Home Health & Hospice Week

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 of outlier payments," the OIG says in the billing report.

However: Many agencies have already been wrestling with Medicare's payment glitch for outliers and have been taking a beating on outlier patients, they say. CMS now says that glitch is fixed (see Eli's HCW, Vol. XXI, No. 28, p. 227).

"Lowering the 10 percent outlier cap raises concern since HHAs with 10 percent or less revenue from outliers tend to be those that serve costly patient populations rather than Medicare abusers," argues the National Association for Home Care & Hospice. "To lower the cap could result in depriving high [use] patients needed home health care."

Plus: The outlier claims glitch led to "large scale underpayments" for outliers, NAHC says. "The impact of this system failure on the data analyzed and conclusions drawn by the OIG which resulted in miscalculation of outlier caps and payments is unknown."