Home Health & Hospice Week

Is a moratorium in the industry's future?

Home health agencies' lives could get even harder if the OIG gets its way.

The HHS Office of Inspector General has found $5 million in inappropriate Medicare payments to HHAs in 2010, it says in a new report. The erroneous payments were due to overlapping stays with hospitals and nursing homes, and to payments made for services after a beneficiary's date of death. "Home health services are vulnerable to fraud, waste, and abuse," the watchdog agency says.

More importantly, the OIG identifies six factors it uses to identify questionable HHA billing (see story, p. 231). One out of four HHAs exceeded the threshold for at least one of the factors, the report notes.

The OIG is making a mountain out of a molehill when it comes to the billing errors, maintains Washington, D.C.-based health care attorney Elizabeth Hogue. The $5 million in inappropriate billing is a miniscule 2.6 hundredths of a percent of the $19.5 billion Medicare paid to HHAs in 2010. And the amount of HHA payments overall is dwarfed by layouts to other provider types such as hospitals.

"It's hard to imagine that dollars recouped from home health agencies come anywhere close to the amounts recouped from other types of pro-viders," Hogue tells Eli. "And yet, the industry's 'rep' continues to include widespread fraud and abuse."

Medicare already has edits in place to address the overlapping claim and date of death problems, points out M. Aaron Little with BKD in Springfield, Mo.

In fact, the edits have been in place since the home health prospective payment system began, the Centers for Medicare & Medicaid Services says in its official comments on the OIG report. But "the overlap situations identified in this report, even though relatively small in number, are not acceptable," CMS says. The agency will identify and fix the loopholes in the system, it pledges in response to the OIG's recommendation to improve edits.

The vast majority of the erroneous payments, $4.8 million, are due to the overlapping claim issue. But the problem may not have any reimbursement impact at all, CMS highlights. For example, if the HHA simply placed an incorrect visit date on its claim due to a data entry error, it can change or delete that visit and resubmit the claim, CMS points out.

A certain number of data entry errors are to be expected in any billing system, says attorney Robert Markette Jr. with Benesch Friedlander Coplan & Aronoff in Indianapolis. "It's not fraud."

OIG Singles Out 4 States For Scrutiny

HHAs located in Florida, Texas, Michigan, and California may not be surprised to see themselves targeted in the OIG's report. Eighty percent of the 2,594 HHAs that exceeded at least one of the OIG's six questionable billing benchmarks was located in these four states. In contrast, these states contained about 47 percent of the nation's 10,341 agencies during that year.

None of these states have Certificate of Need (CON) requirements, the OIG points out. Overall, 97 percent of the HHAs with questionable billing were located in states with no CONs.

Texas had the highest percentage of HHAs with questionable billing at 39 percent, the report says. Florida was next with 25 percent, and California and Michigan trailed with 11 and 5 percent, respectively.

To combat this problem, the OIG recommends that CMS impose a temporary moratorium on new enrollments in Texas and Florida. CMS could implement the moratorium in just certain counties or metro areas, the watchdog agency suggests.

Fraud and abuse-fighting powers granted to CMS under the Affordable Care Act make imposing a moratorium easier, experts point out. And the National Association for Home Care & Hospice has long called for a nationwide moratorium on new HHA enrollment.

Will a moratorium fix anything? The OIG's own stats seem to suggest that providers engaging in fraud and abuse are already in the door, Markette offers. So a new moratorium may not address the problems the OIG identifies.

But CMS is moving ahead with moratorium deliberations anyway. "CMS ... is in the process of assessing a variety of provider types for suitability for moratoria, including HHAs, and is carefully assessing the geographic area to which moratoria will apply," it says in its comments.

"It seems like CMS is being extremely cautious about imposing a moratorium," Hogue observes. "I think this is very wise."