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Home Health & Hospice Week

Compliance:

Watch Out For Fraud Hot Spots

Published on Fri Sep 26, 2003

Care quality, upcoding top fraud hit list. 

Have you been so preoccupied with reimbursement and day-to-day operations that you've forgotten to keep on top of fraud issues?

If so, you're not alone, industry experts say. And you could put yourself at risk of serious fraud and abuse charges if you're not careful.

Failure to provide quality care is quickly becoming the HHS Office of Inspector General's favorite target, attorney Deborah Randall said in a Sept. 23 session at the American Health Lawyers Association and Health Care Compliance Association Fraud and Compliance Forum in Washington, DC.

Existing home health quality initiative (HHQI) and outcome-based quality improvement (OBQI) tools will make it easy for the feds to scrutinize this area. Because of those initiatives, many home health agencies already are focusing on improving patient outcomes, said Randall, with Arent Fox Kintner Plotkin & Kahn in Washington, DC.

But agencies may be putting themselves at risk by failing to accurately measure patients' improvement due to faulty OASIS collection methods, she warned.

Other home care fraud hot spots include:

  • Upcoding. HHAs can make the mistake of pushing their nurses for higher home health resource group codes depending on which OASIS answers are selected. While it's legal to show nurses how much the code their OASIS answers determine is worth, agencies can't pressure them to pick higher-paying answers, Randall reminded listeners.

  • Underserving patients. HHAs that claim they can provide few or no aide services to patients might soon find the feds knocking on their doors. Agencies must find a way to make sure patients receive reasonable and necessary aide services, Randall insisted.

  • Bundling. HHAs don't like to think about the supplies covered under consolidated billing, but they need to. "Reckless disregard" of bundling can land an agency in hot water, Randall cautioned.

  • M0175. The OIG is in the middle of a series of reports about answering this OASIS item incorrectly (see pdf of Eli's HCW, Vol. XII, No. 27, p. 210). The watchdog agency already has said it wants millions in recoupments based on incorrect hospital discharge information in OASIS, and fraud investigations and charges might not be far behind.

  • Therapy visits. Intentional manipulation of therapy visits, or even just visit estimates, could land providers in the hot seat, Randall said. Bumping a patient up to 10 therapy visits means thousands of extra dollars for that episode, so agencies had better make sure those visits are justified.

    And saying on the request for anticipated payment that a patient needs 10 or more visits when they won't be provided means a big infusion of cash at the beginning of the episode. Even if an agency pays it back out of its final claim payment, it's like a no-interest loan from the government for the 60 days of the episode, which incurs the feds' wrath.

  • Unsigned orders. Agencies should check all bills for complete, signed orders before submitting them, Randall recommended. This should be part of an HHA's compliance plan.

  • Kickbacks. Agencies must be ever vigilant about kickbacks to either referral sources or patients - don't get overly generous with those holiday gift baskets or educational lunches.

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