Home Health & Hospice Week

If you're providing too much help with insulin injections, the HHS Office of Inspector General could soon be on your doorstep. The Centers for Medicare & Medicaid Services covers assisted insulin injections when a patient can't self-inject insulin and there's no family member or caregiver to help. But outlier payments for insulin injections are out of control -- and curbing those payments is at the top of the OIG's target list, according to its 2010 Work Plan, released earlier this month.

Standard practice: Injections given daily or multiple times each day to patients who are physically or mentally incapacitated result in outlier payments under the Medicare prospective payment system (PPS) because the cost greatly exceeds the episode payment, explains Judy Adams, president and CEO of Adams Home Care Consulting in Chapel Hill, N.C. "CMS pays 80 percent of the excess 'cost' based on the PPS-per-visit rate, and because the visits for insulin injections are short, the amount of money paid can be very high," she says.

Problem: High payment rates for short visits leaves the door wide open for fraudsters looking to make a quick buck. For instance, in 2008, Florida's Dade County accounted for 69 percent of all outlier payments for the entire country, but an investigation found that many patients didn't need insulin and weren't even diabetic.

But this wasn't the only area of suspicion.

"There was a rapid major increase in the number of outlier episodes associated with insulin administration, and they occurred only in certain geographic areas," Adams says. For years, this has sent up red flags to CMS and agencies across the nation, but hasn't kicked off major federal oversight until now -- and Medicare has paid a steep price in the form of millions of dollars in fraudulent payments.

The OIG's promised new focus is guaranteed to bring outlier payments back down to reasonable levels, Adams believes. Here's what you should do to get ready:

Most agencies have streamlined their insulin injection program, but now's the time to go over your policies and procedures with a fine-toothed comb, Adams advises. You must ensure you strictly meet each of the requirements for this benefit, including making sure that:

• Patients are homebound;

• Patients require insulin to treat their diabetes;

• Patients can't inject themselves due to physical or psychological reasons;

• No caregiver is available to provide the injections, and the patient can't be taught to self-inject;

• You re-assess patients every certification period to be sure they still need your help to inject insulin and that no caregiver comes forward to help;

• You document each above requirement, as well as your efforts to locate caregivers for your patients.

So long as you meet these requirements, you can feel safe that the OIG won't be knocking on your door. If any area is lacking, now's the time to shore it up and make sure your procedures keep it strong.

Push Self Injection With

Just because your patients struggle with self injection doesn't mean you should give up on teaching them to do it.

Options: You should continue the patienttraining efforts established in your policies and procedures. If a patient's vision problems prohibit self injection or make it difficult, contact Services for the Blind to find out which special devices can help.

You may also consider working with experts certified to offer diabetes self-management programs.

Note: The OIG also plans to take a close look at payments for those diabetes self-management training services. However, as long as you maintain thorough documentation and only use the training for patients diagnosed with diabetes, you won't have a problem, Adams says.

Resource: You can read the Work Plan at oig.hhs.gov/08/Work_Plan_FY_2010.pdf.