Home Health & Hospice Week

Don’t ignore any ‘credible information’ on potential overpayments, the feds warn.

If your patients improve too much while under your care, don’t be surprised when the OIG comes knocking.

That’s one of the reasons the HHS Office of Inspector General slapped hospital-based Palos Community Hospital Home Health Agency with a recommendation to repay more than $680,884, based on 2015 and 2016 claims the agency audited.

The OIG begins its audit report by trotting out the Comprehensive Error Rate Testing program-derived Medicare payment error rate of 42 percent in 2016 for home health. The agency fails to mention that the home health payment error rate has fallen drastically to 12.1 percent for 2019, according to newly released error rate statistics from the Centers for Medicare & Medicaid Services (see related story, this page).

In the Palos audit, the OIG pulled 100 claims for review from the not-for-profit HHA located in Lemont, Illinois. An “independent medical review contractor” deemed 16 of the claims noncom­pliant with Medicare requirements, resulting in an overpayment of $22,428. Then the OIG estimated, based on Palos’ total claims submitted for the time period, that Palos owes $680,884 for 2015 and 2016.

For example: The HHA’s “records showed that [a] patient was initially homebound after having undergone a left total knee replacement and was limited by pain, decreased knee range of motion, and weakness. She was living in a residence with steps to the entrance. She took medications, including Warfarin, which placed her at risk of fall-related complications related to bleeding. She was limited to ambulating very short distances at the start of care. Leaving the home would have required a considerable and taxing effort at the start of care. However, during the episode of care, which started on February 28, 2015, her mobility status improved. By March 11, 2015, she was able to ambulate 350 feet indoors and 40 feet times two outdoors and had progressed to negotiating stairs without hands-on assistance.”

Decision: “Leaving the home did not require a considerable or taxing effort after March 11, 2015. The medical information does not support that she remained homebound after this date,” the OIG says.

In its recent audits, where the OIG used an outside contractor for medical review, the targeted HHAs have fought back and succeeded in getting a large portion of the noncompliant claims cleared (see Eli’s HCW, Vol. XXVIII, Nos. 20, 21, 31, and 39-40). But in this audit, the Palos Health CEO, physician Terrence Moisan, merely submits an extremely brief letter saying “Palos Community Hospital Home Health Care concurs with the OIG audit findings and recommendations. PCH has implemented an action plan which includes monitoring of PCH Home Health clinical documentation.”

A problem: If reviewers continue to cut home health episodes short, HHAs will face an increased risk of Low Utilization Payment Adjustments — especially under the Patient-Driven Groupings Model’s 30-day billing periods, experts warn.

The OIG uses “computer matching, data mining, and data analysis techniques” to identify “HHAs at risk for noncompliance with Medicare billing requirements,” the report adds.

The agency also warns that “providers that receive credible information of a potential overpayment” — including an OIG audit’s findings — “must (1) exercise reasonable diligence to investigate the potential overpayment, (2) quantify the overpayment amount over a 6-year lookback period, and (3) report and return any overpayments within 60 days of identifying those overpayments (60-day rule).”

Note: The 29-page report is at https://oig.hhs.gov/oas/reports/region5/51700022.pdf.