(August 14, 2011): Home health agencies in Texas and Oklahoma remain under considerable scrutiny by Medicare contractors tasked with identifying fraud and abuse perpetrated against the Medicare Trust Fund. As discussed below, these Medicare contractors have a number of tools at their disposal, many of which can effectively place a home health agency in financial peril in very little time whatsoever. As our friend D.K. Everitt is fond of saying, “Compliance is not an Option.” Now, more than ever, it is essential that you review both your past and current documentation, coding, billing and medical necessity practices to better ensure that your current practices fully comply with applicable statutory and regulatory requirements.
I. Overview of the ZPIC Audit Program for Zone 4:
Over last few years, the government’s reliance on private contractors to both identify overpayments and potential instances of fraud has greatly increased. Health Integrity is the Zone Program Integrity Contractor (ZPIC) awarded the contract for Zone 4 (Texas, Oklahoma, Colorado and New Mexico) by the Centers for Medicare and Medicaid Services (CMS).
II. Health Integrity Audits of Home Health Claims Are Accelerating:
As home health agencies in Texas and Oklahoma can readily attest, Health Integrity audits of claims billed to Medicare have increased over the past year. The Health Integrity audits may involve one or more of the following:
Unannounced site visits – leading to probe samples, statistically relevant samples and other actions. Failure to cooperate can lead to revocation from the Medicare program. Notably, there are no statutory restrictions preventing contractors from showing up unannounced and requesting to see documentation related to Medicare claims. Should Health Integrity show up at your home health agency, you will likely find that Health Integrity’s auditors are both to-the-point and professional in their dealings you and your staff. Our clients have generally found that Health Integrity’s reviewers have researched an agency’s billing practices before they arrive. When they show up, they will already have a listing of the claims-related records to be pulled. ZPICs have been known to show up with their own scanner or copier. This has led to problems for providers later on because they failed to receive a copy from the contractor before they left. Should a ZPIC ask you to make copies, the contractor will often identify a handful to take with them and ask that you forward the other within a set period.
Unannounced interview of home health patients and their families– Health Integrity is actively conducting interviews of home health patients and their families in an effort to determine whether a patient was truly “homebound” during the claim period(s) at issue.
Pre-payment audit– the number of home health agencies and other providers placed on pre-payment review appears to have significantly increased over the last six months
Post-payment audit– Health Integrity is actively conducting post-payment audits of Texas and Oklahoma home health agencies and are extrapolating alleged damages identified in these post-payment audits.
Suspension – exercise caution when using Electronic Medical Records EMR) software – some software programs are better than others. Avoid any program which minimizes the need for individualization and the documentation of patient-specific observations. As always, it is important that home health agencies properly document the medical necessity of skilled care. In some instances, ZPICs have expressed concern that the patient records generated appeared to be “cloned.”
Medicare number revocation – take care if your home health agency is subjected to a site visit. As a participating provider, you have an obligation to cooperate with the ZPIC’s review. Should you fail to cooperate, a ZPIC can recommend to CMS that your Medicare number be revoked. This is a very real threat and should not be discounted. This becomes even more complicated if the ZPIC’s representatives go beyond mere claims-related questions and appear to be seeking information which could subject you (in your individual capacity), to possible civil and / or criminal liability. Remember your obligations as a participating provider but call your attorney.
Referral for criminal investigation and prosecution — ZPICs are actively referring cases to HHS-OIG and DOJ for formal civil and criminal review.
III. Primary Reasons of Health Integrity Audits:
We currently represent a number of home health agencies around the country in connection with post-payment audits and the appeal of overpayment assessments levied by Health Integrity and other ZPICs. Our clients often ask why their home health agency was targeted by the ZPIC for audit. After handling many of these cases, the following reasons for targeting have been cited by the ZPIC or ultimately learned when handling the case:
Predictive Modeling / Data Mining — As Chapter 2, Sec. 2.3 of the MPIM details: “Claims date is the primary source of information to target abuse activities.” Data mining may have been used to examine a home health agency’s “error rate.” This would provide the provider’s history of repeated overpayments or improperly filed claims.
Complaints — These can include “complaints” filed by beneficiaries, physicians, other providers (such as competitors), disgruntled current and former employees.
Referrals — ZPIC audits may be generated based on referrals from other CMS contractors (other ZPICs, PSCs, RACs, MACs, QA Staff), State MFCUs, Offices of the U.S. Attorney, or other Federal agencies. Notably, it appears that private payors are now also referring cases to the government.
Reports — HHS-OIG and GAO regularly issue reports addressing areas of concern.
State Licensing Boards — State Medical Boards, Nursing Boards, Pharmacy Boards and other regulatory entities responsible for handling State licensing responsibilities regularly hear or learn of improper actions by providers. This information may be shared with one or more Federal agencies and ultimately be referred to the ZPIC handling a certain zone.
IV. Preparing for Health Integrity Audits:
While many home health agencies believe that their Compliance Plan is satisfactory, it has been our observation that many of the plans currently in place are little more than copies taken from a sample off of the internet. Unfortunately, many providers view Compliance Plans as mere paperwork, rather than as a useful “audit tool” to be used by the organization on an ongoing basis. When properly constructed, an effective Compliance Plan can both improve the quality of patient care rendered and assist a provider in its efforts to fully comply with applicable statutory and regulatory requirements. Therefore, it is imperative that you take steps to ensure that your Compliance Plan takes into account each of the unique risks faced by your home health agency.
To be clear, although there are a number of steps you can take to reduce the likelihood of a ZPIC audit, there is no way to entirely eliminate the risk. Nevertheless, the development, implementation and consistent application of an effective Compliance Plan can greatly reduce an organization’s potential liability. In many respects, an effective Compliance Plan is similar to a flu shot. Although a flu shot cannot prevent you from getting sick, it will hopefully reduce the severity of your illness should you catch the flu. Similarly, if you have implemented and diligently adhered to an effective Compliance Plan, you could still be audited by a ZPIC, a Recovery Audit Contractor (RAC) or by a law enforcement agency, such as the Department of Health and Human Services, Office of Inspector General (HHS-OIG). However, as a compliant home health agency, an auditor is much more likely to find that your billing practices comply with applicable coverage requirements.
Robert W. Liles serves as Managing Partner at Liles Parker, Attorneys & Counselors at Law. Mr. Liles has extensive experience representing home health agencies and other providers in connection with the appeal of post-payment audits conducted by ZPICs and RACs. Mr. Liles has conducted “gap analyses” of many provider organizations and has worked with these providers to implement effective Compliance Plans. Should you find that your organization is being audited, feel free to call give him a call for a complimentary consultation. He can be reached at: 1 (800) 475-1906.