Home Health & Hospice Week

Watchdog agency pushes for HHA surety bonds — again.

Home health agencies just can’t seem to get a break from the HHS Office of Inspector General lately.

In the past week, the OIG has issued three reports highlighting problems with HHAs.

Report #1: The new report, “Inadequate Edits and Oversight Caused Medicare To Overpay More Than $267 Million for Hospital Inpatient Claims With Post-Acute-Care Transfers to Home Health Services,” may seem like it affects hospitals — but it also has major implications for HHAs. In the report, the OIG says the hospitals improperly coded their claims when there was a discharge to HH “early,” and Medicare systems allowed the upcoding to occur.

Reminder: When hospitals discharge patients to home health early, the DRG payment is supposed to be prorated. But in a loophole, hospitals can use condition code 42 (home health not related to inpatient stay) to avoid the proration. The system also allowed claims with condition code 43 (home health not within 3 days of discharge) to bypass proration, even when the patient did have home health in that time frame.

When medical reviewers looked at 150 sampled claims from 2016 and 2017, they found only three were properly paid. Medicare “improperly paid 147 with $722,288 in overpayments,” leading the OIG to estimate a $267 million overpayment to hospitals during the two-year period.

Why it matters to HHAs: The OIG urges the Centers for Medicare & Medicaid Services to recoup the $722,288, reprocess all the other overpaid claims from those years, use data mining to identify hospitals that abuse code 42 billing, and educate hospitals about proper billing for proration, among other measures. The OIG also wants to see code 43 exceptions eliminated, or at least claims system edits that block their improper usage. The more CMS leans on proration, the less likely hospitals will be to discharge patients to home health, industry experts fear.

In its comments on the report, CMS agrees to all except eliminating the code 43 exception. The relatedness determi­nation is required by law, the agency says.

The 34-page report is at https://oig.hhs.gov/oas/reports/region4/41804067.pdf.

Report #2: HHAs and hospices, as usual, feature in the OIG’s annual compendium of unimplemented recommen­dations. The OIG wants CMS to implement surety bond requirements for HHAs, require ordering provider identifi­cation for home health services in Medicare Advantage, and take steps to allow electronic verification of personal care service workers for Medicaid home health.

On the hospice side, the OIG urges CMS to include accreditation survey information on Hospice Compare, include complaint survey data on Hospice Compare, more closely oversee hospices with a record of survey deficiencies, prevent duplicative Part D payments for drugs that hospices should cover, improve survey practices related to neglect and abuse, “modify” payments for hospice care furnished to nursing home residents, more closely oversee General Inpatient Care, and tighten up survey practices in multiple ways.

The 77-page report is at https://oig.hhs.gov/reports-and-publications/compendium/files/compendium2020.pdf.

Report #3: The OIG audited an HHA in Puerto Rico and found 14 percent of the claims improper. Using data mining and data analysis, the OIG identified Condado Home Care Program Inc. in San Juan as a target for scrutiny and audited 100 claims from 2016.

Condado incorrectly billed Medicare for beneficiaries who were not homebound, did not require skilled services, and were under a noncompliant plan of care. It also billed incorrect HIPPS payment codes, the OIG charges. The HHA should repay at least $97,000 due to the mistakes, the OIG says.

In a letter responding to the report, Condado notes improvements it has made to its policies and procedures, but didn’t comment on the overpayment allegation.

The 36-page report is at https://oig.hhs.gov/oas/reports/region2/21701022.pdf.