Home Health & Hospice Week

Standardized guidance is in Program Integrity Manual.

For a new report, the HHS Office of Inspector General reviewed how Medicare Administrative Contractors and Qualified Independent Contractors use extrapolation to apply a claims error rate to the provider’s claims universe and calculate a much larger overpayment amount, and how the extrapolation gets overturned on appeal.

“Given the large difference between overpayment amounts in the sample and extrapolated amounts, it is critical that the process for reviewing extrapolations during an appeal is fair and reasonably consistent,” the OIG says in the report summary.

Problem: “CMS did not always provide sufficient guidance and oversight to ensure that these [extrapolation] reviews were performed in a consistent manner,” the OIG says. One inconsistency involving a type of simulation testing “was associated with at least $42 million in extrapolated overpayments that were overturned in fiscal years 2017 and 2018.”