Home Health Audits Are Up and Running
Today's blog is the first in a 3-part series on home health audits. We will answer some common questions and then review the current workplan from the Office of Inspector General (OIG)...
Home health ADR, TPE and UPIC audits have resumed and are on the rise for 2021. The OIG has 5 active work-plans in place for home health providers. Since home health auditing has been quiet during the pandemic and throughout 2020, we are in a unique situation. We have both a new payment model and a pandemic response-- and neither have been audited. In fact, with the PDGM model approaching the 18-month mark, the sample size and time frame could allow the beginning of extrapolations.
Q. What is the purpose of the OIG and why do they have "work-plans"?
A. "The mission of the OIG, as mandated by Public Law 95-452, as amended, is to protect the integrity of the Department of Health and Human Services (HHS) programs, as well as the health and welfare of beneficiaries served by those programs. This statutory mission is carried out through a nationwide network of audits, investigations, and inspections conducted by other operating components..."
Q. Why does CMS continue to audit home health specifically?
A. In short, the OIG has data that indicates home health is often paid in error, they call these "improper payment error rates". CMS acknowledges that home health accounts for only about 5% of its fee-for-service spending in post acute care, however, improper payments to HHAs totaled more than 18% or about $7.7 billion in 2016 alone. Home health's error rates are improving (thanks to TPE and PCR) with 2018 data showing the error rate at 17.6%, but this is still much higher than the national error rate for all provider types which was just 8.1% in 2018.
Q. How does a HHA get chosen for an audit anyway?
A. Home health provider's billing requirements are outlined in the Medicare Benefits Policy Manual, Chapter 7. CMS compares these compliance requirements to the OASIS and billing data being reported by HHAs. CMS uses "computer matching, data mining, and data analysis techniques" to identify HHAs that are "at risk" for noncompliance- another words your data looks a little sketchy so CMS requests an audit to determine if what it looks like is really what it is...
Current OIG work-plans with descriptions
"Medicare pays covered medical services first for dual eligible beneficiaries because Medicaid is generally the payer of last resort. We will determine whether States made Medicaid payments for home health services for dual eligible beneficiaries who are also covered under Medicare."
"Recent OIG reports have.. disclosed high error rates at individual HHAs. Improper payments identified in these OIG reports consisted primarily of beneficiaries who were not homebound or who did not require skilled services. We will review compliance with various aspects of the home health prospective payment system and include medical review of the documentation required in support of the claims paid by Medicare.."
"Home health workers often travel to several homes on a weekly basis, which increases their risk of exposure to the COVID-19 and increases the risk of infection among Medicare beneficiaries. HHAs must maintain a coordinated agency wide program for the surveillance, identification, prevention, control, and investigation of infectious and communicable diseases. We will interview corporate officers from the three HHA providers with the largest market share in 2019 as well as HHAs that have recently been cited by CMS for infection control and prevention deficiencies to determine the extent to which their infection control and prevention policy and procedures comply with CMS guidance regarding COVID-19."
"This nationwide study will provide insights into the strategies HHAs have used to address the challenges presented by COVID-19, including how well their emergency preparedness plans served them during the COVID-19 pandemic."
"...We will evaluate home health services provided by agencies during the COVID-19 public health emergency to determine which types of skilled services were furnished via telehealth, and whether those services were administered and billed in accordance with Medicare requirements. [We will report as overpayments any services that were improperly billed. We will make appropriate recommendations to CMS based on the results of our review."