Home Health & Hospice Week

Your arrangements with physicians could land you in hot water with the OIG as the watchdog agency increases scrutiny of the relationships.

The HHS Office of Inspector General lists "Physician Referrals for Home Health Agency Ser-vices" as one of the five home health agency topics it plans to investigate in 2009, according to the new Work Plan for the year.

"We will examine trends in utilization patterns and Medicare reimbursement for services or-dered by referring physicians," the OIG says in the Plan. "We will review Medicare payments for home health claims to identify potential aberrant billing by referring physicians."

Whether the OIG intends to look at physicians billing for certifications and care plan oversight or HHAs billing without proper physician signatures is unclear. The Centers for Medicare & Medicaid Services pays a relatively small amount for cert, recert, and CPO by physicians, so it would be surprising for the OIG to scrutinize those payments, says regulatory consultant Rebecca Fried-man Zuber in Chicago.

The OIG looking into actual referral relationships for kickback problems would also be a surprise, notes Washington, D.C.-based attorney Elizabeth Hogue. The OIG hasn't delved into this compliance hot spot comprehensively before.

Perhaps that's because physicians receive little to no enforcement action based on improper referrals, suggests attorney Marie Berliner with Lambeth & Berliner in Austin, Texas.

Tip #1: To steer clear of compliance trouble, "agencies should definitely review their relationships with physicians, especially written agreements for consulting services," Hogue advises.

The OIG appears to be focusing more on home health and hospice in this year's Work Plan, notes Bob Wardwell with the Visiting Nurse As-sociations of America. Between increased OIG scrutiny and the HHA fraud crackdown CMS just announced (see related story, p. 282), "it would be a real good time for the folks who opened HHAs for a fast buck to get on to their next line of business," Wardwell notes.

The watchdog agency plans to examine the problem that triggered CMS's fraud crackdown -- outlier visits for diabetic patients. The OIG lists "Medicare Home Health Payments for Insulin In-jections" as one of its investigation areas.

"We will examine billing patterns in geographic areas with high rates of home health visits for insulin injections to determine the appropriateness of services billed," the OIG says.

"There are reportedly numerous instances of patients not being homebound, not unable to self-inject and, in some instances, not being diabetic at all," Berliner points out.

Under the increased scrutiny for outliers that's hitting, "you'd better be right," warns attorney Lucien Bernard with Pearson & Bernard in Cov-ington, Ky.

If you serve a geographic area with a high percentage of diabetic patients, be ready for OIG scrutiny, Berliner advises.

Tip #2: "Take the opportunity to review diabetic patient charts for documentation in support of the diabetic diagnosis, homebound status, and the patient's inability to self-inject and/or unwillingness of a family member to be trained to provide the injections," Berliner advises.

The OIG also will focus on therapy this coming year. "We will determine whether payments made to HHAs are correct and supported for the service level claimed," the Work Plan says.

"The fact that newly established therapy thresholds were applied to home health agencies in 2008 should not make it too much of a stretch to see that therapy services in general would be scrutinized," Berliner observes.

The OIG may be concerned that therapy visits provided under arrangement are excessive, Bernard predicts. The contracted therapist has an incentive to increase visits because he is usually paid per visit and the HHA has an incentive to increase visits because under the PPS revisions, many visit increases warrant a reimbursement increase.

Tip #3: "If your average number of therapy visits per episode has changed, you'd better be able to defend and justify the variance, especially now that the therapy thresholds have changed," Bernard counsels.

Tip #4: "Review this information with the provider of their under-arrangement therapy services," Bernard suggests. "Remind them that it's in both of [your] best interests to provide appropriate and medically necessary therapy services." If not, both the agency and the therapist are at risk.

The OIG also will look at Part B therapy services mistakenly paid for while a patient is under a home health plan of care.

Beware OIG site visits: Another topic for OIG review is the Comprehensive Error Rate Testing report for HHAs. Congress recently requested a review of the HHA CERT rate after the OIG declared that CMS lowballed the DME figures (see Eli's HCW, Vol. XVII, No. 31, p. 242).

An audit of HHAs' auditors shouldn't affect agencies much, Bernard notes. But OIG investigators "will also be making site visits to HHAs," he adds. That's "never a good thing."

Finally, the OIG will examine "Accuracy of Coding and Claims for Medicare Home Health Re-source Groups." Investigators will review claims to determine whether HHRGs are accurate and supported by the medical record. This is a perennial favorite topic of the OIG's, Berliner notes.

Note: The Work Plan is online at http://oig.hhs.gov/publications/docs/workplan/2009/WorkPlanFY2009.pdf.