Home Health & Hospice Week

Your own data may single you out for scrutiny.

This month shows why you should be keeping tabs on the HHS Office of Inspector General’s new monthly updates to its Work Plan.

Reminder: Last month, the OIG began updating monthly its Work Plan, which outlines the topics on which it’s focusing (see Eli’s HCW, Vol. XXVI, No. 23). The OIG’s “work planning process is dynamic and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available,” the OIG explained in making the change. Frequent updates “will enhance transparency around OIG’s continuous work planning efforts.”

One of the OIG’s newest topics may have a big impact on home care. The OIG has posted “High-Risk, Error-Prone HHA Providers Using HHA Historical Data” as one of its July additions.

“Using data from the CERT program, we will identify the common characteristics of ‘at risk’ HHA providers that could be used to target pre- and post-payment review of claims,” the OIG says about the report it expects to issue next year.

Why? In 2016, Medicare paid home health agencies about $18.2 billion for home health services, the OIG notes. “CMS’s Comprehensive Error Rate Testing (CERT) program determined that the 2016 improper payment error rate for home health claims was 42 percent, or about $7.7 billion.”

Of course, many HHAs would argue that it’s CMS’s unreasonable interpretation of face-to-face physician encounter documentation requirements that has led to the sky-high CERT payment error rate.

But you can be sure the OIG will come up with a list of factors that will single out agencies for payment review. “The criteria used to identify ‘at-risk’ providers will be critical,” emphasizes Washington, D.C.-based healthcare attorney Elizabeth Hogue.

Stay alert to learn “how the OIG might use this information in addition to pre- and post-payment reviews of claims,” Hogue adds. “It is certainly never a good thing for providers to come under scrutiny based on findings of the OIG.”

Keep in mind: “Data mining seems to play a significant role in fraud and abuse enforcement,” Hogue tells Eli. “It’s increasingly in the numbers.”

Note: See the Work Plan description at www.justice.gov/opa/documents-and-resources-july-13-2017.