Home Health & Hospice Week

Once again, the HHS Office of Inspector General has backed off the number of claims it said were erroneous in an audit, but it still wants the home health agency to repay millions.

The watchdog agency targeted Angels Care Home Health in Salina, Kansas, for a review. The OIG selected a stratified random sample of 100 claims from 2013, 2014, and 2015 with payments totaling $265,960, and “submitted these claims to independent medical review” by an outside party, according to a new report about the audit.

The results: Originally, the review contract- or claimed that 41 of the 72 claims paid in 2014 and 2015 were in error. But after a rebuttal from Angels Care, the OIG reduced the claims error count to 29, resulting in a $57,148 overpayment. (Claims from 2013 were outside the claim reopening period.) The OIG then used extrapolation to determine Angels Care owes $3.8 million for the two years.

Reviewers found patients whose claims were reviewed were not homebound, didn’t require skilled services, and were billed for with incorrect HIPPS codes, the OIG says in its report. Among its recommendations, the OIG urged Angels Care to return the $3.8 million and identify and repay similar problematic claims outside the audit period.

“Angels Care disagrees with the findings, recommendations, and alleged extrapolated overpayment,” the agency’s attorney, Rebekah N. Plowman with Jones Day in Atlanta, says in a response included in the report. Angels Care does admit that 14 claims were in error and an additional two should have been partially paid, as determined by its consultants at Simione Healthcare Consultants, the letter says.

But the OIG shouldn’t base millions in overpayments on a mere 1.12 percent of claims reviewed, Plowman insists. “The statistical sampling methodology used by the OIG is unreliable and inherently flawed, thereby calling into question the statistical validity of the extrapolated overpayment calculated by the OIG.”

And remember: “The OIG’s audit recommendations do not represent final determinations,” Plowman points out. “The Centers for Medicare and Medicaid Services will subsequently determine, through a Medicare contractor, whether a potential overpayment exists, and if such an overpayment is found, Angels Care will have the right to appeal that determination.” Plus, “more than 60 percent of claims are overturned in favor of providers when heard by an administrative law judge as part of the third level of appeal,” she notes in the 11-page response letter.

Resource: The 51-page report is at https://oig.hhs.gov/oas/reports/region7/71605093.pdf.