Home Health & Hospice Week

OIG audit denied nearly half of HHA's high-therapy claims.

If your therapy documentation isn't ironclad, you could lose up to $2,500 per episode.

That's what happened to Trumbull, CT-based Connecticut Home Health Care Inc. when the HHS Office of Inspector General came knocking for an audit of high-therapy claims, according to a new report made public May 25.

Warning: Tougher therapy scrutiny is likely to spread throughout the industry in light of the audit findings, predicts consultant Tom Boyd with Rohnert Park, CA-based Boyd & Nicholas.

The OIG had CHHC's intermediary, Associated Hospital Service, review 40 claims the home health agency billed with 10 to 12 therapy visits in fiscal year 2002. Of those, AHS found 19 had at least some therapy visits that were not reasonable or medically necessary, totaling an overpayment of nearly $42,000.

For seven of the claims, "medical review indicated that a brief period of physical therapy would have been reasonable to assess safety and to set up a home exercise program for reconditioning the patient," the OIG says in its audit report.
 
"As a result, they reduced the allowed number of visits to less than the 10-visit threshold because the unique skills of a physical therapist were not necessary to assist the patient in performing the exercise program," the report continues.

It's not over: In addition to paying back the overpayment and strengthening internal controls to eliminate unreasonable and medically unnecessary therapy visits, the OIG urges CHHC to "identify and submit adjusted claims for Medicare overpayments received subsequent to our audit period."

CHHC "stands behind the number of therapy visits provided as ordered by the physician," the agency says in its response to the report. CHHC believes these patients would not have met their goals with less than the number of therapy visits provided."

AHS overturned one denied claim at the redetermination level, the OIG notes. CHHC is appealing the rest to the administrative law judge, the agency says.

CHHC already has repaid nearly $40,000 of the assessed overpayment and it will submit adjusted claims as the OIG recommends, it says.

PPS Therapy Change Waiting in the Wings

The OIG's focus on the home health prospective payment system 10-visit therapy threshold is no surprise, notes physical therapist Cindy Krafft, director of rehabilitation services for OSF Home Care based in Peoria, IL. "Since PPS started ... and there was significantly more money for 10 or more therapy visits, audits have been on the horizon," Krafft tells Eli.

Agencies' increasing therapy utilization has raised a red flag, Krafft says. "Unfortunately, some gaming has occurred and therapists are seeing more patients 10, 11 or 12 visits than ever before."

Agencies need to involve rehab management in cases with high therapy utilization need to ensure that the services provided are reasonable and necessary, notes the American Physical Therapy Association's Roger Herr.

This report adds fuel to the feds' fire to change the therapy reimbursement methodology under PPS, Boyd notes. CMS has mentioned the therapy threshold as a likely spot for change in the 2007 revisions (see Eli's HCW, Vol. XIV, No. 19,). The OIG's spotlight on the area's problems may seal the deal.

CHHC President Josephine Elliot didn't return phone calls for this story.

Editor's Note: The report (A-01-04-00507) is at www.oig.hhs.gov/oas/reports/region1/10400507.pdf.