Home Health & Hospice Week

Don’t expect the lower rate to translate to easier oversight, however.

After years of being bludgeoned with high Medicare home health payment error rates, home health agencies can now be relieved tbhe rate is appreciably lower.

History: Back in mid-2016, the Centers for Medicare & Medicaid Services, the Medicare Payment Advisory Commission, and others began trumpeting a 59 percent payment error rate Medicare’s Comprehensive Error Rate Testing contractor found for home health claims in 2015. CMS followed up with officially issuing the number in the 2015 CERT report published in October 2016 (see Eli’s HCW, Vol. XXV, No. 38). For 2016, the HHA error rate fell to a still-high 42 percent (see Eli’s HCW, Vol. XXVI, No. 16). For 2017, it was 32 percent (see Eli’s HCW, Vol. XXVII, No. 4).

Now, in a Nov. 15 blog post, CMS has released the 2018 HH rate — a much lower 17.61 percent. That covers claims processed between July 1, 2016, and June 30, 2017. The Department of Health & Human Services issued broad Medicare error rate figures, including the home health rate, in the HHS Fiscal Year (FY) 2018 Agency Financial Report released Nov. 14.

The drop from 32 percent to 17.61 percent represents “a significant $6.92 billion decrease in estimated improper payments from 2015 to 2018,” CMS boasts in the post.

The overall Medicare Fee For Service error rate for 2018 is 8.12 percent, down from 9.51 percent last year, CMS notes. “This represents a $4.59 billion decrease in estimated improper payments from 2017 to 2018,” CMS touts.

The overall drop is due in large part to the error rate reductions for both HHAs and Skilled Nursing Facilities, the agency notes. The SNF error rate declined from 9.33 percent last year to 6.55 percent in the 2018 period, representing a $1.04 billion decrease in improper payments.

RCD Coming Despite Lower Error Rate

The error rate drop for home health is definitely “good news,” says attorney Robert Markette Jr. with Hall Render in Indianapolis. But don’t hold your breath that it will make a big difference in CMS’s policies toward HHAs.

For instance: The National Association for Home Care & Hospice has urged CMS and the Office of Management and Budget to back off the Review Choice Demonstration in light of the newly revealed, drastically reduced error rate. The reduction “happened entirely without CMS’s 2016-17 preclaim review (PCR), a costly and paperwork-intensive program in Illinois that was the precursor to the planned RCD,” NAHC points out.

“The rapid and precipitous decline in overall ‘improper payments’ in home health is due to fixing easily correctable documentation errors and is not related to benefit eligibility,” says NAHC President William Dombi. “It is clear home health agencies have figured out what documentation is required to support valid Medicare claims,” Dombi says in the trade group’s member newsletter.

The drastically lower figure this year may show that HHAs have finally gotten consistent with supplementing physicians’ face-to-face documentation with their own documentation signed into the doc’s record, Markette believes. Or it may represent some undisclosed change in the CERT contractors’ review methodology, he adds.

Either way, it’s a “huge improvement,” Markette cheers. But he remains cynical that CMS will change its course on stringent home health review and policymaking.

You can look to the HHS Agency Financial Report for proof. “Insufficient documentation for home health claims continues to be prevalent, despite the improper payment rate decrease from 32.28 percent in FY 2017 to 17.61 percent in FY 2018,” HHS maintains in the report. “The primary reason for these errors was that documentation to support the certification of home health eligibility requirements was missing or insufficient,” HHS adds.

“While we have made progress on reducing the improper payments rate, we are not satisfied and more work needs to be done to achieve increased and consistent reductions in the future by implementing already existing initiatives as well as innovative processes,” insists CMS Administrator Seema Verma in a release about the 2018 results.

The AFR cites insufficient documentation as accounting for 58 percent of incorrectly paid home health claims; medical necessity 21.3 percent; incorrect coding 11.9 percent; no documentation/failure to respond 5.6 percent; and “other” 6.3 percent.

That means you can expect CMS to continue coming down hard on home health claims — including through RCD which is set to start Dec. 10 in Illinois — Markette says.

HHS lists RCD, Targeted Probe & Educate, Recovery Audit Contractor (RAC) reviews; and CMS’s Plan of Care/certification templates as its “key corrective actions” to combat home health’s high error rate.

Watch for: CMS plans to issue its more detailed CERT report in the next few weeks, a CMS spokesperson tells Eli. Annual CERT reports typically contain more detailed denial data and error rates broken out by provider types.

Note: The blog post is at www.hhs.gov/sites/default/files/fy-2018-hhs-agency-financial-report.pdf. The HHA Agency Financial Report is at www.hhs.gov/sites/default/files/fy-2018-hhs-agencyfinancial-report.pdf. The forthcoming CERT report will be at www.cms.gov/Research-Statistics-Dataand-Systems/Monitoring-Programs/Medicare-FFSCompliance-Programs/CERT/CERT-Reports.html.