Liles Parker PLLC
(202) 298-8750 (800) 475-1906
Washington, DC | Houston, TX
San Antonio, TX | Baton Rouge, LA

We Defend Healthcare Providers Nationwide in Audits & Investigations

Is Your Texas Home Health Agency at Risk for an Audit by Health Integrity?

August 6, 2012 by  
Filed under Home Health & Hospice

(August 6, 2012):  A recent report by HHS-OIG found that a substantial number of home health agency billings in Texas were fraudulent or inappropriate.  If you own or manage a Texas home health agency, this report should be of interest to you.

I.  Primary Problems Identified in Connection with a Typical Texas Home Health Agency:

The report noted that several common schemes were identified among home health agencies and used to sort out potentially fraudulent providers, including:

  1. Overlapping with claims for inpatient hospital stays;
  2. Overlapping with claims for skilled nursing facility stays; and
  3. Billing for services on dates after beneficiaries’ deaths.

The OIG, CMS, and CMS Contractors (ZPICs, RACs, and MACs) are using comparative data mining to view HHS claims under a microscope, looking for any clues of impropriety, such as the errors above. Importantly, OIG found that one in four HHAs (25%) exceeded one of its sample thresholds that indicated questionable billing. Of all those HHAs with questionable billing, the majority were located in Texas.

II.  Recommendations by OIG:

OIG recommended to CMS that several processes occur:

  1. Implement a claims processing edit or improve existing edits to prevent inappropriate HHA payments for the three specific errors identified above
  2. Increase monitoring of billing for home health services
  3. Enforce and consider lowering the 10-percent cap on the total outlier payments an HHA may receive annually
  4. Consider imposing a temporary moratorium on new HHA enrollments in Florida and Texas
  5. Take appropriate action (i.e. audits and overpayment recovery) regarding the inappropriate payments OIG identified in its sample.

III. What Do These Things Mean for a Texas Home Health Agency?

For Texas providers, the most important takeaway is that OIG has recommended (and CMS has stated it will implement) a moratorium on new home health agency enrollment. That means no new agencies in the state of Texas, and, if the ban ever gets lifted, every new home health agency application will be scrutinized with the utmost care. Moreover, if you close down your business, lose a provider number, or attempt to re-open a home health agency, you may not be able to successfully accomplish that in Texas. In addition, CMS may even consider a reassessment of every re-enrollment application it receives from home health agencies in the state of Texas.

Moreover, OIG recommended enforcement of the 10% cap on annual outlier payments. This means that an agency who is an outlier (perhaps because of an unusually complex patient load or a large degree of business) may see their payments capped at 10% greater than the “standard” payment numbers. For a home health agency that is expending a lot of resources on staff and providing high quality care to complex beneficiaries, this could represent a real problem.

Finally, CMS and Health Integrity (the Texas ZPIC) will likely closely monitor each and every home health agency claim. While home healyh agencies will continue to receive funding under the Prospective Payment System (PPS), expect a substantial increase of both post payment audits and prepayment audits. As Health Integrity begins administrative audits of those agencies that were targeted in the sample (they may not even know their claims were reviewed since the process was entirely data-driven), many agencies may face increased scrutiny and across-the-board payment denials.

IV.  Steps Your Texas Home Health Agency Should Take:

There are two steps each home health agency should take. First, if you haven’t already done so, implement an effective compliance plan. Second, retain an experienced Medicare post payment audit appeals attorney to represent you through the appeals process.

A compliance plan will give your organization the tools and understanding it needs to ensure that claims are coded and billed in an appropriate fashion and that your company’s business practices and arrangements comply with the numerous laws concerning patient referrals and illegal payments. An effective compliance program begins with a gap analysis and usually includes all seven elements of a compliance plan as a framework. It is important that your staff receives comprehensive training and clear, consistent guidance on what you and your organization expect from each individual member with regards to compliance. For more ways to do this, call us today.

Second, if your Texas home health agency has received any correspondence from Health Integrity, you should not hesitate to call an experienced Medicare appeals attorney. Both before the audit results come and after, an attorney skilled in Medicare audits and appeals can give you the guidance you need to give your claims their best chance at eventual payment. While the process can be long and arduous, in many cases it is “do or die” for your business. Health Integrity regularly imposes overpayment demands of one million dollars or more when auditing Texas home health claims. When the stakes are that high, you need someone on your side you can trust and who knows how this process works.

Healthcare LawyerRobert Liles represents providers in Medicare post-payment audits and appeals, and similar appeals under Medicaid. In addition, Robert counsels clients on regulatory compliance issues, performs GAP analyses, conducts internal reviews, and trains healthcare professionals on various legal issues. For a free consultation, call Robert today at 1 (800) 475-1906.

  • Advertisement

Speak Your Mind

Tell us what you're thinking...
and oh, if you want a pic to show with your comment, go get a gravatar!

You must be logged in to post a comment.