Home Health & Hospice Week

Report to Congress conveniently omits the fact that OIG had to walk back nearly half of its noncompliant determinations in HHA audits.

For anybody who missed the HHS Office of Inspector General’s slew of hospice audit reports this year, they are highlighted once again in the watchdog agency’s new semiannual report to Congress — and may be on lawmakers’ minds during budget negotiations.

The OIG recaps the eight hospice audit reports it issued between May and July. Three of the eight audits had the OIG-contracted reviewer determine about half of claims were not compliant with billing requirements. The rest had non-compliant rates nearly as high.

Reviewers based most of the adverse determinations on terminal prognosis criteria. However, lack of support for General Inpatient and other higher-level care also figured in the audits, according to the OIG. So did problems with election documentation.

The OIG estimated that Medicare made $121.2 million in unallowable payments to the audited hospices. The highest overpayment amount was $47.4 million to Suncoast Hospice in Clearwater, Florida (see HCW, Vol. XXX, No. 18); the lowest was $3.3 million to Professional Healthcare at Home in Fairfield, California (see HCW, Vol. XXX, No. 22).

The report sent to lawmakers also highlights problems with HHH Medicare Administrative Contractor Palmetto GBA’s handling of hospice caps. Due to internal policies, “Palmetto did not collect lookback overpayments totaling $545,639 or send refunds to hospices totaling $17,513,” the OIG highlights.

On the home health side, the OIG reveals a new home health fraud case in Houston — and one reason the feds were so eager to get rid of Requests for Anticipated Payment.

Uphill Home Health owner Taiwo Dipeolu sold the home health agency to Santa Margarita Healthcare Services in October 2018, the report recounts. During the ownership transition from November 2018 to December 2018, Uphill submitted about $3.9 million in RAPs for home health services that were not provided to Medicare beneficiaries, the OIG relates.

But the feds caught up with Dipeolu. Back in May, Dipeolu signed a settlement agreement with the Centers for Medicare & Medicaid Services and the United States Attorney’s Office for the Southern District of Texas under which he relinquished all rights to $3.9 million that was being held in escrow by CMS, the OIG reports.

The OIG also throws its spotlight on a separate Houston case in which Brenda Rodriguez, the owner and operator of QC Medical Clinic, sold plans of care and other physician-signed documents to HHAs in and around Houston. HHAs then used those documents to support $11 million in false and fraudulent claims for services that were not medically necessary, and often not provided, the report recounts.

Hospices weren’t the only ones getting audit scrutiny this year. The OIG released three HHA audits in April, May and August. The OIG-contracted reviewers found 17, 19, and 39 claims out of 100 not compliant with Medicare billing requirements.

What the semiannual report doesn’t mention is that the OIG had to walk back nearly half of its original noncompliant determinations for one of the audits and about one-third for another of the audits when the agencies challenged the findings (see HCW, Vol. XXX, Nos. 17, 20, and 30). The final agency had two of 19 determinations reversed.

The OIG also reviews its Infection Control audit report of HHAs, in which it found two of eight agencies noncom­pliant with IC requirements based on a questionnaire (see HCW, Vol. XXX, No. 35).

“For 45 years, our agency has been at the forefront of the fight against waste, fraud, and abuse in Medicare, Medicaid, and other HHS programs. And during these challenging times, our mission to protect the public and taxpayer dollars is more important than ever,” says the OIG's Christi A. Grimm in a release about the report that covers April through September. “Our agency has achieved exceptional results in the past year.”