Home Health & Hospice Week

The home health agency industry might explode this year, judging by all the fraud and abuse heat it's taking.

A new joint report from the Department of Health and Human Services and the Department of Justice highlights the anti-fraud measures that hit HHAs in 2010, and which will continue to dog home care providers in the future.

For example: "To prevent excessive payments before they are made," the Centers for Medicare & Medicaid Services' new Center for Program Integrity "began moving toward using predictive modeling techniques (similar to those currently used in the financial sector) to identify high-risk claims for further review prior to payment," HHS and DOJ explain in the annual Health Care Fraud and Abuse Control Program (HCFAC) report.

CMS is conducting predictive modeling pilot projects, with home care providers as some of the first guinea pigs. "Analyses are specifically underway in the areas of home health, durable medical equipment, and compromised beneficiary and provider numbers," the report explains.

In the future: "The long-term plan is to usethese models for prepayment risk scoring to identify claims for further review," HHS and DOJ explain. "The sophisticated analytics will move CMS toward its goal of preventing inappropriate payments before they are made."

"The stated goal of identifying high risk claims for further review will most likely result in delayed payments," warns attorney Robert Markette with Gilliland & Markette in Indianapolis. "It is not clear how they are doing the scoring, but providers whose claims are scored as 'at risk' will find these claims take longer to be reimbursed."

The report's indication that the extra review will be pre-pay is bad news. "Any provider who has been on pre-payment review knows that [it] can really slow down cash flow," Markette points out.

The real risk: "If the predictive model is bad, meaning providers are incorrectly having their claims scored as 'at risk,' these providers will effectively be penalized based on the results of a predictive model," Markette predicts.

The Federal Bureau of Investigation is a major dog in the fraud fight, too. "During FY 2010, the FBI initiated the Home Health Agency Fraud Initiative," the report explains. "The overall goal of this program is to develop intelligence, identify fraudulent providers, and target physicians who exploit this care system for financial gain."

How it works: "The initiative utilizes data analysis, sophisticated and advanced investigative techniques, and traditional investigative strategies to identify and target perpetrators of home health care fraud," HHS and DOJ note.

"The FBI has always investigated health care fraud," Markette tells Eli. "But even they are getting into the focus on home health."

The FBI putting resources into the home health area, even if it's to catch non-health care provider, organized crime types, should keep HHAs on their toes. "Providers need to continue to be diligent with their compliance efforts," Markette cautions. "Going along with a questionable practice of a competitor is more likely to be caught now, because of the increased resources put into fighting fraud."

On the other hand: It's nice to see recognition that it's often not providers who are the bad guys. "A lot of what went on in Miami and Houston was perpetrated by criminals who entered home health with the intent to defraud, not providers who went astray," Markette points out.

Providers in Miami and Texas continue to get special scrutiny. In 2010, Miami was in its second year of the "Home Health Project." Under that initiative, CMS and its contractors placed more than 800 beneficiaries on special edits for homebound, skilled nursing and aide topics, the report says. More than 500 benes also underwent "diabetic edits."

Thirty-two HHAs in Miami have now been put on payment suspension under the project, HHS and DOJ report.

In Texas, the Zone 4 Zone Program Integrity Contractor (ZPIC) investigated aberrant home health billing based on outliers, even though outliers were capped at 10 percent in 2010. ZPIC Health Integrity implemented more than 500 "autodenial" edits and 11 payment suspensions, the report says.

Watch out: Expect to see other ZPICs pick up on hot button issues like outliers and diabetes with edits, Markette forecasts. Unfortunately, "this may make up for the lack of RAC activity in the home health industry," he says.

The report also reviews earlier OIG reports on HHA outliers and durable medical equipment issues ranging from power wheelchairs to support surfaces.

And the report lists examples of OIG fraud settlements with home care providers, including an October 2009 settlement in which Evansville, Ind.- based Omni Home Care paid nearly $2 million to resolve charges that it billed Medicare without securing physician signatures on plans of care (see Eli's HCW, Vol. XVIII, No. 39, p. 303).

Overall, the government's health care fraud prevention and enforcement efforts recovered more than $4 billion in FY 2010, HHS says in a release about the report. "This is the highest annual amount ever recovered." HHS Secretary Kathleen Sebelius and U.S. Associate Attorney General Thomas Perrelli give credit to their HEAT and expanded Medicare Fraud Strike Force teams for the recordbreaking number.

HHS and DOJ also tout the new Affordable Care Act anti-fraud provisions ranging from stepped-up enrollment screening to payment suspensions to moratoria.