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Home Health & Hospice Week

Industry Note:

OIG Wants Outlier Cap Lowered

Published on Thu Aug 23, 2012

HHAs serving a high number of outlier patients under the prospective payment system may see their resources diminished further, if the HHS Office of Inspector General gets its way.In a recent report, the OIG highlighted questionable billing statistics (see Eli's HCW, Vol. XXI, No. 29), including outlier payments. The median outlier payment amount per beneficiary was $13 in 2010, and the OIG designated $403 as the threshold for questionable HHA billing of outliers. More than 1,680 HHAs exceeded that threshold in 2010, the OIG reports. Despite the 10 percent outlier cap that went into place that year, 424 agencies still exceeded the 10 percent payment ceiling, the OIG adds. And agencies who didn't exceed the 10 percent mark still exceeded the questionable billing threshold the OIG set, the watchdog agency notes.Recommendation: "CMS should reevaluate the 10-percent cap and consider lowering it, if appropriate, to better prevent fraud and inappropriate billing [...]
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