(November 8, 2013): Health Integrity serves as the Zone Program Integrity Contractor (ZPIC) for Zone 4. This zone is comprised of Texas, Oklahoma, New Mexico and Colorado. Generally, Health Integrity has been assigned responsibility for handling Medicare Part A, Medicare Part B, and Durable Medical Equipment (DME) claims. Health Integrity has been especially aggressive in its review and audit of home health care claims submitted to Medicare for payment by providers within Zone 4. While prior enforcement efforts have typically included postpayment audits and placing problem providers on suspension, recent enforcement efforts have tended to focus on actions designed to prevent the submission of improper claims in the first place, such as placing a provider on prepayment review. Most recently, home health agencies in Texas and Oklahoma received a Health Integrity educational letter advising targeted specific home health agencies that Medicare is concerned about certain practices of home health providers. As the letter detailed, home health agencies receiving these letter have been “flagged” by the contractor as:
“[S]ubmitting claims and/or billing patterns indicative of higher risk of aberrant practices in comparison to expectations, standard thresholds, and/or established norms.”
As the Health Integrity educational letter further sets out, there are a number of specific Medicare medical necessity, documentation and other regulatory concerns that are currently under review by the ZPIC.
I. Nature of Medicare Concerns Discussed in the Health Integrity Educational Letter:
The various challenges faced by home health agencies may vary from one to agency to another. Nevertheless, there are a handful of “general” risks facing all home health agencies that are outlined in Health Integrity’s November 1st letter. These areas of recurring concern include:
Is the Patient Truly Confined to His / Her Home?
As Health Integrity’s letter states, under Chapter 7 § 30.1 of the Medicare Benefit Policy Manual, a patient’s medical records must accurately reflect that the patient qualified as “homebound” during the specific period under review. Denials based on lack of homebound status are not new – home health agencies should have a solid handle on these requirements by now. Having said that, it isn’t merely enough for a patient to merely qualify as homebound – you and your staff need to fully and accurately document the specific clinical facts which support each patient’s homebound status. Detail is important. Is the patient ever absent from the home? If so, what is the reason for the absence? How long were gone? In consideration of any absences, does the patient continue to qualify as homebound? All of these are important questions to be asked.
Importantly, as of November 19, 2013, the Centers for Medicare and Medicaid Services (CMS) will require Medicare beneficiaries to meet two sets of criteria before their home health agency even considers whether they have an ordinary inability to leave home. As MLN Matters Number: MM8444 provides:
An individual shall be considered "confined to the home" (homebound) if the following two criteria are met:
Criteria-One:The patient must either:
Because of illness or injury, need the aid of supportive devices such as crutches, canes, wheelchairs, and walkers; the use of special transportation; or the assistance of another person in order to leave their place of residence
Have a condition such that leaving his or her home is medically contraindicated.
If the patient meets one of the criteria in Criteria-One, then the patient must ALSO meet two additional requirements defined in Criteria-Two below.
Criteria-Two:There must exist a normal inability to leave home;
Leaving home must require a considerable and taxing effort.
Are Timely, Valid Physician Orders in the Record Which Support the Care Provided?
How was each patient referred to your home health agency for care and treatment? What are the qualifications of the referring physician? Who signed the patient’s “Plan of Care”? When was it received back from the physician? What types of treatment were ordered by the referring physician? Were any verbal orders documented in the record? Have all Orders been signed and dated in a timely fashion? Were all supplemental physicians’ orders signed and dated before the claim was billed to Medicare? If so, identify the orders and list the dates they were signed. Were the services billed properly?
Is there a Need for Skilled Care?
Documenting a patient’s need for and receipt of “skilled care” has been a perennial problem for many home health agencies. In most instances, we have found that the agency’s clinical staff has not been properly trained to document skilled care issues. What specific skilled services (e.g. injections, wound care, catheter changes, gait training) were provided to the patient during a particular episode? Ultimately, home health agencies should re-familiarize themselves with Chapter 7 §§ 40.1, 40.2 of the Medicare Benefit Policy Manual.
Are "Length of Stay" Issues to be Considered?
Data mining is enormously helpful to the government in identifying home health providers whose business and / or clinical practices essentially make them an “outlier” when compared to the practices of their peers. A patient’s length of stay on service is one of the most common comparisons used by ZPICs when making targeting decisions. Provide a detailed rationale as to why the patient was admitted to / recertified for home health services at the beginning of this episode.
II. Why is Our Home Health Agency Receiving a Health Integrity Educational Letter?
Not all home health agencies in Texas, Oklahoma and the rest of Zone 4 received a copy of Health Integrity’s “Educational Letter” dated November 1, 2013. If your home health agency received a copy of Health Integrity’s letter, it could be based on the fact that your agency has previously received a number of ADR’s, been placed on prepayment review or been subjected to a prior review or one type or another. Alternatively, your home health agency may have been sent Health Integrity’s letter based solely on the ZPIC’s data mining findings. Your agency may be an outlier in terms of its business or clinical statistics. As such, your agency has now been “flagged” by the ZPIC.
In any event, it is extremely important for you to recognize the importance of Health Integrity’s Educational Letter. Pursuant to the Medicare Modernization Act of 2003, 42 U.S.C. § 1395ddd(f)(3), (§ 1893(f)(3) of the Act):
A Medicare contractor may not use extrapolation to determine overpayment amounts to be recovered by recoupment, offset, or otherwise unless the Secretary determines the –
(A) there is a sustained or high level of payment error; or
(B) documented educational intervention has failed to correct the payment error.
The CMS Medicare Program Integrity Manual § 3,10.1.4 provides specific guidance on when statistical sampling may be used. As the section states:
"The PSC BI units and the contractor MR units shall use statistical sampling when it has been determined that a sustained or high level of payment error exists, or where documented educational intervention has failed to correct the payment error."
Both fundamental fairness and a plain reading of both the underlying statute and CMS guidelines require that Medicare overpayment auditors (including Health Integrity) have justification before beginning a statistical sampling of a provider’s Medicare claims. If the auditors could select anyone for audit without cause, the administrative burden on providers would be extraordinarily high. Therefore, the justification for a high error rate or failed education must be based on evidence that exists before the sample is selected. In light of the "Educational Letters" recently sent to home health providers by Health Integrity, the ZPIC will now be free to seek extrapolated damages since they can now allege that continuing problems were not corrected through educational intervention.
III. How Should Our Home Health Agency Respond to Health Integrity Educational Letter?
If your agency has received a Health Integrity Educational Letter, one option would be for you to just take the information in stride, remind your staff of their regulatory obligations and hope for the best. A more affirmative approach would be to review your practices and ensure that the concerns set out in Health Integrity’s letter are not problems in your organization. Should you find that deficiencies are present, remedial action should immediately be taken and any overpayments must be immediately refunded to Medicare. While the specific approach taken by your home health agency in responding to Health Integrity’s concerns will differ from one organization to another, we believe that it is imperative that all recipients review their practices to help better ensure that Medicare’s regulatory requirements are being met.
Robert W. Liles serves as Managing Partner at Liles Parker, Attorneys and Counselors at Law. Our firm represents home health agencies and other health care providers around the country in connection with ZPIC enforcement actions, prepayment reviews, postpayment audits, and a wide range of other regulatory matters. Should you have any questions or concerns regarding your home health agency, please give us a call for a free consultation: 1 (800) 475-1906.