Home Health & Hospice Week

Plus: MAC needs to collect all cap overages, watchdog agency highlights.

Home health and hospice agencies aren’t playing a starring role in the HHS Office of Inspector General’s latest Semiannual Report to Congress, but they do get some less-than-desirable attention.

During the Oct. 1, 2022 to March 31, 2023 reporting period, “OIG’s investigative work led to $892.3 million in expected investigative recoveries and 345 criminal actions,” the OIG says in its report released June 5. “OIG also took civil actions, such as assessing monetary penalties, against 324 individuals and entities, and excluded 1,365 individuals and entities from Federal health care programs,” the watchdog agency adds.

The OIG highlights an investigative recovery in a particularly egregious home health case in Houston. A husband, wife, and another individual “conspired to submit claims to Medicare for home health services for patients who did not need services or did not receive services and for whom physicians had not ordered such services,” the report relates. “Furthermore, billing emails showed that many of the claims … were for Medicare beneficiaries who were dead for more than 3 years or incarcerated in prison.”

Felix Amos and his wife Oluyemisi Amos, owners of five HHAs in the area, pleaded guilty in the case. Felix Amos was sentenced to two-and-a-half years in federal prison followed by three years of supervised release, and was ordered to pay $21.2 million in restitution, the OIG notes. Oluyemisi Amos was sentenced to six years in prison. After a four-day jury trial, office manager Fausat Adekunle was found guilty and ordered to serve 12 years in federal prison followed by three years of supervised release, and to pay restitution of $21.2 million.

The OIG also highlights a report titled Home Health Agencies Used Multiple Strategies To Respond to the COVID-19 Pandemic, Although Some Challenges Persist. In that report, the OIG urged the Centers for Medicare & Medicaid Services to “evaluate how HHAs are using telehealth — specifically, the types of services and the characteristics of patients who benefit from these services.”

CMS seems to have listened to that recommendation, since telehealth claims reporting requirements for home health agencies will take effect on July 1, as finalized in the 2023 home health final rule (see HHHW by AAPC, Vol. XXXI, No. 41).

The Semiannual Report also references the OIG’s earlier report on home health utilization from 2016 to 2022. The work was undertaken at the behest of lawmakers concerned about the impact of phasing out the home health rural add-on.

Reminder: By 2022, only about 17 percent of counties that originally received the rural add-on were still receiving it — at a lower rate of 1 percent.

The agency repeats its lackluster findings. “Many variables during the audit period, including the COVID-19 pandemic, may have affected utilization of services,” which went down during the timeframe. “Therefore, we could not determine the cause of any changes in utilization of services during this period,” the OIG concluded.

The OIG did urge CMS to implement a new zip code claims edit, however.

On the hospice side, the OIG lists no fraud cases for once. But it does recap its report on hospice cap overages not collected by HHH Medicare Administrative Contractor National Government Services.

Out of $213.4 million in total cap overpayments, “NGS did not attempt to collect … $2.1 million in net lookback overpayments because of its internal policy of not pursuing lookback cap calculation amounts that were less than a set threshold,” the OIG explains.

The OIG urged CMS to “discontinue its internal policy of waiving certain overpayment collections related to lookback years,” among other things (see HHHW by AAPC, Vol. XXXI, No. 43).

Watch for CMS to pick up some if not all of the OIG’s recommendations in the future, experts caution.

Note: The 106-page report is online at https://oig.hhs. gov/reports-and-publications/archives/semiannual/2023/spring-sar-2023.pdf.