Home Health & Hospice Week

Seventeen claims lead to multi-million payback estimate.

The latest home health agency target of an OIG audit has fared better than many of the agencies that preceded it over the past year, but the feds still want a hefty repayment.

The HHS Office of Inspector General released an audit report of Catholic Home Care, a not-for-profit faith-based HHA in Farmingdale, New York, that has served the Long Island community for more than 100 years, according to its president, nurse Kim Kranz. It’s at least the twelfth HHA audit report the OIG has issued over the past year.

An independent review contractor for the OIG reviewed a 100-claim sample from 2017 and 2018, originally finding 19 claims out of compliance with billing requirements due to a lack of skilled service need. After CHC submitted a rebuttal to the findings penned by SimiTree Healthcare Consulting, the OIG pulled back the determinations for two of those claims. That’s a significantly lower rate than many audit targets have seen.

The OIG then extrapolated the 17 disallowed claims with their $25,742 in reimbursement to a universe of $103 million for the audit period, resulting in an estimated overpayment of $4.2 million.

The OIG’s findings “rely on the apparent ‘stability’ of the patient on a particular date during the care period in question rather than on the overall condition of the patient and continuity of care through discharge,” Kranz notes in the response letter. “While many of the conditions with which the patients suffered are chronic and subject to periods of ‘plateauing,’ that alone does not render home care services either unnecessary or unreasonable,” she says.

The CHC letter cites both the 2014 Jimmo v. Sebelius court decision banning a so-called improvement standard and the 2020 McKee v. Azar settlement of a lawsuit on the issue.

Reminder: Under the McKee settlement, Medicare agreed to pay the home health claim for “a patient who required skilled nursing visits to assess and treat her serious medical conditions, which included difficulty breathing, digestive problems, and significant swelling in her legs with a continuing need for leg wound care,” the Center for Medicare Advocacy notes in a release about the case.

Important: “Jimmo requires Medicare coverage determinations to be based on individuals’ need for skilled care, not on their potential for improvement or on their stability,” the Center emphasizes in the release. “Skilled nursing, or physical, occupational, or speech therapy may be required to maintain a person’s condition or to prevent or slow deterioration.”

Note: The 40-page audit report is at https://oig.hhs.gov/oas/reports/region2/21901013.pdf.