Home Health & Hospice Week

Avoid 'the problem that can bankrupt you.'

Breathe fresh life into your compliance plan or you could get slammed with a million-dollar-plus settlement with the feds.

That was the fate of a Lexington, KY-based home health agency, according to a new report from the HHS Office of Inspector General.

In the OIG's Semiannual Report to Congress, the agency touts its accomplishments for the second half of fiscal year 2006, noting that it achieved a record $38.2 billion in Medicare savings and expected recoveries attributable to fraud, waste and abuse.

Noteworthy in the Dec. 4 report is a settlement between the OIG and Nurses Registry and Home Health of Lexington. In addition to agreeing to pay the federal government $1.6 million, Nurses Registry must enter into a three-year corporate integrity agreement (CIA) to resolve charges that included upcoding claims

The case is one from which HHAs should learn, says attorney Robert Markette Jr. with Gilliland Markette & Milligan in Indianapolis. The lesson is loud and clear: "Negligence doesn't pay," says Markette.

The settlement resolves allegations that Nurses' Registry submitted claims for unallowable expenses related to advertising, community education, rental expenses and liaison salaries, benefits and meals, according to the report. The settlement also settles allegations that Nurses' Registry upcoded claims under Medicare's home health prospective payment system.

Nurses Registry didn't reply to a request from Eli to comment on the case.

Audit For Coding Accuracy

Inadvertent or fraudulent upcoding of claims remains a top concern for agencies, warns Markette. Even if there is no intention to defraud, coding missteps can pave the way to plenty of trouble, he says.

Watch for this: A coder preparing a Part B claim might consistently code for group therapy when it should have been family therapy.

Another example: A claim had a primary diagnosis of diabetes and the HIPPS code reflects the points for diabetes. Sounds reasonable, right?

Wrong: The documentation shows the focus of the care was a venous stasis ulcer. That means the claim was coded incorrectly as 250.80 (Diabetes with other specified manifestations, type II or unspecified type, not stated as uncontrolled) followed by 454.0 (Varicose ulcer [lower extremity, any part]). Venous stasis ulcers are not manifestations of diabetes, so coding diabetes as the primary diagnosis was upcoding.

A compliance plan that includes regular self audits can help agencies ensure accurate coding and documentation, experts agree.

Fail to do regular audits and you could be faced with paying back claims--with interest and penalties, even without any allegation of fraud.

Keep Tabs On Cost Reports

In addition to targeting OASIS assessments, prospective claims and supporting documentation, agencies should also take a close look at their cost reports, experts agree.

"[The Nurses Registry] case shows that cost reports still matter," stresses Connie Raffa, attorney with Arent Fox in New York City.

If you're like many agencies, you already have an outside party preparing your cost reports, notes Markette. But that doesn't mean that your reports are unassailable.

Tip: It will probably pay to have a third party audit from time to time, coaches Raffa.

Apply the same "audits-are-worth-it" mentality to your Medicare and Medicaid claims, she says. "That way, if you do have a problem, say with an unintentional pattern of upcoding, you may be able to catch it before it becomes the problem that can bankrupt you."