HHS I.G. Audit: 'Medicare Home Health Agency Provider Compliance Audit – Caretenders of Jacksonville, LLC'
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Here are excerpts:
Why OIG Did This Audit
Under the home health prospective payment system (PPS), the
Our prior audits of home health services identified significant overpayments to HHAs. These overpayments were largely the result of HHAs improperly billing for services to beneficiaries who either were not confined to home (homebound) or were not in need of skilled services.
Our objective was to determine whether
How OIG Did This Audit
We selected a stratified random sample of 100 home health claims and submitted these claims to an independent medical review to determine whether the services met coverage, medical necessity, and coding requirements.
What OIG Found
Caretenders did not comply with Medicare billing requirements for 39 of the 100 home health claims that we reviewed. For these claims, Caretenders received overpayments of
What OIG Recommends and Caretenders Comments
We recommend that Caretenders: exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any returned overpayments as having been made in accordance with this recommendation. We also recommend that Caretenders ensure that: (1) the homebound statuses of Medicare beneficiaries are verified and continually monitored and the specific factors qualifying beneficiaries as homebound are documented, (2) beneficiaries are receiving only reasonable and necessary skilled services, and (3) the correct HIPPS payment codes are billed.
In written comments on our draft report, Caretenders agreed that one of the 55 claims we found to have been improperly billed was paid in error. Caretenders disagreed with our remaining findings and our two recommendations. Caretenders reviewed the claims we questioned and challenged our independent medical review contractor's decisions, maintaining that nearly all of the sampled claims were billed correctly. To address these concerns, we asked our medical review contractor to review Caretenders' written comments and claim rebuttals. Based on the results of that review and our review of additional documentation provided by Caretenders, we reduced the sampled claims incorrectly billed from 55 to 39 and revised the related findings and recommendations. We maintain that our remaining findings and recommendations, as revised, are valid.
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TABLE OF CONTENTS
INTRODUCTION ... 1
Why We Did This Audit ... 1
Objective ... 1
Background ... 1
The Medicare Program and Payments for
Home Health Agency Claims at Risk for Incorrect Billing ... 2
Medicare Requirements for Home Health Agency Claims and Payments ... 2
Medicare Requirements for Providers to Identify and Return Overpayments ... 3
How We Conducted This Audit ... 4
FINDINGS ... 5
Caretenders Did Not Always Comply With Medicare Billing Requirements ... 5
Beneficiaries Were Not Homebound ... 5
Beneficiaries Did Not Require Skilled Services ... 7
Incorrectly Billed Health Insurance Prospective Payment System Codes ... 9
Overall Estimate of Overpayments ... 9
RECOMMENDATIONS ... 9
CARETENDERS COMMENTS AND OFFICE OF INSPECTOR GENERAL RESPONSE ... 10
Caretenders Comments ... 10
Beneficiary Homebound Status ... 11
Caretenders Comments ... 11
Beneficiary Need for Skilled Nursing Services ... 11
Caretenders Comments ... 11
Incorrectly Billed Health Insurance Prospective Payment System Code ... 12
Caretenders Comments ... 12
60-Day Rule Recommendation ... 13
Caretenders Comments ... 13
Strengthen Procedures Recommendation ... 13
Caretenders Comments ... 13
APPENDICES
A: Audit Scope and Methodology ... 15
B: Medicare Requirements for Coverage and Payment of Claims for
C: Sample Design and Methodology ... 22
D: Sample Results and Estimates ... 24
E: Types of Errors by Sample Item ... 25
F: Caretenders Comments ... 30
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INTRODUCTION
WHY WE DID THIS AUDIT
For calendar year (CY) 2016, Medicare paid home health agencies (HHAs) about
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OBJECTIVE
Our objective was to determine whether Caretenders complied with Medicare requirements for billing home health services on selected types of claims.
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BACKGROUND
The Medicare Program and Payments for
Medicare Parts A and B cover eligible home health services under a prospective payment system (PPS). The PPS covers part-time or intermittent skilled nursing care and home health aide visits, therapy (physical, occupational, and speech-language pathology), medical social services, and medical supplies. Under the home health PPS, CMS pays HHAs for each 60-day episode of care that a beneficiary receives.
CMS adjusts the 60-day episode payments using a case-mix methodology based on data elements from the Outcome and Assessment Information Set (OASIS). The OASIS is a standard set of data elements that HHA clinicians use to assess the clinical severity, functional status, and service utilization of a beneficiary receiving home health services. CMS uses OASIS data to assign beneficiaries to the appropriate categories, called case-mix groups,/1 to monitor the effects of treatment on patient care and outcomes, and to determine whether adjustments to the case-mix groups are warranted. The OASIS classifies HHA beneficiaries into 153 case-mix groups that are used as the basis for the Health Insurance Prospective Payment System (HIPPS) codes/2 and represent specific sets of patient characteristics./3
CMS requires HHAs to submit OASIS data as a condition of payment./4
CMS administers the Medicare program and contracts with four of its Medicare administrative contractors to process and pay claims submitted by HHAs.
Home Health Agency Claims at Risk for Incorrect Billing
In prior years, our reviews at other HHAs identified findings in the following areas:
* beneficiaries did not always meet the definition of "confined to the home,"
* beneficiaries were not always in need of skilled services,
* HHAs did not always submit the OASIS data in a timely fashion,
* services were not always adequately documented, and
* HIPPS billing codes were incorrectly billed.
For the purposes of this report, we refer to these areas of incorrect billing as "risk areas."
Medicare Requirements for Home Health Agency Claims and Payments
Medicare payments may not be made for items and services that "are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member" (Social Security Act (the Act) Sec. 1862(a)(1)(A)). Sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act and regulations at 42 CFR Sec. 409.42 require, as a condition of payment for home health services, that a physician certify and recertify that the Medicare beneficiary is:
* confined to the home (homebound);
* in need of skilled nursing care on an intermittent basis or physical therapy or speech-language pathology, or has a continuing need for occupational therapy;
* under the care of a physician; and
* receiving services under a plan of care that has been established and periodically reviewed by a physician.
Furthermore, as a condition for payment, a physician must certify that a face-to-face encounter occurred no more than 90 days prior to the home health start-of-care date or within 30 days of the start of care (42 CFR Sec. 424.22(a)(1)(v)). In addition, the Act precludes payment to any provider of services or other person without information necessary to determine the amount due the provider (Sec. 1833(e)).
The determination of "whether care is reasonable and necessary is based on information reflected in the home health plan of care, the OASIS as required by 42 CFR Sec. 484.55 or a medical record of the individual patient" (Medicare Benefit Policy Manual (the Manual), chapter 7, Sec. 20.1.2). Coverage determination is not made solely on the basis of general inferences about patients with similar diagnoses or on data related to utilization generally but is based upon objective clinical evidence regarding the beneficiary's individual need for care (42 CFR Sec. 409.44(a)).
Appendix B contains the details of selected Medicare coverage and payment requirements for HHAs.
Medicare Requirements for Providers To Identify and Return Overpayments
The
Providers must report and return any identified overpayments by the later of (1) 60 days after identifying those overpayments or (2) the date that any corresponding cost report is due (if applicable). This is known as the 60-day rule./5
The 6-year lookback period is not limited by OIG's audit period or restrictions on the Government's ability to reopen claims or cost reports. To report and return overpayments under the 60-day rule, providers can request the reopening of initial claims determinations, submit amended cost reports, or use any other appropriate reporting process./6
Caretenders/7 is a limited liability home health care provider with headquarters in
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FINDINGS
Caretenders did not comply with Medicare billing requirements for 39 of the 100 home health claims that we reviewed. For these claims, Caretenders received overpayments of
* services provided to beneficiaries who were not homebound,
* services provided to beneficiaries who did not require skilled services, and
* claims that were assigned incorrect HIPPS codes.
These errors occurred primarily because Caretenders did not have adequate controls to prevent the incorrect billing of Medicare claims within the selected risk areas. On the basis of our sample results, we estimated that Caretenders received overpayments of at least
As of the publication of this report, all of these overpayments are outside of the 4-year reopening period.
CARETENDERS DID NOT ALWAYS COMPLY WITH MEDICARE BILLING REQUIREMENTS
Caretenders incorrectly billed Medicare for 39 of the 100 sampled claims, which resulted in overpayments of
Beneficiaries Were Not Homebound
Federal Requirements for
For the reimbursement of home health services, the beneficiary must be "confined to the home" (sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act and 42 CFR Sec. 409.42). According to section 1814(a) of the Act:
[A]n individual shall be considered to be "confined to his home" if the individual has a condition, due to illness or injury, that restricts the ability of the individual to leave his or her home except with the assistance of another individual or the aid of a supportive device (such as crutches, a cane, a wheelchair, or a walker), or if the individual has a condition such that leaving his or her home is medically contraindicated. While an individual does not have to be bedridden to be considered "confined to his home," the condition of the individual should be such that there exists a normal inability to leave home and that leaving home requires a considerable and taxing effort by the individual.
CMS provided further guidance and specific examples in the Manual (chapter 7, Sec. 30.1.1). Revision 172 of section 30.1.1 (effective
Revisions 172 and 208 state that for a patient to be eligible to receive covered home health services under both Part A and B, the law requires that a physician certify in all cases that the patient is confined to his or her home and an individual will be considered "confined to the home" (homebound) if the following two criteria are met:
Criteria One
Patients 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 places of residence or
* have a condition such that leaving their homes is medically contraindicated.
If the patient meets one of the Criteria One conditions, 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.
Caretenders Did Not Always Meet Federal Requirements for Home Health Services For 33 of the sampled claims, Caretenders incorrectly billed Medicare for home health episodes for beneficiaries who did not meet the above requirements/13 for being homebound for the full episode (16 claims) or for a portion thereof (17 claims)./14
Example 1: Beneficiary Not Homebound--Entire Episode
The physical therapy assessment documentation for one beneficiary showed that, from the start of the episode, the patient was able to ambulate without an assistive device. During the episode of care, it was documented the beneficiary had no shortness of breath, was not at risk of falling, and had been cleaning over several days which is consistent with a level of mobility beyond that needed for basic activities of daily living. Therefore, leaving the home did not require a considerable or taxing effort.
Example 2: Beneficiary Not Homebound--Partial Episode
For another beneficiary, records showed that, from the start of the episode, the beneficiary was initially homebound, limited to ambulating 50-75 feet due to dyspnea and pain. The beneficiary had an unsteady gait, the need of an assistive device and help from another person to leave the home. However, later in the episode, the beneficiary was ambulating 175 feet without an assistive device, exhibited increase in activity, and showed improvement in pain management and balance. At that point, leaving the home no longer would have entailed a considerable or taxing effort.
These errors occurred because Caretenders did not have adequate oversight procedures to ensure that it verified and continually monitored the homebound status of Medicare beneficiaries under its care and properly documented the specific factors that qualified the beneficiaries as homebound.
Beneficiaries Did Not Require Skilled Services
Federal Requirements for Skilled Services
A Medicare beneficiary must need skilled nursing care on an intermittent basis; physical therapy, or speech-language pathology; or the beneficiary must have a continuing need for occupational therapy (sections 1814(a)(2)(C) and 1835(a)(2)(A) of the Act and 42 CFR Sec. 409.42(c)). In addition, skilled nursing services must require the skills of a registered nurse or a licensed practical nurse under the supervision of a registered nurse, must be reasonable and necessary to the treatment of the patient's illness or injury, and must be intermittent (42 CFR Sec. 409.44(b) and the Manual, chapter 7, Sec. 40.1)./15
Skilled therapy services must be reasonable and necessary to the treatment of the patient's illness or injury or to the restoration or maintenance of function affected by the patient's illness or injury within the context of the
Medicare Home Health Agency Provider Compliance Audit:
Coverage of skilled nursing care or therapy does not turn on the presence or absence of a patient's potential for improvement, but rather on the patient's need for skilled care. Skilled care may be necessary to improve a patient's current condition, to maintain the patient's current condition, or to prevent or slow further deterioration of the patient's condition (the Manual, chapter 7, Sec. 20.1.2).
Caretenders Did Not Always Meet Federal Requirements for Skilled Services For 14 of the sampled claims, Caretenders incorrectly billed Medicare for an entire home health episode (3 claims) or a portion of an episode (11 claims) for beneficiaries who did not meet the Medicare requirements for coverage of skilled nursing or therapy services./16
Example 3: Beneficiary Did Not Require Skilled Services
A physician's plan of care ordered skilled nursing and physical therapy services for the treatment of unspecified asthma, obesity, abnormality of gait and generalized muscle weakness.
The beneficiary was not homebound as they were ambulating independently in and out of the home. The beneficiary missed two nursing visits for being out of the residence with friends, indicating she was not homebound. Caretenders provided skilled nursing services to the beneficiary, however, the beneficiary did not have skilled nursing needs.
The initial physical therapy (PT) assessment documented that the beneficiary had no complaints and the current level of safe function was consistent with the beneficiary's prior level of function. The beneficiary's range of motion of bilateral lower extremities and strength were within functional limits. The beneficiary ambulated at a modified independence level with a cane and without loss of balance, at their residence including a flight of stairs with railings. The PT assessment documented that the patient was at maximum functional potential.
These errors occurred because Caretenders did not always provide sufficient clinical review to verify that beneficiaries initially required skilled services or continued to require skilled services.
Incorrectly Billed Health Insurance Prospective Payment System Codes Medicare payments may not be made for items and services that "are not reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member" (the Act Sec. 1862(a)(1)(A)). CMS's Medicare Claims Processing Manual, Pub. No. 100-04, states: "In order to be processed correctly and promptly, a bill must be completed accurately" (chapter 1, Sec. 80.3.2.2).
For five sampled claims, Caretenders assigned an incorrect HIPPS billing code to the Medicare claim./17
The OASIS and other supporting medical records did not support the billing code that Caretenders used. Using the correct HIPPS billing code, we computed the payment amount in error by subtracting the correct payment amount from the original payment. We attributed these incorrect HIPPS codes to clerical errors.
OVERALL ESTIMATE OF OVERPAYMENTS
On the basis of our sample results, we estimated that Caretenders received overpayments totaling at least
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RECOMMENDATIONS
We recommend that Caretenders:/18
* based on the results of this audit, exercise reasonable diligence to identify, report, and return any overpayments in accordance with the 60-day rule and identify any returned overpayments as having been made in accordance with this recommendation and
* strengthen its procedures to ensure that:
- the homebound status of Medicare beneficiaries is verified and continually monitored and the specific factors qualifying beneficiaries as homebound are documented,
- beneficiaries are receiving only reasonable and necessary skilled services, and
- HIPPS codes are billed correctly.
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View full report at https://oig.hhs.gov/oas/reports/region4/41606195.pdf
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