Home Health & Hospice Week

You may feel like your life is getting tougher as federal agencies ramp up enforcement against Medicare fraud, but just wait -- it could get even harder.

Home health agencies and durable medical equipment suppliers are especially vulnerable to improper payments under Medicare, warned the Government Accountability Office's Kathleen King in June 15 testimony before Congress.

King profiled the challenges and strategies for preventing improper Medicare payments in her June 15 testimony before two House committees. If the Centers for Medicare & Medicaid Services takes the GAO's advice, providers could find they have more payment hoops to jump through to obtain their rightful reimbursement.

And CMS is likely to take that advice following President Obama's directive to cut Medicare improper payment rates in half, observers predict (see Eli's HCW, Vol. XIX, No. 22, p. 175).

Target: The GAO zeroes in on home care issues in its recommendation to focus post-payment reviews on the most vulnerable areas. If CMS targets claims for postpayment reviews on the most at-risk areas, the GAO believes that payment errors and overpayment recoupment can be better streamlined. There's a good chance these at-risk areas will include home care and DME claims, King's testimony implied. "We reported in 2009 that two contractors paying home health claims conducted postpayment reviews on fewer than 700 of the 8.7 million claims that they paid in fiscal year 2007," she said in her statement. "Further, we found that they were not using evidence, such as findings from prepayment reviews, to target their post-payment review resources on providers with a demonstrated high risk of improper payments."

The GAO also wants docs pulled into the fraud-fighting loop. "Cross-checking claims for home health services with the physicians who prescribed them can be a further safeguard against fraud, waste, and abuse, but we have found that this is not always done," King complained.

And CMS should direct Recovery Audit Contractors to review DME and HHA claims, the GAO adds. Right now RACs mainly focus on hospitals because of the dollar amounts involved in the claims and the RACs' contingency fee payment structure.

The GAO also recommends:

• Strengthening provider enrollment process and standards. King said that checking the background of providers when they apply for Medicare provider status can reduce the risk of enrolling potentially fraudulent providers.

• Improving pre-payment claims reviews. To ensure that Medicare pays claims correctly the first time, the GAO recommends that CMS "further enhance its ability to identify improper claims through additional automated pre-payment claim review" before they're paid.

• Improving contractor oversight. CMS should expand its oversight of Medicare contractors (the MACs), which are the entities that process the claims.

• Developing a "robust process" for addressing identified vulnerabilities. CMS should specifically address mechanisms to resolve vulnerabilities that lead to improper payments so that issues can be quickly resolved.