Is heightened scrutiny coming your way? In response to recent home health investigations, the HHS Office of Inspector General “has identified serious … program vulnerabilities in both the fiscal integrity of payments made for services delivered and the quality of care received in home and community settings.”
So, yes, the OIG intends to ramp up fraud-fighting activities in the home care and hospice industry — and is requesting an additional $10 million to do so.
In its newly released FY 2020 Justification of Estimates for the Appropriations Committees document, the OIG notes that “this request for funding will support expansion of OIG’s fraud, waste, and abuse prevention, detection, and enforcement efforts to help ensure the integrity, quality, and safety of services rendered in homes and other community settings.”
With more consumers desiring services that allow them to remain in home and community settings, program integrity takes on “heightened urgency,” the OIG states.
To demonstrate integrity issues, the OIG cites “more than 450 criminal and civil actions and … $1.3 billion in expected receivables” from home health investigations during FYs 2013–2017. And “OIG efforts contributed to an almost 12 percent decrease in home health payments in … four geographic hot spots from 2015 through 2018. Nationally, the decrease in home health spending over this same time was four percent,” the agency says. The hot spots are identified as Florida, Texas, and “select areas in Southern California and the Midwest.”
“The 12 percent decrease in spending from 2015 to 2018 in select areas may be more attributable to the Pre-Claim Review Demonstration,” offers attorney Robert Markette Jr. with Hall Render in Indianapolis. “That really knocked down home health spending in Illinois, and it never bounced back.”
The OIG also reiterates the $808 million in “improper payments” Medicare made to home care providers in 2017.
This reference is “a bit disingenuous,” Markette responds. “They are supposed to be going after fraud, but the ‘improper payments’ area is much broader and has a lot more to do with the ridiculous documentation requirements,” he insists. “Just because my face-to-face document doesn’t meet some auditor’s standard, doesn’t mean I fraudulently provided the service.”
“We continue to see instances in which fraud enforcers have very little understanding of the type of services they are investigating, including Medicare-certified home health and hospice,” says Washington, D.C.-based healthcare attorney Elizabeth Hogue.
“The consequences of this continued general lack of knowledge can have dire consequences for providers. Even if providers are ultimately able to show that their activities were appropriate, the costs of defending themselves are very substantial and may ultimately drive them out of business,” Hogue says.
When the FBI recently raided a hospice, for example, “the FBI interviewed staff members and berated them for caring for patients for longer than six months which, of course, is not necessarily problematic,” Hogue relates. “Anecdotally, enforcers don’t seem to understand even the basics.”
Regarding the $10 million funding to subsidize “outreach, education, audits, evaluations, inspections, investigations, and administrative enforcement,” Hogue suggests the OIG would be better off investing “additional funds on educating staff members so that enforcement efforts are more effective and fair to providers.”
“With Review Choice on the immediate horizon, do they really need more money?” Markette asks, referencing PCR’s replacement.
The OIG’s “desire to use data to drive their efforts means more data mining, perhaps on a broader scale,” Markette predicts. Under the Patient-Driven Groupings Model, that might mean pinpointing agencies’ utilization differences between the current Prospective Payment System and PDGM.
“OIG may look at that and think fraud, because of the presumption that any shifts are proof of practicing to the payment,” Markette says. The true picture is likely “the more realistic and less criminal theory that when you change what you pay for, it changes what agencies can afford to provide,” he tells Eli.
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