Home Health & Hospice Week

Newest report piles on the pressure.

A government watchdog agency wants a San Diego home health agency to cough up $5.9 million based on 32 denied claims, but the agency isn’t taking the improper billing charges lying down.

In a new report, the HHS Office of Inspector General releases the findings of an audit of Mission Home Health of San Diego Inc., noting that its review found 32 of 100 sampled claims noncompliant with billing requirements based on homebound, medical necessity, documentation, and upcoding issues. The report is part of a string of HHA audits the OIG has undertaken based on a history of “significant overpayments to HHAs,” it says.

The OIG arrives at the $5.9 million repayment number by extrapolating the error rate to the agency’s 2015 and 2016 claims universe, the time period of the audit.

Mission fires back at the review determinations. “We dispute nearly all of the findings,” says Mission spokesperson Kate Sayre tells Eli. “Nearly all of the sampled claims were billed correctly,” Sayre maintains.

In its comment letter, Mission takes particular aim at the homebound determinations that made up a large portion of the findings. “The OIG’s medical reviewer consistently fixated on the distance that beneficiaries could walk to determine homebound status,” Mission says in a response letter prepared by legal counsel Barry Bass & Sims and included in the report. That’s “not only clinically inappropriate, but also directly contrary to Medicare guidance,” according to the letter.

Mission also criticizes the reviewer’s credentials for reviewing home health claims. The OIG vaguely describes the reviewer as a “physician who is duly licensed to practice medicine” and “familiar with the guidelines and protocols in the areas of treatment under review,” Mission says in the letter. There’s no evidence the reviewer has home health expertise and “every single one of the reviewer’s findings with respect to homebound status and the need for skilled services was flawed,” the agency challenges. The criteria they used to determine homebound status “simply are not the standards … under applicable federal regulations,” the agency adds.

The HHA also attacks the OIG’s statistical extrapolation techniques and other perceived errors.

Mission does allow that four of the audited claims were billed inappropriately — two were based on plans of care lacking physician signatures and two had upcoded HIPPS codes.

In response to Mission’s letter, the OIG did decide to recategorize six claims it originally ruled improper as legitimate, bringing the number of dinged claims down from 38 to 32.

“Mission plans to appeal most all of the claims through the appeals process,” Sayre says.

Mission won’t be the last HHA targeted by the OIG. The agency “is not our fan,” rues attorney Robert Markette Jr. with Hall Render in Indianapolis. The OIG’s small samples extrapolated to create large overpayment amounts are always problematic.

The OIG’s new string of HHA audits is adding to the pile-on of pressures HHAs are facing, including continued coping with PDGM and resumption of medical review and routine surveys. v

Note: The 55-page report is at https://oig.hhs.gov/oas/reports/region9/91803008.pdf.