OIG Report Addresses Home Health

Last week the Department of Health and Human Services (HHS) Office of Inspector General (OIG) issued its Semiannual Report to Congress. This report summarizes activities of the Office of Inspector General (OIG), Department of Health and Human Services (HHS), for the 6-month period that ended March 31, 2013. The Report addressed work of the OIG in fulfilling its responsibilities, such as to identify and investigate fraud and abuse, assign individuals to the Program Exclusion list, and approve and monitor Corporate Integrity Agreements.

In the report the OIG projected expected recoveries of about $3.8 billion for the first half of 2013 including over $521 million in audit receivables and about $3.28 billion in investigative receivables. In addition, 1,661 exclusions from Federal health programs, 484 criminal actions against individuals or entities that engaged in crimes against HHS programs; and 240 civil actions were reported on. Although no hospice providers were identified in the Report, the results of a number of OIG home health federal Medicare and Medicaid program initiatives are detailed.

HOME HEALTH INVESTIGATIONS

According to the OIG, “HHAs are considered to be particularly vulnerable to fraud, waste, and abuse” resulting in the Centers for Medicare & Medicaid Services (CMS) designation of newly enrolling HHAs as high-risk providers.

The Semiannual Report referenced a 2012 OIG report where they “found one in four HHAs had questionable billing” concentrated in certain geographic areas. The report also referenced findings of a study of two Medicare Administrative Contractors (MAC), stating that they “prevented $275 million in home health agency (HHA) improper payments.” Additionally, although Medicare Zone Program Integrity Contractors (ZPIC) “did not identify any HHA-specific vulnerabilities and varied substantially in their efforts to detect and deter fraud” all four ZPICs recommended administrative actions and law enforcement in a number of cases. The OIG also reported that, in 2011, Medicare inappropriately paid five HHAs with suspended or revoked billing privileges.

On the Medicaid front, the OIG referenced a New York analysis of Federal Medicaid reimbursement of home health services. According to a review, 17 claims were improperly claims where the “plan of care was not reviewed every 60 days” as required by regulation.

After projecting these findings to the universe of claims, the OIG estimated that the State improperly claimed $69.1 million in Federal Medicaid reimbursement between January 2007 and December 2009.

In its review of the Medicaid Third Party Liability the OIG found that, although States had increased Medicaid savings from third-party liability recoveries they still face longstanding challenges with identification and recovery from third parties. They concluded that “$4 billion in third-party liability overpayments remain at risk of not being recovered.”

HEAT ACTIVITIES

The Strike Force of the Health Care Fraud and Prevention and Enforcement Actions Team (HEAT) focused it attention on health care providers in nine cities: Miami, FL; Los Angeles, CA; Detroit, MI; Houston, TX; Brooklyn, NY; Baton Rouge, LA; Tampa, FL; Chicago, IL; and Dallas, TX. Strike Force efforts resulted in filing of charges against 148 individuals and entities, including charges against 91 in home health. Individuals charged with more than $230 million in home health care fraud included doctors, nurses, and other licensed medical professionals.

CMS RECOMMENDATIONS

The reports referenced several recommendations to CMS, with several that will directly impact home health in the future:

• Establishment of additional contractor performance standards for high-risk providers in fraud-prone areas - including newly enrolled HHAs
• Develop a system to track revocation recommendations and respond to them in a timely
• Required refund of $69.1 million by New York to the Federal Government and issue guidance to CHHAs in New York City on Federal and State requirements for physicians' orders and plans of care
• Work with States to address longstanding challenges related to identification of insurance coverage and recovery of payments, address States' challenges with 1-year timely filing limits for Medicare and TRICARE, and work to strengthen enforcement mechanisms designed to deal with uncooperative third parties.