CMS Develops Pilot Program To Better Estimate Home Health Agency Fraud

CMS is developing a pilot program to determine how many Medicare fraud cases are taking place in home health agencies. A contractor search is currently underway to help implement the new initiative. Many Medicare fraud experts are commending the endeavor, believing the move to be positive in an industry with long-standing allegations of fraud.

Between 2010 and 2014, there were nearly $1 billion in improper Medicare payments and fraud identified relating to the home health benefit, according to the OIG. Statistically valid estimates of the rate of fraud in Medicare does not currently exist for home health agencies. The new contractor will focus on developing a methodology to estimate the extent of probable fraud of home health agencies in the Medicare fee-for-service program. The initial pilot will focus on agencies in Florida, which accounted for $2.1 billion of total Medicare home health spending in 2013.

Contractors will begin by reviewing 130 home health claims in the Miami-Dade County area. As part of the review process, the contractor will interview beneficiaries and their medical providers and make unannounced visits to the offices of onsite home health agencies. Any formed methodology is expected to be replicated later for a larger, nationwide program. CMS hopes the new initiative will help it better allocate its resources.

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Summary Of Latest OIG Report On Hospices

Earlier this month, the OIG released a report on hospices, titled “Medicare Hospices Have Financial Incentives To Provide Care In Assisted Living Facilities.” The report provides information to inform CMS’ payment reform decisions and is part of the OIG’s larger body of work on hospice care. Although the report focuses on Assisted Living Facilities (ALFs), many of the issues discussed pertain to the hospice benefit more broadly. The issues are similar to those that both the OIG and MedPAC have identified in other hospice settings, such as nursing facilities. The report explores the financial incentives created by the current payment system and the potential for hospices to target beneficiaries in ALFs because they may offer hospices the greatest financial gain. The findings in this report and previous OIG reports show that payment reform and more accountability are needed to reduce incentives for hospices that solely focus on certain types of diagnoses or settings.

Click here to see the report.

Click here to read a summary of the report from NAHC.

OIG Report Examines Hospitalizations of Nursing Home Patients

A new OIG report reviews the extent to which Medicare nursing home residents are hospitalized.  The report discovered that in FY 2011, one quarter of Medicare residents in nursing homes were transferred to hospitals for inpatient admissions where Medicare spent $14.3 billion. The OIG states that the higher than average resident hospitalization rates can be avoided through better care and recommends that CMS develop a quality measure that describes hospitalization rates and then assess this measure during surveys of nursing homes.  CMS agrees with OIG on the recommendations and is working on developing a hospitalization measure for nursing home residents and a re-hospitalization measure for Medicare SNF residents.  In addition, CMS will add these measurers to the quality measures surveyors review.

Click here to see the report

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OIG Set To Lose 400 Staffers Nationwide

According to The Center For Public Integrity, the Office of Inspector General (OIG) is set to lose a total of 400 staffers deployed nationwide as a primary defense against health care fraud and abuse. While Medicaid is set to expand by as many as 20 million people starting next year under the Affordable Care Act, the agency has failed to act on 1,200 complaints over the past year.  This becomes an increasing concern due to Federal agencies having reported an estimated $115.3 billion in improper payments in fiscal year 2011, more than half of that figure being attributed to Medicare and Medicaid.

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OIG To CMS: Stop Improper Part D Prescribing

According to a recently released report by the Office of Inspector General (OIG), more than 700 general-care physicians wrote potentially dangerous and unnecessary prescriptions for elderly and disabled patients in 2009. As a result, the OIG has asked the Centers for Medicare & Medicaid Services (CMS) to take a series of actions to stop inappropriate Part D prescribing.

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NY Received $27.5M In Improper Medicaid Payments

Federal regulators at the Department for Health and Human Services (HHS) Office of Inspector General (OIG) say the state of New York took nearly $27.5 million in improper Medicaid payments. A report issued earlier today found 84 out of 100 Medicaid claims submitted did not comply with federal and state regulations.

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MedPAC Home Health Recommendations

Late last week, MedPAC released its annual report to Congress on payment policy. Below is a summary summary of recommendations for home health.  Stay tuned to the HMS Healthcare Management Solutions blog for the hospice recommendations later today.

Home Health Recommendations:

  • The Health & Human Services (HHS) Secretary, with the Office of the Inspector General (OIG), should conduct medical review activities in counties that have abnormal home health utilization. New authorities should be implemented to suspend payment and enrollment of new providers if they indicate significant fraud.
  • Congress should direct the HHS Secretary to begin a two-year rebasing of home health rates in 2013 and eliminate the market basket update for 2012.
  • The HHS Secretary should revise the home health case-mix system to rely on patient characteristics to set payment for therapy and non-therapy services and should no longer use the number of therapy visits as a payment factor.
  • Congress should direct the HHS Secretary to establish a per episode copay for home health episodes that are not preceded by hospitalization or post-acute care use.