Home Health & Hospice Week

The latest audit in the HHS Office of Inspector General’s home health agency focus area shows why it pays to push back on the watchdog agency’s findings.

The OIG’s “independent medical review contractor” sampled and reviewed 100 claims from Visiting Nurse Association of Maryland in Baltimore. The audit covered claims from 2015 and 2016, the OIG says in its audit report. LHC Group Inc. bought the VNA in fall of 2019, the Lafayette, Louisiana-based chain says in a release.

Of the 100 claims the OIG contractor reviewed, it originally found 36 noncompliant with Medicare billing requirements. After the VNA challenged the results, the OIG and its contractor pulled that back to finding 19 claims noncompliant and changed the adjustment for five of those 19.

Background: This is at least the tenth HHA audit for which the OIG has released audit reports in the past year. In most of those reports, the OIG has significantly backed off its number of claims found noncompliant in response to the audited agency’s challenges.

As justification for the string of HHA audits, the OIG cites the Centers for Medicare & Medicaid Services Compre­hensive Error Rate Testing program’s finding “that the 2016 improper payment error rate for home health claims was 42 percent, or about $7.7 billion. 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 that “using computer matching, data mining, and data analysis techniques, we identified HHAs at risk for noncompliance with Medicare billing requirements.”

The OIG reviewer denied or downcoded VNAM’s claims based on the usual standards — homebound status, skilled need, plan of care issues, and incorrect HIPPS code assignment.

In protesting the OIG contractor’s findings, the VNA took aim at reviewers’ liberal use of “rule of thumb” elements such as distance a patient could ambulate, degree of motion, and accessibility of the patient’s home when determining homebound status.

“For at least 19 of the 28 claims denied … on the basis of homebound status, the OIG reviewer denied or downcoded a claim based on the beneficiary’s ‘ability to walk a certain number of feet,’ a specific example of a ‘rule of thumb’ that may not be used,” Baker Donelson attorneys Donna Senft and Deborah Samenow argued in the VNA’s 18-page response letter included in the report.

The VNA also claimed that a lack of home health-specific credentials for the OIG reviewers led to such problems, as well as things like not understanding the difference between physical and occupational therapy services and failing to understand coverage criteria for observation and assessment, teaching and training, care plan management, etc.

“For each claim reviewed, the OIG reviewer/s were a physician or additionally a certified coding specialist/ registered health information technician, not clinicians with specialized expertise in nursing, physical therapy, occupa­tional therapy, or speech language pathology, as required by the Medicare Program Integrity Manual,” the response letter criticizes.

The OIG insists that “all medical necessity determi­nations were made by licensed physicians who were board certified in an area appropriate to the treatment under review,” although it does not reveal what those areas were.

Even after reducing the noncompliant claim count, the OIG still found 19 claims invalid to the tune of $25,295. Using extrapolation to the VNA’s $49.1 million in payments in 2015 and 2016, the OIG estimates that the VNA owes $2.1 million in repayments.

The VNA challenged the sampling and extrapolation methodology in its letter, to no avail. The provider said it agreed with the OIG’s noncompliant finding for only three claims, which was too small of an amount to be extrapolated. It did agree to repay the amounts for those claims, however.

Note: A link to the report is at https://oig.hhs.gov/oas/reports/region3/31700009.asp.