that “Caretenders received overpayments of at least $4.4 million for the audit period,” the report notes.

In a seven-page response letter to the draft report, Caretenders’ attorney, Jennifer L. Weaver with law firm Waller Lansden Dortch & Davis in Nashville, objects to the OIG’s findings. “For each of the fifty-five denied claims, Caretenders is submitting detailed responses which demonstrate that the patients at issue were in fact homebound and had skilled needs, and were provided quality care from Caretenders that was reasonable and medically necessary, correctly coded and properly documented,” Weaver says in the letter.

For example: The letter notes a patient receiving observation and assessment services “related to her labile blood sugar readings.” On multiple visits, “the skilled nurse continued to instruct Patient … on her diet and eating times and how that affects her blood sugar readings,” Caretenders says. “Had Caretenders discharged Patient … prematurely, the moment her blood sugar readings improved, there is a strong likelihood those improvements would not have been maintained and a reasonable potential Patient … could have suffered further complications or another acute episode,” the letter stresses. “The Medicare Benefit Policy Manual explicitly provides the three-week skilled nursing cushion to prevent such an eventuality.”

Caretenders agrees with just one of the claims determinations, noting that “only a single claim … had a minor coding error resulting from the biller simply checking the wrong box.” That error should have resulted in about $180 less payment, Weaver acknowledges.

Audits of home health and hospice agencies are on the rise. Wise providers will make sure they are prepared.

“It is always better to prevent instead of cure,” the American Health Information Management Association says on its website. Providers looking to protect themselves in an OIG probe should take steps including conducting internal audits and educating staff based on the results, AHIMA urges.

OIG Estimates Millions In HHA, Hospice Overpayments

Meanwhile, the OIG’s latest message to Congress is that the home health and hospice industries are riddled with fraud and abuse.

The OIG touts its long list of HHA audits in its latest Semiannual Report to Congress released May 28. The report outlines the seven HHA audits the OIG released in the reporting period of October 2020 through March 2021.

The OIG estimated overpayments for the seven agencies ranging up to $3.3 million, based on review of a 100-claim sample for each. Though it didn’t specify its justification in the report, the OIG’s determinations were largely based on homebound and medical necessity criteria.

Since the end of the report’s time period, the OIG has released more home health and hospice audits (see above).

The report to Congress also tallies the OIG’s hospice audits, listing three hospice audit reports from the October-to-March time period with estimated overpayments reaching as high as $8.3 million. As with HHAs, the OIG has issued multiple hospice audit reports since that time period as well.

The OIG report details the problems the agency found with the hospice claims, mainly related to terminal prognosis, care level documentation, and Notices of Election.

Note: The 42-page Caretenders audit report is at www.oig.hhs.gov/oas/reports/region4/41606195.pdf. The 104-page OIG Semiannual Report to Congress is at www.oig.hhs.gov/reports-and-publications/archives/semiannual/2021/2021-spring-sar.pdf.