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Home Health & Hospice Week

Fraud & Abuse:

Will The OIG Scare Your Docs Away From CPO?

Published on Fri Oct 15, 2004

Annual work plan also targets therapy upgrade, rehospitalizations among hot spots.

All your hard marketing work may go down the drain as the OIG plans an assault on physician care plan oversight.

CPO claims are on the HHS Office of Inspector General's hit list for this fiscal year, the watchdog agency reveals in its latest work plan. A jump in CPO reimbursement from $15 million in 2000 to $41 million in 2001 has made the feds cast a suspicious eye on the physician payments for 30 minutes or more of qualified management activities regarding home health patients.

In an earlier study of CPO claims in Puerto Rico, none of the claims met the requirements for CPO billing, said a hard-hitting OIG report released early this summer (see Eli's HCW, Vol. XIII, No. 19, p. 146). And physician Part B carriers have issued restrictive CPO billing rules.

Those developments may have dampened some of physicians' enthusiasm for the home health-related payment. But further OIG reports, as promised in the work plan, could send docs running scared from CPO billing altogether, experts worry.

Make or break it: CPO is still very under-used by physicians, points out Bob Wardwell with the Visiting Nurse Associations of America. "So the results of this study could promote its appropriate use or recreate the same panic among physicians that caused many to avoid home health referrals," Wardwell worries.

Such a panic could threaten HHAs' relationships with their referring physicians if the agencies have used CPO as a significant marketing tool. Also, physicians could be less willing to refer patients to home care if they identify the benefit with fraud or abuse threats.

Physicians may end up viewing CPO billing as a "fraud trap," warns Wardwell, a former CMS top official. And it reminds docs of their responsibility to police the home health benefit - a burden they may not be happy about and would rather avoid by not making home care referrals.

Other HHA issues in the work plan include:

  • Rehospitalizations and ER visits. The OIG wants to scrutinize quality in home care under the prospective payment system, and the agency plans to use rates of rehospitalization and emergency room visits to monitor quality of care, the work plan indicates. But home care providers think those two indicators aren't very representative of quality.

    "We have some concerns about these two measures," says Brian Ellsworth with the Connecticut Association for Home Care. Too many outside variables besides HHA care affect these measures, Ward-well agrees.

    For example, patients who are Medicaid-eligible have higher rates of hospitalization than those who don't, CAHC points out in a recent comment letter to the National Quality Forum. NQF is considering recommending the measures for publicly reported outcomes.

    That difference is due to the fact that Medicaid eligibility often also indicates patients who live alone without caregiver support, have multiple comorbidities and at least some noncompliance with care plans, CAHC argues. HHAs can't do anything about those factors, so judging their quality on hospitalization is unfair.

    Likewise, hospice patients see higher emergency room admission rates, and patients with chronic conditions see both higher rehospitalizations and ER visits, CAHC says. Those factors also are out of an agency's control.

  • Therapy. Now that the OIG has M0175 under its belt, its next big PPS target appears to be the $2,000 payment upgrade home health episodes receive when a patient requires 10 or more therapy visits. The OIG will study whether therapy visits comply with Medicare regulations, as well as the duration of visits, the work plan indicates.

    With items like this, HHAs face a "degree of cooperation between various governmental bodies, especially the interface between the PPS program, including OASIS data, and fraud enforcement," says Burtonsville, MD-based health care attorney Elizabeth Hogue. "It is a new day for HHAs in this regard."

    It may be agencies' own data that hangs them on this and other issues, Hogue points out. If PPS data shows a big spike in therapy visits or therapy visits of very short duration, it's likely to appear HHAs are trying to game the system - and that means a crackdown.

  • Outliers. The OIG aims to determine whether the current outlier system is equitable and whether outliers cluster in certain home health resource groups (HHRGs) or geographic locations, according to the work plan. But given that the Centers for Medicare & Medicaid Services has already said it will change outlier policy starting in January, "it seems a little bit late in the game" for a study, Wardwell notes.

  • Access. The OIG plans to update its reports gauging access to home care for beneficiaries discharged from the hospital. "I'm disappointed in their access study," Wardwell tells Eli. "If they just wind up interviewing hospital discharge planners again, its unlikely the study will be illuminating. This is a topic that deserves better."

    Home health agencies seem back in the fraud and abuse spotlight after a brief hiatus when PPS began, Hogue says. And it will be the feds' use of agencies' own data that proves a major hurdle in this phase of enforcement. "It will be increasingly difficult for HHAs to defend themselves against data which is likely to overwhelmingly support enforcement efforts, including recoupments of monies," she forecasts. 

    Editor's Note: The OIG's work plan for Medicare is at     http://www.oig.hhs.gov/publications/docs/workplan/2005/2005WPCMS.pdf.

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