The Office of the Inspector General for the Department of Health and Human Services issued the FY 2013 Work Plan today. The big story has been about the Hospital readmission issue, which is a big push with CMS and PPACA (Obamacare). However, there are many areas that Home Health Agencies (and nurses) need to pay attention too:
HHAs—Home Health Face-to-Face Requirement (New)
We 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. (Patient Protection and Affordable Care Act (Affordable Care Act), § 6407.) The encounters must occur within 120 days: either within the 90 days before beneficiaries start home health care or up to 30 days after care begins. (42 CFR § 424.22.) 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 health care. (OEI; 01-12-00390; expected issue date: FY 2013; work in progress. Affordable Care Act.)
HHAs—Employment of Home Health Aides With Criminal Convictions (New)
We 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. (Social Security Act, §1891(a)(5), implemented at 42 CFR § 484.12(a).) 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. (OEI; 12-12-00630; expected issued date: FY 2013; work in progress)
HHAs—States’ Survey and Certification: Timeliness, Outcomes, Followup, and Medicare Oversight
We will review the timeliness of HHA recertification and complaint surveys conducted by State Survey Agencies and Accreditation Organizations, the outcomes of those surveys, and the followup of complaints against HHAs. We will also look at CMS oversight designed to monitor HHA surveys. CMS relies on the survey and certification process to ensure HHA compliance with Medicare CoPs. HHAs must be surveyed at least every 36 months. (Social Security Act, § 1891(c)(2).) Regulations on surveys to validate the accreditation process are at 42 CFR § 488.8, and instructions on surveys to monitor State Survey Agencies’ performance are in CMS’s State Operations Manual, §§ 4157 and 4158. (OEI; 06-11-00400; expected issue date: FY 2013; work in progress)
HHAs—Missing or Incorrect Patient Outcome and Assessment Data
We will review home health agencies Outcome and Assessment Information Set (OASIS) data to identify payments for episodes for which OASIS data were not submitted or for which the billing codes on the claims are inconsistent with OASIS data. OASIS data are electronically submitted to CMS, independently of the home health agency’s claim for episode payment. Federal regulations require that HHAs submit OASIS data as a condition for payment. (42 CFR § 484.210(e).) HHAs receive prospective payments on the basis of 60-day episodes of care. The OASIS is a standard set of data items used to assess the clinical needs, functional status, and service utilization of a beneficiary receiving home health services and includes the billing code for the episode of care. (OAS; W-00-13-35600; various reviews; expected issue date: FY 2013; new start)
HHAs—Medicare Administrative Contractors’ Oversight of Claims
We will review the activities that CMS and its contractors performed to identify and prevent improper home health payments from January to October 2011. We will also 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. Previous OIG and the Department of Justice (DOJ) investigations indicate that the home health benefit may be susceptible to fraud. (OEI; 04-11-00220; expected issue date: FY 2013; work in progress)
HHAs—Home Health Prospective Payment System Requirements
We will review compliance with various aspects of the home health PPS, including the documentation required in support of the claims paid by Medicare. Some beneficiaries who are confined to their homes are eligible to receive home health services. (Social Security Act, §§ 1835(a)(2)(A) and 1861(m).) Such services include part-time or intermittent skilled nursing care, as well as other skilled care services, such as physical, occupational, and speech therapy; medical social work; and home health aide services. (OAS; W-00-12-35501; W-00-13-35501; various reviews; expected issue date: FY 2013 ;work in progress and new start)
HHAs—Trends in Revenues and Expenses
We 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. We will examine various Medicare and overall revenue and expense trends for freestanding and hospital-based HHAs. Since the home health PPS was implemented in October 2000, HHA expenditures have significantly increased. Home health services are paid under a PPS pursuant to the Social Security Act, § 1895, added by the Balanced Budget Act of 1997 (BBA), § 4603. (OAS; W-00-10-35428; various reviews; expected issue date: FY 2013; work in progress)
Some related general sections after the jump.
Some other areas to pay attention to that may impact Home Health Agencies:
Physicians and Other Suppliers—Noncompliance With Assignment Rules and Excessive
Billing of Beneficiaries
We will review the extent to which physicians and other suppliers fail to comply with assignment rules and determine to what extent beneficiaries are inappropriately billed in excess of amounts allowed by Medicare. We will also assess beneficiaries’ awareness of their rights and responsibilities regarding potential billing violations and Medicare coverage guidelines. Physicians participating in Medicare agree to accept payment on “assignment” for all items and services furnished to individuals enrolled in
Medicare. (Social Security Act, § 1842(h)(1).) CMS defines “assignment” as a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to allow the physician or other supplier to request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or supplier. The physician or other supplier in return agrees to accept the Medicare-allowed amount indicated by the carrier as the
full charge for the items or services provided. (OEI; 07-12-00570; expected issue date: FY 2014; work in progress)
Medicare and Medicaid Security of Portable Devices Containing Personal Health
Information at Contractors and Hospitals
We will review security controls implemented by Medicare and Medicaid contractors as well as hospitals to prevent the loss of protected health information (PHI) stored on portable devices and media, such as laptops, jump drives, backup tapes, and equipment considered for disposal. Recent breaches related to
Federal computers, including one involving a CMS contractor, have heightened concerns about protecting sensitive information. We will assess and test contractors’ and hospitals’ policies and procedures for electronic health information protections, access, storage, and transport. OMB recommended that all Federal departments and agencies take action to protect sensitive information by following the National Institute of Standards and Technology’s Special Publications 800-53 and 800-53A.
(OMB Memorandum M-06-16, issued June 23, 2006.) (OAS; W-00-12-41014; various reviews; expected issue date: FY 2013; work in progress)
Medicare Integrity Program—CMS’s Overall Strategy (New)We will review CMS’s overall strategy to maintain the integrity of the Medicare. The Medicare
Integrity Program (MIP) was established through 42 U.S.C. § 1395ddd and requires CMS to contract with entities to carry out various program integrity activities to safeguard against fraud, waste, and abuse in Medicare Parts A and B. Over the past few years, Congress has submitted multiple letters to CMS questioning the effectiveness of the program integrity efforts of these contractors. We will also determine how CMS allocates funds for MIP activities and review the measures CMS uses to evaluate the performance and overall effectiveness of the MIP. (OEI-03-12-00690; expected issue date: FY 2013 work in progress)
Comprehensive Error Rate Testing Program—Fiscal Year 2012 Error Rate Oversight
We will review certain aspects of the CERT Program to evaluate CMS’s efforts to ensure the accuracy ofthe FY 2012 error rate and to reduce improper payments. Through CERT, national, contractor-specific, and service-type error rates are computed. The CERT program’s national estimated improper payments for FY 2011 were $28.8 billion (8.6 percent-error rate). In November 2003, CMS assumed responsibility for estimating and reporting improper Medicare FFS payments and national error rates. The CERT Program was established by CMS to meet the requirements of the Improper Payments Elimination and Recovery Improvement Act of 2011 (IPERA) and to monitor the accuracy with which Medicare claims are billed and paid. (CMS’s Medicare Program Integrity Manual, Pub. 100-08, ch. 12.) Effective August 1, 2008, the CERT program also samples inpatient records, replacing the Hospital Payment Monitoring Program. (OAS; W-00-13-40048; various reviews; expected issue date: FY 2013; new start)
Exclusions From Program Participation
OIG may exclude individuals and entities from participation in Medicare, Medicaid, and all other Federal health care programs for many reasons, some of which include program-related convictions, patient abuse or neglect convictions, licensing board disciplinary actions, or other actions that pose a risk to beneficiaries or programs. (Social Security Act, § 1128, § 1156, and other statutes.) Exclusions are generally based on referrals from Federal and State agencies. We work with these agencies to ensure the timely referral of convictions and licensing board and administrative actions. In fiscal year (FY) 2011, OIG excluded 2,662 individuals and entities from participation in Federal health care programs. The total for FY 2012 will be published in OIG’s Fall FY 2011 Semiannual Report to Congress. Searchable exclusion lists are available on OIG’s Web site at: http://exclusions.oig.hhs.gov/.
Provider Compliance Training
In spring 2011, OIG and its government partners provided in-person provider compliance training in Houston, Tampa, Kansas City, Baton Rouge, Denver, and Washington, D.C. The sessions focused on the realities of Medicare and Medicaid fraud and the importance of implementing an effective compliance program. To expand access to providers nationwide, we broadcasted a free online live Webcast of the May 18 training in Washington. These and other training materials are available on OIG’s Provider Compliance Training Web site along with corresponding slides and written handouts. Also available are 13 educational video and audio podcasts covering various topics to help prevent fraud, waste, and
abuse. Our provider compliance training effort continues.
Medicare Strike Force Teams and Other Collaboration
OIG devotes significant resources to investigating Medicare and Medicaid fraud. We conduct investigations in conjunction with other law enforcement entities, such as the Federal Bureau of Investigation (FBI), the United States Postal Inspection Service, the Internal Revenue Service (IRS), and State Medicaid Fraud Control Units (MFCU). The Health Care Fraud Prevention and Enforcement Action Team (HEAT) was started in 2009 by the Department of Health and Human Services (HHS) and DOJ to strengthen programs and invest in
new resources and technologies to prevent and combat health care fraud, waste, and abuse. Using a collaborative model, Medicare Fraud Strike Force teams coordinate law enforcement operations among Federal, State, and local law enforcement entities. These teams, now a key component of HEAT, have a record of successfully analyzing data to quickly identify and prosecute fraud. The Strike Force teams were formed in March 2007 and are operating in nine major cities. The effectiveness of the Strike Force model is enhanced by interagency collaboration within HHS. For example, we refer credible allegations of fraud to CMS so it can suspend payments to perpetrators. During Strike Force operations, OIG and CMS work to impose payment suspensions that immediately prevent losses from claims submitted by Strike Force targets.
• OIG investigates individuals, facilities, or entities that, for example, bill or are alleged to have billed Medicare and/or Medicaid for services not rendered, claims that manipulate payment codes to inflate reimbursement amounts, and false claims submitted to obtain program funds.
• We also investigate business arrangements that allegedly violate the Federal health care antikickback statute and the statutory limitation on self-referrals by physicians.
• OIG also examines quality-of-care issues in nursing facilities, institutions, community-based settings, and other care settings and instances in which the programs may have been billed for medically unnecessary services, for services either not rendered or not rendered as prescribed, or for substandard care that is so deficient that it constitutes “worthless services.”
• Other areas of investigation include Medicare and Medicaid drug benefit issues and assisting CMS in identifying program vulnerabilities and schemes, such as prescription shorting (a pharmacy’s dispensing of fewer doses of a drug than prescribed, charging the full amount, and then instructing
the customer to return to pick up the remainder).
Working with law enforcement partners at the Federal, State, and local levels, we investigate schemes to illegally market, obtain, and distribute prescription drugs. In doing so, we seek to protect Medicare and Medicaid from making improper payments, deter the illegal use of prescription drugs, and curb the danger associated with street distribution of highly addictive medications. We assist State MFCUs to investigate allegations of false claims submitted to Medicaid and will continue to strengthen coordination between OIG and organizations such as the National Association of Medicaid Fraud Control Units and the National Association for Medicaid Program Integrity. Highlights of recent enforcement actions to which OIG has contributed are posted to OIG’s Web site at: https://oig.hhs.gov/fraud/enforcement/criminal/.