Tag Archives: Medicare

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.

What’s next for home health? Experts at conference admit they’re baffled

In a week of intense debate in the nation’s capital over efforts to repeal and replace Obamacare, the future of myriad home health regulations remains as uncertain as other health care issues. 

But one thing IS certain, according to Home Health Care Solutions owner J’non Griffin, who joined other home health experts at the 2017 Illinois Home Care and Hospice Conference & Exhibition near Chicago this week. Whether lawmakers change, repeal or leave in place existing Medicare requirements, agencies must continue to streamline their processes and focus on quality improvements to remain profitable in the increasingly challenging home health  field. 

Agencies in Florida hoping for a reprieve from an April 1 rollout of pre-claim reviews by the Centers for Medicare and Medicaid Services are likely to be disappointed, according to keynote speaker William Dombi, who serves as The National Home Care Association’s Vice-President  for Law. 

The eyes of the nation remain fixed on the D.C. debate over replacing the Affordable Health Care Act with an as-yet-unnamed plan which has been alternately dubbed Trumpcare,  Ryancare and Obamacare Lite. How the proposed replacement would impact home health has not yet been determined.

Meanwhile, the clock ticks inexorably toward the April 1 deadline in Florida, leaving little time or attention for NACH’s efforts to derail PCRs.

“The Washington perspective is that we are all crazy at this time. No one knows at all,” Dombi told hundreds of home health professionals attending the Illinois conference. “My concern is that day after day, hope of something in Florida diminishes.” 

NAHC has prioritized stopping the PCR process in additional states, including Florida, and curtailing the process in Illinois, which became the first state to undergo a PCR demonstration in August, 2016. Dombi said NACH is petitioning CMS to allow agencies which have had consistently high affirmation rates to opt out of the PCR process without being penalized financially. 

But NAHC’s efforts to get lawmakers to support the repeal of PCRs have been largely overshadowed by the bigger repeal efforts on Capitol Hill, and the political fallout. Republican lawmakers unveiled the replacement health care act promised by the Trump administration this week to major discord in Washington D.C., with condemnation from Democrats, the American Medical Association, the American Hospital Association, and even some Republicans. 

What will happen next is anyone’s guess, Dombi told conference attendees. He describes the situation as “very chaotic.” 

As federal lawmakers grapple with complex issues such as the extent of individual rights to health care, whether responsibility for health care is a federal or state priority and whether the role of the government in health care should be as partner or provider,  Dombi sees some areas of hope on the horizon for home health. 

The new administration’s Secretary of  Health and Human Services, Tom Price, has a sound grasp of many home health concerns and a history of support for many of them, Dombi said. 

Price has indicated some support for delaying new Conditions of Participation for Medicare which are scheduled to become effective July 13, Dombi said.  The new CoPs will require many operational changes for home health agencies, and there is some concern within the industry that there is not enough time for agencies to fully implement all the changes.

With no interpretive guidelines released four months away from the implementation,  NAHC believes surveyors aren’t ready for new CoPs and has been lobbying for a delay. Word in D.C. is that Price is “seriously considering” NAHC’s position, according  to Dombi.

However, it is important to note that no delays of PCRs or CoPs have been approved at this time. Industry experts at the Illinois conference strongly encouraged agencies to proceed as if new Conditions of Participation, Pre-Claim Reviews and Value Based Purchasing initiatives (in which agencies are rewarded or penalized depending on how well they make improvements) are inevitable. 

No one knows if or when or where CMS will expand Value-Based Initiatives beyond the nine states in the current trial, whether PCRs will proceed to other states after the Florida rollout, or exactly what will happen next in home health, but agencies must be prepared anyway, PPS Plus educator Jennifer Warfield told her conference audience.

“Even if the actual term Value Based Purchasing goes away, the future of your agency is always going to be tied to its improvement processes,” she said. 

Joyce Ryan Boin with Strategic Health Care  Solutions encouraged agencies to redirect their focus toward education and ongoing strategy for measurable improvement. 

“We’re not in Kanas any more,” she said. 

 EDITOR’S NOTE:  Check out HHS Owner J’non Griffin’s four-part webinar series on the new Conditions of Participation, providing an overview and highlighting compliance strategies for agencies to develop a QAPI program. The series begins March 15 at 10:30 a.m. CT, and will continue March 29, April 11 and April 25. 
For details or to register, click here.