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OIG issued its work plan for 2007. I have included any work plan issues related to home health in this post.
Reimbursement related matters OIG will be reviewing include, outlier payments, home health therapy, Medicaid reimbursement for home health services, and long distance physicians claims.
OIG will also be evaluating the accuracy of the home health compare website.
Another one that jumped out at me was the evaluation of cyclical non-compliance. As part of CMSs mandate to evaluate the quality of care provided by HHAs, OIG will be looking at trends in compliance. One of their areas of concern is whether agencies show a pattern of cyclical non-compliance. In other words, do they see patterns of certain tags popping up, being fixed, and then resurfacing in a later survey. An important factor in this review will be how do they define a cycle once a year, once every two years, once every three years.
In conjunction with this review, OIG will be looking at the sanctions imposed on HHAs to determine if they were appropriate. I would guess that this means they will be evaluating the penalties imposed upon HHAs identified as cyclically non-compliant.
It will be interesting to see what OIG determines, but I cant help but think that after the review, they will recommend stiffer penalties to agencies that demonstrate cyclical non-compliance. (Whatever they define that to mean.) How this affects providers will hinge upon how the determine a cycle of non-compliance.
With my two cents out of the way, here is the excerpt.
Medicare Home Health
Home Health Outlier Payments
We will determine whether outlier payments to home health agencies (HHA) were in compliance with Medicare laws and regulations. Medicare makes outlier payments as a loss-sharing mechanism for costly cases in which the estimated cost exceeds a threshold amount for each case-mix group. We will evaluate the frequency of outliers and whether they cluster in certain home health resource groups (HHRG) or geographical areas. We also plan to determine whether the current outlier methodology is equitable to all HHAs.
(OAS; W-00-04-35107; various reviews; expected issue date: FY 2007; work in progress)
Enhanced Payments for Home Health Therapy
We will determine whether HHAs' therapy services met the Medicare regulations threshold for higher payments. We will analyze the number and duration of therapy visits provided per episode period.
(OAS; W-00-04-35108; various reviews; expected issue date: FY 2007; work in progress)
Cyclical Noncompliance in Medicare Home Health Agencies
We will examine trends and patterns in HHA survey and certification deficiencies. The Social Security Act requires that CMS survey the quality of care and services furnished by HHAs, as measured by indicators of medical, nursing, and rehabilitative care, every 36 months. We will also identify whether any HHAs show patterns of cyclical noncompliance with certification standards and whether CMS applies appropriate sanctions to noncompliant HHAs.
(OEI; 09-06-00040; expected issue date: FY 2007; work in progress)
Accuracy of Data on the Home Health Compare Web Site
We will determine to the extent to which the Home Health Compare Web site includes accurate and complete information on Medicare-certified home health agencies. The CMS maintained Web site provides beneficiaries and their families with information on all home health agencies certified by Medicare as of January 2003. We will also examine how CMS identifies and updates missing and incorrect information on the database.
(OEI; 00-00-00000; expected issue date: FY 2007; new start)
Accurately Coding Claims for Medicare Home Health Resource Groups
The review will determine the extent to which Medicare HHAs accurately code the HHRG in the Outcome and Assessment Information Set. We will also determine the extent to which providers improperly code HHRGs and the level of inappropriate payments made as a result of any miscoding.
(OEI; 00-00-0000; expected issue date: FY 2008; new start)
Home Health Rehabilitation Therapy Services
This review will determine the extent to which rehabilitation therapy services provided by HHAs were provided by appropriate staff and were medically necessary. We will determine the extent to which patients' plans of care identified the need for the amount and level of therapy they received. We will also determine the amount of reimbursement that providers received due to medically unnecessary HHA therapy.
Long Distance Physician Claims Associated with Home Health and Skilled Nursing Facility Services
We will determine if Medicare Part B long distance physician services are inappropriately billed for beneficiaries of home health and skilled nursing facility services. Previous inspections identified instances of physicians ordering or billing for services that would normally require face-to-face examination for beneficiaries who live a significant distance from the physician's office.
Medicare Medical Equipment and Supplies
Durable Medical Payments for Beneficiaries Receiving Home Health Services
We will review medical records for durable medical equipment (DME) items and supplies furnished to beneficiaries receiving HHA services to determine whether the items and supplies were reasonable and necessary for the beneficiaries' conditions.
Medicaid Payments for Medicare-Covered Home Health Services
Home health services constitute a significant portion of both Medicare and Medicaid expenditures. Medicare pays a prospective payment rate for each 60-day episode of home health coverage for a beneficiary. Most States pay for Medicaid home health services on a fee-for-service basis. This evaluation will determine the appropriateness of Medicaid payments for Medicare-covered home health services.
Identification of Potential Abusive Claims Volumes
We will analyze claims filed by providers participating in the Medicaid program to identify potentially abusive claims volume. We plan to analyze areas such as outpatient prescription drug claims, home health care services, DME supplies, and psychiatric services, to identify beneficiaries and/or providers' claims that need further review
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