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Health Integrity Educational Letter Sent to Home Health Agencies in Texas and Oklahoma

November 8, 2013 by  
Filed under Home Health & Hospice

Has your home health agency received a Health Integrity educational letter?(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:   

A.    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

OR

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;

AND

Leaving home must require a considerable and taxing effort.

B.    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?

C.    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.

D.    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.

Healthcare LawyerRobert 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

Robert W. Liles Invited to Speak at the WDTX DOJ Working Group for Health Care Fraud Meeting

September 12, 2010 by  
Filed under Firm News

Robert Liles has been asked to speak at the WDTX DOJ Working Group meeting(September 12, 2010):  Robert W. Liles, Managing Partner at Liles Parker, has been asked to serve as the main speaker at the quarterly DOJ Working Group conference sponsored by the U.S. Attorney’s Office for the Western District of Texas.  The Working Group consists of Federal civil and criminal Prosecutors, FBI agents, HHS-OIG agents and investigators, MFCU agents and investigators, ZPIC auditors and Investigators and representatives of the MAC responsible for processing Part A, Part B and DME Medicare claims.  The session will focus on changes to the False Claims Act, the Federal Anti-Kickback Statute and the Health Care Fraud Statute as a result of the recent enactment of the Health Care Reform Act last March.   Mr. Liles will also discuss the concerns of health care providers with current enforcement initiatives.

Since 2001, Mr. Liles has worked in private practice, representing the interests of health care providers in administrative actions (such as ZPIC audits of Medicare claims), civil cases (such as False Claims Act cases), and criminal matters (such as Anti-Kickback allegations).  Prior to entering private practice, Mr. Liles worked as an Assistant U.S. Attorney in the Southern District of Texas.  In early 1997, he was selected to serve as the nation’s first National Health Care Fraud Coordinator for the Executive Office of United States Attorneys in Washington, D.C.

Prior to entering law, Mr. Liles worked for many years in the health care industry.  He received a Master’s in Health Care Administration from Trinity University in 1985.  Trinity is recognized as one of the foremost universities in the country for educating and training future hospital administrators.  In addition to an M.H.A., Mr. Liles also holds an M.B.A.

Mr. Liles’ varied background provides a unique perspective of both the health care industry and the needs and concerns of health providers.

Liles Parker has an office in San Antonio, Texas.  Our attorney in San Antonio is Rebecca Reed.  Ms. Reed is a former Bexar County prosecutor.  Should your practice or clinic have questions regarding a ZPIC audit, RAC audit, False Claims Act allegations or a possible criminal case, please give us a call for a free consultation at 1 (800) 475-1906.

HHS-OIG Issues Report on Improper Claims for Nonemergency Transportation Services

OIG is Concerned About Improper Claims for Nonemergency Medical Transportation Services(September 6, 2010):  The Department of Health and Human Services, Office of Inspector General (OIG) recently issued its report examining the costs of nonemergency transportation services reimbursed by Medicaid.  Pursuant to 42 C.F.R. § 431.53, Texas and other States are required to ensure that Medicaid patients have transportation to medical facilities and providers to obtain covered Medicaid services.

In Texas, the Texas Health and Human Services Commission has contracted with the Texas Department of Transportation to administer this nonemergency transportation program. The Department of Transportation has subcontracted with various private transportation providers to provide these services.

I.  OIG’s Findings Regarding Nonemergency Transportation Services:

Upon audit, OIG found that one transportation provider had allegedly provided nonemergency transportation services for which the Texas Health and Human Services Commission had improperly claimed reimbursement by Medicaid.

As set out in OIG’s report, Nonemergency Medical Transportation Costs in the State of Texas, 35 of the 100 sampled nonemergency transportation claims sampled were found by the auditors to be unallowable or partially unallowable.  Reasons for denial included:

  •  Nonemergency transportation was allegedly provided by drivers who did not have a criminal background check or who had a prohibited criminal history on file with the subcontractor.
  • The Medicaid beneficiary allegedly cancelled the transportation request in advance of the trip or was a “no-show” at the origination address.
  • The Medicaid beneficiary allegedly did not receive a Medicaid-covered health care service on the transportation date.
  • The Medicaid claims were paid at a premium rate applicable for transportation between two counties when the transportation was actually provided within the same county.

II. Recommendations:

In light of these findings, we recommend that providers review their practices to ensure that these and other specific risk areas regularly encountered in the provision of nonemergency transportation services are incorporated in their Compliance Plan and assessed as part of the provider’s recurring compliance review activities.  In this heightened enforcement environment it is essential that ambulance and nonemergency transportation providers continue to take steps to ensure that all applicable statutory and regulatory provisions are met.

Liles Parker attorneys have represented both ambulance and non-emergency transportation providers reimbursed by Medicare and Medicaid.  Should your transportation company be audited, give us a call. For a free consultation call:  1 (800) 475-1906.

HEAT Strike Force Update: Prosecutions in Texas Increased in March 2010

The Texas HEAT Strike Force is actively investigating Medicare fraud throughout the state.(April 3, 2010):  The Federal government is taking considerable steps to stop Medicare fraud and abuse. Notably, the number of publicly-disclosed HEAT Strike Force investigations and prosecutions in Texas significantly increased last month.  Two of the cases disclosed involved mental health professionals:

 

  • A Psychologist was convicted of health care fraud and money laundering, in connection with various claims fraudulently billed to Medicare.  Instances of improper conduct included billing for more than twenty-four hours of services in a single day; billing for services in a single day which amounted to more than double the normal business hours of the Psychologist’s practice; billing for services allegedly rendered during weekends, holidays, and times that the Psychologist was known to be out-of-town and away from the practice; and, submitting claims for services and evaluations not actually performed by the Psychologist, as required by law.
  • An unlicensed Behavioral Health Counselor was charged with Medicaid fraud for allegedly engaging in aggravated identity theft.  The defendant allegedly improperly acquired Medicaid beneficiaries’ information, including names, addresses and Medicaid numbers, then used the information to file false claims through a behavioral counseling service the defendant owned.  These behavioral counseling services were billed to Medicaid but allegedly not provided to the beneficiaries for which they were billed.

Since being established approximately a year ago, Texas’ HEAT Strike Force has significantly increased both investigations and prosecutions throughout the State.  Both enforcement efforts and the frequency of Medicare audits are anticipated to increase throughout 2010 and following years.  In addition to the increasing number of civil and criminal cases brought by the Texas HEAT Strike Force, the number of administrative overpayment cases is anticipated to grow as well.  It is essential that Texas providers continue their efforts to ensure that both business operations and billing practices fully comply with applicable statutory and regulatory requirements.

Liles Parker PLLC includes a number of attorneys with extensive former experience as Federal and / or State prosecutors.  Should your organization find itself under investigation, call us today for a complimentary consultation at: 1 (800) 475-1906.