Home Health & Hospice Week

HHAs, hospices racked up more than $3.5 million in wrong payments, according to latest CERT reckoning.

Home health and hospice agencies may not be able to claim quite as much moral high ground this year regarding Medicare’s improper payment figures.

Background: When the Department of Health and Human Services calculated an improper payment rate under the Comprehensive Error Rate Testing program for 2015, the HHA rate came in at a whopping 59 percent. Every year since then it’s fallen — 42 percent for 2016; 32 percent for 2017; a much lower 17.6 percent for 2018; 12.1 percent for 2019; and 9.30 percent for 2020.

Now HHS says the 2021 rate is a slightly higher 10.24 percent for 2021, equaling $1.89 million, according to the HHS Financial Agency Report for 2021. Although HHS declares in its report that “the change is not statistically significant,” HHAs can no longer point to steadily declining payment error rates as proof that the industry isn’t fraud- and abuse-prone.

The same trend has occurred for hospices since 2016 as well. Hospices’ payment error rate was 10.7 percent for 2015, then spiked to 15.9 percent for 2016, then fell again to 14.7 percent for 2017, 11.7 percent for 2018, 9.7 percent for 2019, and 6.69 percent for 2020. That rate is now back up to 7.77 percent for 2021, equaling $1.68 million, according to the report.

As with home health, HHS claims that “the change is not statistically significant” for the hospice rate.

For both home health and hospice claims, missing and insufficient documentation continues to be “the primary reason for these errors,” HHS explains. Medical necessity is a distant second for both provider types, the report shows.

The Centers for Medicare & Medicaid Services notes that it suspended CERT program activities for a while in 2020 due to the COVID-19 Public Health Emergency. Then after resuming them in August 2020, “CMS adjusted CERT program data collection by reducing the sample size for Reporting Year (RY) 2021 and RY 2022 to account for the challenges incurred by providers and suppliers during the PHE, while continuing to maintain appropriate account­ability measures and meet statutory obligations,” according to its CERT webpage. “Claims with dates of service within the COVID-19 PHE were reviewed in accordance with all applicable CMS waivers and flexibilities,” the agency adds.