Home Health & Hospice Week

Ambulation distance figures prominently in audit findings.

The HHS Office of Inspector General is seeing a chal-lenge to its latest charges of incorrect billing.

Background: The OIG has been releasing a series of audits of home health agencies, noting that it put the agencies’ claims under scrutiny thanks to the Comprehensive Error Rate Testing (CERT) findings from 2016 indicating a 42 percent error rate for HHAs. The OIG fails to mention that the most recent CERT report found a much lower 12.1 percent error rate in 2019 (see HCW by AAPC, Vol. XXIX, No. 1).

This time, the OIG audited Mercy Health Visiting Nurse Services, a nonprofit HHA located in Muskegon, Michigan, served by HHH Medicare Administrative Contractor National Government Services. Mercy is a wholly owned subsidiary of Trinity Health at Home, part of the Catholic Trinity Health system based in Livonia, Michigan.

The OIG audited a sample of 100 Mercy claims from 2016 and 2017, and judged that 23 of them were incorrectly billed due to homebound and medical necessity issues. Specifically, 16 claims had homebound problems and 16 had problems with skilled services (some claims had both).

Extrapolating the $42,466 in overpayments it found, the OIG declares that Mercy has a $1.07 million overpayment that it should repay.

But Trinity Health at Home disputes those findings on multiple grounds for all but two claims, according to its comments on the draft report. “The contracted medical reviewers incorrectly applied Medicare coverage and payment policies,” the company maintains.

On the homebound issue, Trinity argues that one of the problems was that the reviewers used distance of ambulation as a “rule of thumb” for determining homebound status, which is not allowed. “Any presumption or general precondition that fails to take into account a beneficiary’s individual care needs constitutes an improper ‘rule of thumb,’” THAH interim CEO Mark McPherson says in the response letter.

On the medical necessity side, reviewers improperly ruled out patients based on their conditions’ chronic nature, among other problems, THAH contends. And they “ignored documentation clearly supporting the medical necessity of skilled nursing services for observation and assessment when a beneficiary presented a high risk of complications,” the nine-state chain insists.

Bottom line: “THAH is confident its appeal of the claims at issue through Medicare’s administrative appeals process will ultimately result in substantially favorable outcomes and a much lower payment error rate, if any,” it says in its response letter.

The OIG’s response: Unlike in multiple recent audits, the OIG doesn’t give on its review conclusions. “We maintain that our findings and recommendations are valid,” it says.

Note: Links to a brief and the full report are at https://oig.hhs.gov/oas/reports/region5/51800035.asp.