As OIG looks at improper payments, agencies should look at coders

Here’s why  it’s important to know who is REALLY handling your coding and billing

It may be time to take a harder look at your agency’s coding and billing practices to determine whether you’re at unnecessary risk of being charged with fraud  — particularly in light of this summer’s announcement that the U.S. Health and Human Services Office of Inspector General (OIG) will launch a new probe to identify improper payment patterns.

The OIG will use data from the Centers for Medicare and Medicaid Services CERT Program (Comprehensive Error Rate Testing) to look for agencies with improper payments, honing in on any identifiable patterns to compile a list of common characteristics among agencies CMS believes were improperly paid.

Last year, CERT identified some $7 billion in improper payments among home health claims.

“This new initiative by the OIG sends a strong message to the home health industry,” said J’non Griffin, owner and president of Home Health Solutions LLC. “The period of hesitancy during the administration changeover earlier this year is ending, and we’re getting back to business as usual, with continuing scrutiny on home health for evidence of fraud or wrongdoing.”

How can agencies mitigate their risks for fraud or non-compliance?

Outsourcing services to a competent and professional firm is one of the best ways in which an agency can continue to focus on delivering quality health care instead of struggling to meet the compliance burden – but J’non cautions that outsourcing may have its own risks.

Agencies which rely on outsourcing for coding and billing should protect themselves by being especially  diligent not just in vetting the reputation and credentials of the firms contracted to provide services, but in ascertaining the credentials of the employees who actually perform the outsourced work for the company, J’non said.

Questions which agencies should be asking as they seek reputable outsourcing firms include:

How many of the reviewers are clinicians?

Are employees experienced in the home health and hospice fields? How many years of experience do they have?

Are they credentialed in home health and hospice specific coding?

Are the reviewers located in this country or abroad?

Are they HIPAA trained?

Are they familiar with the U.S. Health and Human Services Office of Inspector General focus on suspected fraud? Do they understand the importance of compliance to your agency’s success?

Are they knowledgeable about CMS requirements and otherwise well prepared to protect your agency?

“These are important questions for agencies to ask – more important in the long run than pricing,” J’non said. “Agencies can’t afford the cost of shoddy work quality in such heavily scrutinized circumstances.”

The HHS Who’s Coding You Challenge

Home Health Solutions LLC has announced an industry-wide “Who’s Coding You?” challenge in an effort to take the anonymity out of the outsourcing business and reassure home health agencies about the credentials and knowledgeability of our staff.

Over the next few months, we’ll be spotlighting the names, faces and credentials of all our team members to introduce to the world the people who make up our company.

“We’re proud of the HHS team and confident in the commitment to quality our team members show every day,” J’non said. “Instead of hiding our best and important assets behind the company name, we want to show them off, creating the opportunity for agencies to get to know each one of them, and learn firsthand how committed they are to doing the right thing for the agencies we serve.”

Other OIG concerns

Other areas of concern for agencies included on  the July work plan posted by the OIG include plans to evaluate Medicare Part A payments to home health agencies to determine whether claims billed to Medicare Part B for services and items were permissible and in accord with federal regulations. Certain supplies, items and services provided to inpatients are covered under Part A and should not be separately billable to Part B.

According to Section 1842 (b)(6)(F) of the Social Security Act, consolidated billing for all home health services is required while the beneficiary is under a home health plan of care authorized by a physician. The Act established a Medicare prospective payment system that pays home health agencies (HHA) for home services and covers all of their costs for furnishing services to Medicare beneficiaries. Pursuant to the home health consolidated billing requirements, the HHA that establishes a beneficiary’s home health plan of care has Medicare billing responsibility for services furnished to the beneficiary. Payment is made to the HHA whether or not the item or service was furnished by the HHA or by others by arrangement.

The OIG will review Medicare Part A payments to HHAs to determine whether claims billed to Medicare Part B for items and services were allowable and in accord with Federal regulations.

The OIG work plan also announced that it will review Medicare claims paid for telehealth services provided at distant sites that do not have corresponding claims from originating sites to determine whether those services met Medicare requirements.

Here is a link to review the OIG work plan.

Palmetto GBA expands Probe & Educate initiative

Home health agencies in the 16 states served by Palmetto GBA Medicare Administrative Contractor could see a significant increase in the amount of records reviewed as part of an expanded Probe & Educate initiative.

Some agencies could be required to provide as many as 20-40 records on average instead of the five records requested for previous Probe & Educate reviews, according to Bobby Lolley, Executive Director of the Home Care Association of Florida.

“This review will be extensive, with 20-40 records on average being requested, not just another five records like in previous rounds,” Lolley said in an email to HCAF forum members this week.

Agencies subject to the significantly increased record requests are those which received denials of two or more records reviewed in an earlier round of the Probe & Educate initiative.  Some of those agencies did not receive specific instruction they were expecting from the MAC as part of the process because the Probe & Educate initiative was suspended earlier this year.

Lolley said all agencies in Round 2 can be subject to further review, even those agencies which did not complete Round 1 and receive one-on-one education from the MAC before that round was suspended.

Lolley said Palmetto provided the following  statement to a home health coalition request for clarification about agencies which did not receive one-on-one instruction : “Providers are being progressed if they did not request education on or before their due date. We have a number of providers that missed their deadline to request education, so yes, there is a chance that they have been progressed before they are receiving their education.“

Focus on the F2F

“Mac reviewers will be looking at the claims to ensure that agencies are in compliance with Medicare eligibility and payment requirements,“ said J’non Griffin, owner of Home Health Solutions.  “In Round 1, a substantial number of agencies had problems with the Face-to-Face.”

Additional concerns included a lack of specific orders for therapy and services, omissions and inconsistencies in documentation, but the Face-to-Face was one of the most troublesome areas for agencies, she said.

“Agencies which have not yet received training in the Face-to-Face should make doing so a priority,” J’non said.

J’non will offer an online audio training session titled “Make the Face-to-Face Count” next Thursday, July 13, reviewing valid and invalid F2F items pulled from actual charts, and discussing specific methodologies.  For details, click here.

Hospice agencies may be interested in an online audio training program titled “Improving Hospice Documentation,” presented by HHS Special Projects Director Heather Calhoun on Tuesday, July 11.  For details, click here. 

The 16 states in the Palmetto GBA area include Alabama, Arkansas, Florida, Georgia, Kentucky, Louisiana, Mississippi, New Mexico, Illinois, Indiana, Ohio, Oklahoma, North Carolina, South Carolina, Tennessee, and Texas.

How your home health agency can avoid ADRs

EDITOR’S NOTE: This article is reprinted from the July issue of The Absolute Agency, a free monthly best practices guide for home health agencies published by Home Health Solutions. Click here if you’d like to subscribe.

You’ve read and re-read your claim before submitting it, and you have all the documentation in place – but there it is: the dreaded request for additional documentation.

First of all, don’t panic.

 An ADR does not necessarily mean your agency has done anything wrong. Many things outside your agency’s control can trigger these requests, including probes or edits that are service-specific, provider-specific, beneficiary-specific or diagnosis driven. In many cases the OASIS will trigger a frequently-abused HIPPS code.

If you really have done your homework, evaluating and scoring your patients according to Medicare’s own definitions and supplementing the OASIS with high quality clinical notes and assessments, your ADR experience is likely to be much less stressful.

You may simply need to do a better job of connecting the dots for the MAC reviewer by providing information that was inadvertently omitted, or pointing out documentation the busy reviewer overlooked.

 “Try to look at any ADR as a learning experience that can sharpen your documentation skills, identify weaknesses in your operation and shore up your processes to protect against future ADRs,” advises J’non Griffin, owner of Home Health Solutions.

   Sometimes, of course, it’s more than the luck of the draw that attracts ADRs. Agencies make mistakes. OASIS scores aren’t well supported, or call into question the patient’s homebound status, phraseology is vague or subjective rather than clinical, and it’s difficult to tell what’s actually going on with the patient’s condition.

When the agency has not clearly documented from the beginning, attempting to sort through the confusion can turn into a time-consuming bout of evidence-collecting and careful explanation.

J’non and the HHS team have helped agencies of all sizes across the country successfully respond to ADRs, and they have identified a few of the Red Flags likely to capture the notice of MACs. The good news is that agencies can address many of these risk areas before submitting claims just by carefully reviewing documentation.

“There’s no magic deterrent to protect any agency, but you can take steps to insulate yourself by being aware of certain triggers and becoming proactive about avoiding these errors or improving documentation in these areas,” J’non says.


   Here are some of the trouble areas that can trigger an ADR for an agency:

– Contradictory answers on the OASIS
– Inadequate Face-to-Face documentation
– Multiple re-certifications
-Recertifying when there is no new or exacerbated diagnosis in the record
– Recertifying for a “later episode”
– Minor treatment changes that do not support medical necessity
– No evidence of a continuing need for skilled care
– Multiple episodes of observation and assessment of chronic con
– Repetitive education or education that does not address a knowledge deficit
– Discharges followed by re-admissions without any intervening change in the patient’s condition
– Inconsistencies in patient treatment



   When your agency has received an ADR, these tips may help you complete it in a timely and thorough manner:

  •  Look at the ADR due date and mark it on a calendar. With a limited response time, it is imperative to complete your information gathering tasks by the deadline. We recommend setting a target date for submitting your response prior to the actual due date to ensure timeliness.
  • Use a team approach to address the ADR. Nursing, therapy and medical records will likely need to work together to review and collect the data needed.
  • Carefully review the ADR and note each piece of requested documentation. There’s no better way than an old-fashioned checklist to make certain that you are addressing each request.
  •  Additional documentation which has not been requested may be provided to support payment of the claim. Signed and dated physician certifications, for example, may not be on the list of requested documentation in an ADR, but this is a foundational piece for establishing the validity of your claim.
  • On the other hand, do not make the mistake of overloading the reviewer with too much documentation. A file bulging with too much information, particularly information which was not requested, will not be happily received by an overloaded reviewer behind in his or her cases. Choose your evidence wisely, based on the strength it adds to your case.
  • Resist the urge to alter or attempt to correct any original documentation. Explain and supplement to make your case stronger.
  •  Assemble all documents in order of request. Your goal is to make the process as easy as possible for the reviewer, and providing the information in a manner that is easy to sort through will be helpful. Some agencies use page numbers specific to the particular case. Others identify documentation pages with highlighted text, or provide an index. There is no right or wrong way — but your submission must be easy for the reviewer to figure out.
  • Create a persuasive Cover Letter. This is arguably the most important part of your response. The Cover Letter will justify the care delivered by your agency and briefly tell the reviewer what supportive documentation is being submitted and how to easily find it. Don’t make the Cover Letter too long. It should briefly summarize the patient’s needs, the skilled services provided to meet those needs, and the patient’s response/progress. Make it as easy to read as possible. No one likes to read two pages of text unbroken by paragraphs! Use bulleted points, and consider adding some bold-faced titles to help the reviewer quickly scan the material. See how we have used bold-faced titles such as “Some ADR Triggers” and “Tips for Responding” here to break up the text? You may wish to do the same thing in your Cover Letter with helpful titles such as “What We’re Submitting” or “Skilled Services We Provided.”
  • Keep a copy of all documents submitted to the Contractor.


   ADRs are intimidating and time-consuming. Sometimes, the surest way to navigate an ADR is to turn to an experienced clinical consultant who can guide you through the process, make certain that you include all the key elements needed to support your claim.
The consultant can also show you how to make process improvements to reduce the risk of future ADRs or claim denials.
Home Health Solutions can provide the support you need to take the pain out of the ADR process. If you’d like more information about our ADR services, call us at 888-418-6970 or email: