Home Health & Hospice Week

You may be thrilled to have one physician or practice that is a great referral source -- but that situation could land you under reviewers' microscope in the wake of the record-breaking fraud case against Dr. Jacques Roy and three Dallas home h alth agencies.

The Centers for Medicare & Medicaid Services suspended Medicare payments for 78 HHAs in conjunction with the indictments against Roy and the HHAs Apple of Your Eye Healthcare Services Inc., Ultimate Care Home Health Services Inc., and Charry Home Care Services Inc. In a suspension letter obtained by Eli, CMS and its Zone 4 Zone Program Integrity Contractor Health Integrity tell agencies that "the average physician certifies no more than 5-10% of the plans of care (POCs) for a single home health agency's patient roster."

Beware: CMS and the HHS Office Of Inspector General "are data mining to determine what they see as the average percentages of referrals from any one physician to a legitimate home health agency," points out attorney Janice Arnold with Mitchell Day in Ridgeland, Miss.

"Whenever an HHA has the preponderance of their business from one source, there is risk," cautions attorney Liz Pearson with Pearson & Bernard in Covington, Ky. CMS and the OIG "can and do track physician info on certification of POCs."

HHAs with those higher percentages are likely to raise red flags, Pearson says. They can expect "at least some claim review" from Home Health & Hospice Medicare Administrative Contractors, and possibly attention from ZPICs and other fraud-fighting agencies.

Do this: HHAs should ask themselves if there are any physicians whose referrals to the agency top 10 percent, Arnold counsels. "Agencies might want to stop and take a look at any situation in which a physician's referrals significantly exceed 10 percent, and also appear skewed in comparison to the amount of referrals the agency receives from other physicians," Arnold advises.

You may not need to get too concerned in every case, however. "Remember, the cited 'average' means there are some referral percentages considered normal that were lower and some that were higher," Arnold tells Eli.

And higher percentages also may be perfectly normal in certain geographic areas, notes Pearson. For example, in some small rural areas, many referrals will come from a few sources. HHAs with higher percentages will need to be even more careful to engage compliance toolslike conducting thorough internal audits and screening patients themselves for home care eligibility (see related story, p. 83).

"All this fraud is killing the industry," says attorney Robert Markette Jr. with Benesch Friedlander Coplan & Aronoff in Indianapolis. The high-profile busts, usually conducted by the HEAT program's Medicare Fraud Strike Forces, of Roy and others are giving lawmakers ammunition to ratchet down HHA payments and law enforcement authorities and Medicare contractors license to put agencies under scrutiny.

"If you think you're going to get away with it, those days are over," declares Markette of home care fraud enterprises. Agencies whose billing data is not within typical parameters can expect scrutiny from MACs, ZPICs, the OIG, and others.

In the face of the government's increasing concern about fraud, HHAs need to acknowledge their role as gatekeepers to Medicare's home care benefit, Markette advises. That may mean differing  with referral sources on whether a patient is homebound and not just going along with the doc's certification.

A CMS spokesperson continues to maintain that the agency will be issuing a list of the 78 HHAs whose Medicare payments have been suspended, but the list hadn't been made public at press time. One billing services provider in the Dallas area speculates that the delay is because not all 78 HHAs have been contacted yet. For example, one agency that contacted the biller received its letter a week late due to an address mix-up, the biller reports.

The suspended agencies have a chance to submit a rebuttal letter within 15 days, but experts don't expect to see many -- if any -- reversals of the suspension. Pearson has seen "little attention given to the rebuttal by CMS," she says.

Unless they have significant reserves, HHAs under Medicare payment suspension are goners,experts agree. One agency under suspension in the case already has started referring its patients to other agencies, the billing company owner relates.