Home Health & Hospice Week

Plus: Here’s how OIG changes may play out under forthcoming PDGM.

A federal watchdog agency would like to bring even more investigations, audits, and other fraud-fighting activities to bear on the home care and hospice industry — and $10 million more with which to do it.

In its newly released FY 2020 Justification of Estimates for the Appropriations Committees document, the HHS Office of Inspector General notes that “this request for funding will support expansion of OIG’s fraud, waste, and abuse prevention, detection, and enforcement efforts to help ensure the integrity, quality, and safety of services rendered in homes and other community settings.”

The OIG’s problem: “Program integrity and patient safety in home- and community-based settings take on heightened urgency as consumers increasingly seek and prefer services provided in home and community settings and as technology expands the range of services that can be provided safely in a home setting,” the agency contends. “OIG has identified serious … program vulnerabilities in both the fiscal integrity of payments made for services delivered and the quality of care received in home and community settings.”

The OIG runs down its numbers. Its “home health investigations resulted in more than 450 criminal and civil actions and yielded $1.3 billion in expected receivables for FYs 2013–2017,” the agency says. And “OIG efforts contributed to an almost 12 percent decrease in home health payments in … four geographic hot spots from 2015 through 2018. Nationally, the decrease in home health spending over this same time was four percent.” The hot spots are identified as Florida, Texas, and “select areas in Southern California and the Midwest.”

Opposing view: “The 12 percent decrease in spending from 2015 to 2018 in select areas may be more attributable to the Pre-Claim Review Demonstration,” offers attorney Robert Markette Jr. with Hall Render in Indianapolis. “That really knocked down home health spending in Illinois and it never bounced back.”

The OIG also points out the $808 million in “improper payments” Medicare made to home care providers in 2017.

This reference is “a bit disingenuous,” Markette responds. “They are supposed to be going after fraud, but the ‘improper payments’ area is much broader and has a lot more to do with the ridiculous documentation requirements,” he insists. “Just because my face-to-face document doesn’t meet some auditor’s standard, doesn’t mean I fraudu­lently provided the service.”

Bottom line: “They routinely conflate fraud and poor documentation to make the numbers look better,” Markette criticizes.

“We continue to see instances in which fraud enforcers have very little understanding of the type of services they are investigating, including Medicare certified home health and hospice,” adds Washington, D.C.-based healthcare attorney Elizabeth Hogue. “The consequences of this continued general lack of knowledge can have dire consequences for providers. Even if providers are ultimately able to show that their activities were appropriate, the costs of defending themselves are very substantial and may ultimately drive them out of business,” Hogue says.

For example: When the FBI recently raided a hospice, “the FBI interviewed staff members and berated them for caring for patients for longer than six months which, of course, is not necessarily problematic,” Hogue relates. “Anecdotally, enforcers don’t seem to understand even the basics.”

The OIG’s solution: The $10 million increase would fund “outreach, education, audits, evaluations, inspections, investigations, and administrative enforcement.” And “OIG plans to focus additional efforts in the geographic area that did not see as great a decline in home health expenditures as the remaining three geographically targeted areas.”

Instead: The OIG should spend “additional funds on educating staff members so that enforcement efforts were more effective and fair to providers,” Hogue counters.

“With Review Choice on the immediate horizon, do they really need more money?” Markette asks, referencing PCR’s replacement.

Regardless, here’s where the OIG plans to put the additional money:

• $4.5 million: Adding “‘boots on the ground’ to take enforcement actions against fraud perpetrators, including building OIG’s capacity to respond to referrals generated by its own analyses,” the justification document says. “This would allow OIG to open more criminal, civil, and administrative investigations, … conduct more audits, and increase monitoring of suspicious billers.” Likely targets would be “additional geographic hotspots to conduct site visits of high-risk home health agencies.”
• $1.5 million: Utilizing “new data models and tools to support data-driven audits, evaluations, and investigations. These models and tools will help OIG detect and target new and emerging fraud schemes, trends, and migration of known fraud schemes.”
• $4 million: Conducting reviews “expected to result in new recommendations for targeted program safeguards and improvements to prevent fraud, waste, and abuse and patient neglect; create efficiencies; and promote patient-centered outcomes while eliminating unnecessary burden on legitimate providers.”

The increased budget and corresponding efforts “will not only help consumers, but will also help honest providers compete on a level playing field that is not distorted by the schemes of dishonest ones,” the OIG argues.

PDGM Impact

Watch for: The OIG’s “desire to use data to drive their efforts means more data mining, perhaps on a broader scale,” Markette predicts. Under the Patient-Driven Groupings Model, that might mean pinpointing agencies’ utilization differences between the current PPS and PDGM.

“OIG may look at that and think fraud, because of the presumption that any shifts are proof of practicing to the payment,” Markette says. The true picture is likely “the more realistic and less criminal theory that when you change what you pay for, it changes what agencies can afford to provide,” he tells Eli.

The agency is requesting a total of $403.2 million to oversee HHS programs in FY 2020, $323.2 million of which would go for oversight of Medicare and Medicaid, “including Health Care Fraud and Abuse Control (HCFAC) Program activities and law enforcement activities coordinated with HHS and the Department of Justice,” HHS Inspector General Daniel R. Levinson notes in the document.

Enforcement in the home and community is one of the OIG’s four “priority areas” for the year. The others address prescription drug abuse, including opioid abuse; Medicaid fraud and abuse; and children served by grant-funded programs. Secondary “key areas” include cybersecurity and managed care programs, Levinson adds.

ROI: “In FY 2017, the HCFAC program, in which OIG is a major participant, returned to the Federal Government $4 for every $1 invested,” the document highlights.

Note: The justification document is at https://oig.hhs.gov/reports-and-publications/archives/budget/files/2020budget.pdf.