Home Health & Hospice Week

Only 2 percent of reviewed claims fail OIG's coverage test.

A new federal report on home health coverage contains some good news for a change, but that doesn't mean you should let down your guard.

In a record review for 495 beneficiaries that used home health services in 2008, the HHS Office of Inspector General found only 2 percent of records for patients who failed to meet the home care eligibility requirements for homebound and skilled need.

"Home health agencies are doing a fairly good job in determining Medicare coverage in spite of all the allegations of home health fraud and abuse," cheers the National Association for Home Care & Hospice.

The "OIG's own analysis shows things aren't as bad as they like to pretend," says attorney Robert Markette Jr. with Benesch Friedlander Coplan & Aronoff in Indianapolis. "Although, they appear to be ready to ignore their own analysis," Markette tells Eli.

To wit: "Our study identified only 2 percent of claims as being for services that were not medically necessary," the OIG acknowledges in the report. "However, other OIG studies and investigations, as well as joint efforts between HHS and DOJ, have demonstrated that home health is an area at increased risk for fraud." HHAs could be falsifying records to make patients appear eligible, the agency implies.

"Further investigations beyond the medical record are needed to determine whether beneficiaries are eligible, services are furnished, and Medicare requirements for payment are met," the watchdog agency concludes. "OIG will continue to monitor Medicare home health claims to determine whether the services are appropriate and merit payment."

Bottom line: "Increased oversight is ex-pected to continue," NAHC says.

The Centers for Medicare & Medicaid Services proposed one new oversight tool in the March 6 Federal Register. Under a "probable fraud measurement pilot," CMS would collect information from HHAs, referring physicians and Medicare beneficiaries in a national random sample. The pilot would estimate the percentage of total payments and the percentage of all claims that are associated with probable fraud for Medicare fee-for-service home health, says the Federal Register notice that seeks approval from the Office of Management and Budget for the information collection.

The pilot highlights "the cloud that hangs over home health in terms of image and reputation in oversight agencies," NAHC points out. "Even one fraudulent provider affects the reputation of the whole community."

Payment Errors Exceed 20%

While HHAs passed the OIG's coverage test with flying colors, they didn't do as well with billing accuracy. The OIG found that agencies submitted 22 percent of claims in error.

However, about half of those were upcoded while the other half were downcoded, NAHC notes. That points to increased complexity in the billing system rather than agency fraud or abuse, the trade group suggests.

OIG reviewers also found other problems like plans of care that were missing dates and discharge planning information.

Note: The report is at http://oig.hhs.gov/oei/reports/oei-01-08-00390.pdf.