Home Health & Hospice

OIG Issues Annual Work Plan

Homecare Insider, October 22, 2012

The Department of Health and Human Services Office of Inspector General (OIG) has issued its annual work plan for 2013. The work plan contains a section dedicated to home health and hospice and includes a number of provisions within Part I: Medicare Part A and Part B. Each provision highlights the topics that the OIG intends to investigate or review.

According to the work plan, there are seven home health focused provisions.

Several of the provisions are similar or the same as last year and two are brand new. A summary of the provisions can found below:

Home Health Face-to-Face Requirement

  • A new provision.
  • The OIG will determine the extent to which home health agencies (HHA) are complying with a statutory requirement that physicians (or certain practitioners working with physicians) who certify beneficiaries as eligible for Medicare home health services have face-to-face encounters with the beneficiaries.
  • OIG work conducted before the Affordable Care Act mandate went into effect found that only 30 percent of beneficiaries had at least one face-to-face visit with the physicians who ordered their home healthcare.

Employment of Home Health Aides With Criminal Convictions

  • A new provision.
  • The OIG will determine the extent to which HHAs are complying with State requirements that criminal background checks be conducted with respect to HHA applicants and employees. Federal law requires that HHAs comply with all applicable State and local laws and regulations.
  • A previous OIG review found that 92 percent of nursing homes employed at least one individual with at least one criminal conviction; however, this review could not determine whether the nursing home employees were disqualified from working in nursing homes because OIG did not have access to detailed information on the nature of the employees’ crimes. Nearly all States have laws prohibiting certain care-related entities from employing individuals with prohibited criminal convictions.

States’ Survey and Certification of Home Health Agencies: Timeliness, Outcomes, Follow-up, and Medicare Oversight

  • The OIG will continue to review the timeliness of home health agency (HHA) recertification and complaint surveys conducted by State Survey Agencies and Accreditation Organizations, the outcomes of those surveys, and the nature and follow-up of complaints against HHAs.
  • The Centers for Medicare and Medicaid Services (CMS) oversight activities designed to monitor the timeliness and effectiveness of HHA surveys will also be reviewed.

Missing or Incorrect Patient Outcome and Assessment Data

  • The OIG will review home health agencies OASIS data to identify payments for episodes for which OASIS data were not submitted or for which the billing code on the claim is inconsistent with OASIS data.

Medicare Administrative Contractors’ Oversight of Claims

  • The OIG will review the activities that CMS and its contractors performed to identify and prevent improper home health payments from January to October 2011.
  • It will determine the extent to which CMS and its contractors performed activities to identify and address potential fraud among HHAs. In 2010, Medicare paid approximately $19.5 billion to 11,203 HHAs for services provided to 3.4 million beneficiaries. This review is based on Previous OIG and Department of Justice (DOJ) investigations that indicate that the home health benefit may be susceptible to fraud.

Home Health Prospective Payment System Requirements

  • The OIG will review compliance with various aspects of the home health PPS, including the documentation required in support of the claims paid by Medicare.

Home Health Agency Trends in Revenues and Expenses

  • The OIG will review cost report data to analyze HHA revenue and expense trends under the home health PPS to determine whether the payment methodology should be adjusted.
  • It will also examine various Medicare and overall revenue and expense trends for freestanding and hospital-based HHAs.

In addition to the home health provisions, the annual work plan featured two hospice provisions. These provisions are the same provisions that were in last year’s report with some very minor changes. These include:

Marketing Practices and Financial Relationships with Nursing Facilities

  • The OIG plans to review hospices’ marketing materials and practices and their financial relationships with nursing facilities.
  • The OIG found that 82 percent of hospice claims for beneficiaries in nursing facilities did not meet Medicare coverage requirements. MedPAC, an independent congressional agency that advises Congress on issues affecting Medicare, has noted that hospices and nursing facilities may be involved in inappropriate enrollment and compensation. MedPAC has also highlighted instances in which hospices aggressively marketed their services to nursing facility residents.
  • The review will be focused on hospices that have a high percentage of their beneficiaries in nursing facilities.

General Inpatient Care

  • The OIG will review the use of hospice general inpatient care in 2011. We will assess the appropriateness of hospices’ general inpatient care claims and hospice beneficiaries’ drug claims billed under Part D.
  • It will review hospice medical records to address concerns that this level of hospice care is being misused.

Read the report in its entirety here.