HHS I.G. Audit: 'Medicare Home Health Agency Provider Compliance Audit – Visiting Nurse Association of Maryland'
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Here are excerpts:
Report in Brief
Why OIG Did This Audit
Under the home health prospective payment system (PPS) during calendar years 2015 and 2016, 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 were not confined to the 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 contractor to determine whether the services met coverage, medical necessity, and coding requirements.
What OIG Found
VNA did not comply with Medicare billing requirements for 19 of the 100 home health claims that we audited. For these claims, VNA received overpayments of
What OIG Recommends and VNA Comments
We recommend that VNA 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 VNA 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, (3) services are provided in accordance with beneficiaries' plans of care, and (4) the correct HIPPS payment codes are billed.
In written comments on our draft report, VNA stated that it disagreed with the majority of our findings. VNA concurred with our finding regarding the homebound determination for one claim and also concurred that an incorrect HIPPS payment code was assigned to two sampled claims identified in our draft report. VNA stated that it would promptly make a repayment for those three claims but also stated that it did not have any repayment obligation with respect to the other claims that we found were paid in error. VNA retained a health care consultant to review 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 had our independent medical review contractor review VNA's written comments on our draft report as well as the spreadsheet prepared by VNA's consultant. Based on the results of that review, we reduced the sampled claims incorrectly billed from 36 to 19 and revised the related finding 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
Visiting Nurse Association of
How We Conducted This Audit ... 4
FINDINGS ... 4
Visiting Nurse Association Billing Errors ... 5
Beneficiaries Were Not Homebound ... 5
Beneficiaries Did Not Require Skilled Services ... 7
Services Were Not Delivered in Accordance With the Plan of Care ... 8
Incorrect Health Insurance Prospective Payment System Codes Were Assigned to Claims ... 9
Overall Estimate of Overpayments ... 9
RECOMMENDATIONS ... 10
VISITING NURSE ASSOCIATION COMMENTS AND
OFFICE OF INSPECTOR GENERAL RESPONSE ... 10
Beneficiary Homebound Status ... 11
Visiting Nurse Association Comments ... 11
Skilled Services ... 12
Visiting Nurse Association Comments ... 12
Qualifications of the Medical Review Contractor ... 14
Visiting Nurse Association Comments ... 14
Estimation of Overpayments ... 14
Visiting Nurse Association Comments ... 14
APPENDICES
A: Audit Scope and Methodology ... 17
B: Medicare Requirements for Coverage and Payment of Claims for
C: Sample Design and Methodology ... 24
D: Sample Results and Estimates ... 26
E: Types of Errors by Sample Item ... 27
F: Visiting Nurse Association Comments ... 30
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INTRODUCTION
WHY WE DID THIS AUDIT
For calendar year (CY) 2016, Medicare paid home health agencies (HHAs) about
This audit is part of a series of audits of HHAs. Using computer matching, data mining, and data analysis techniques, we identified HHAs at risk for noncompliance with Medicare billing requirements. Visiting Nurse Association of
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OBJECTIVE
Our objective was to determine whether VNA 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./1
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, 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) payment 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 audits 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 in a timely fashion, and
* services were not always adequately documented.
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 section 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 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
Visiting Nurse Association of
VNA is a home health care provider with its main office in
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FINDINGS
VNA did not comply with Medicare billing requirements for 19 of the 100 home health claims that we audited. For these claims, VNA received overpayments of
* services provided to beneficiaries who were not homebound,
* services provided to beneficiaries who did not require skilled services,
* services that were not delivered in accordance with the beneficiary's plan of care, and
* claims that were assigned incorrect HIPPS payment codes.
These errors occurred primarily because VNA 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 VNA received overpayments of at least
As of the publication of this report, all 100 claims in our sample are outside of the Medicare 4-year claim-reopening period.
VISITING NURSE ASSOCIATION BILLING ERRORS
VNA incorrectly billed Medicare for 19 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 his home" (the Act Sec.Sec. 1814(a)(2)(C) and 1835(a)(2)(A) and Federal regulations (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:
Criterion 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 his or her place of residence or
* have a condition such that leaving his or her home is medically contraindicated.
If the patient meets one of the Criterion One conditions, then the patient must also meet two additional requirements defined in Criterion Two below.
Criterion Two
There must exist a normal inability to leave home, and leaving home must require a considerable and taxing effort.
VNA Did Not Always Meet Federal Requirements for Home Health Services For 16 of the sampled claims, VNA incorrectly billed Medicare for home health episodes for beneficiaries who did not meet the above requirement for being homebound for the full episode (6 claims) or for a portion thereof (10 claims)./11
Example 1: Beneficiary Not Homebound - Entire Episode
The physical therapy evaluation documentation for one beneficiary showed that, from the start of the episode, the patient was able to transfer and ambulate with a one-handed assistive device on both even and uneven surfaces and on stairs, and he had caregiver assistance available. For the entire episode, leaving the home did not require a considerable or taxing effort.
Example 2: Beneficiary Not Homebound - Partial Episode
For another beneficiary, records showed that the patient was initially homebound and was being treated for myocardial infarction. The patient had shortness of breath when walking more than 20 feet or when climbing stairs. At the start of care, leaving the home would have required a considerable and taxing effort for this patient. By a later date in the episode, the patient was able to ambulate 165 feet and had progressed to higher-level gait activities and ambulation outdoors. The patient was able to ambulate on unlevel surfaces without hands-on assistance. Leaving the home would no longer require a considerable and taxing effort.
These errors occurred primarily because VNA did not have adequate controls to prevent the incorrect billing of Medicare claims within selected risk areas. VNA did not provide a reason why these errors occurred because VNA officials contended that these claims met Medicare requirements.
Beneficiaries Did Not Require Skilled Services
Federal Requirements for Skilled Services
A Medicare beneficiary must be in need of either skilled nursing care on an intermittent basis or physical therapy or speech-language pathology, or have a continuing need for occupational therapy (the Act Sec.Sec. 1814(a)(2)(C) and 1835(a)(2)(A) and Federal regulations (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)./12
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 patient's unique medical condition (42 CFR Sec. 409.44(c) and the Manual, chapter 7, Sec. 40.2.1).
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).
VNA Did Not Always Meet Federal Requirements for Skilled Services
For four of the sampled claims, VNA incorrectly billed Medicare for an entire home health episode (1 claim) or a portion of an episode (3 claims) for beneficiaries who did not meet the Medicare requirements for coverage of skilled nursing or therapy services./13,14
Example 3: Beneficiary Did Not Require Skilled Services
The medical information for a beneficiary supported that the beneficiary was homebound at the start of care and remained homebound throughout the home health episode. Home health services were ordered for monitoring, medication oversight, and education. Home health services were to assess the beneficiary's activities for daily living and adaptive device use as well as the beneficiary's training in wheelchair transfers. A physical therapy evaluation was indicated to assess the beneficiary's mobility and need for an assistive device or home exercise program. However, the beneficiary had been non-ambulatory for a long period of time and was receiving occupational therapy treatments addressing his mobility impairment and remaining activities of daily living. Ongoing physical therapy services were excessive after the initial evaluation.
These errors occurred primarily because VNA did not have adequate controls to prevent the incorrect billing of Medicare claims within selected risk areas. VNA did not provide a reason why these errors occurred because VNA officials contended that these claims met Medicare requirements.
Services Were Not Delivered in Accordance With the Plan of Care
As a condition of coverage and payment, 42 CFR sections 409.42(d) and 424.22(a)(1)(iii) require that a plan of care be established and periodically reviewed by a physician. The plan of care must include those items listed in 42 CFR section 484.18(a). Federal regulations at 42 CFR section 484.18(a) state, "Orders for therapy services include the specific procedures and modalities to be used and the amount, frequency, and duration." In addition, 42 CFR section 409.43(b) states, "The physician's orders for services in the plan of care must specify the medical treatments to be furnished as well as the type of home health discipline that will furnish the ordered services and at what frequency the services will be furnished." For one sampled claim, VNA did not deliver services in accordance with the plan of care. For the claim, a physical therapy visit was made that was not covered by a physician's order.
Physical therapy had discharged the patient on an earlier date; a new physical therapy order was not received until after the physical therapy visit.
VNA did not provide a reason why this error occurred because VNA officials contended that the claim met Medicare requirements.
Incorrect Health Insurance Prospective Payment System Codes Were Assigned to Claims
Federal Requirements for Billing 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)). In addition, 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" (Medicare Claims Processing Manual, Pub No. 100-04, chapter 1, Sec. 80.3.2.2).
VNA Did Not Always Meet Federal Requirements for Billing Health Insurance Prospective Payment System Codes
For two sampled claims, VNA assigned incorrect HIPPS payment codes to the claims.15 The OASIS and other supporting medical records did not support the HIPPS billing code that VNA used. The incorrect HIPPS billing codes resulted in higher HHA payment for the two claims.
Using the correct HIPPS billing code, we computed the payment amount in error by subtracting the correct payment amount from the original payment./16
VNA did not provide a reason why these errors occurred because VNA officials contended that these claims met Medicare requirements.
OVERALL ESTIMATE OF OVERPAYMENTS
On the basis of our sample results, we estimated that VNA received overpayments totaling at least
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RECOMMENDATIONS
We recommend that
* 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
* ensure that:
- the homebound statuses of Medicare beneficiaries are verified and continually monitored and the specific factors qualifying beneficiaries as homebound are documented,
- beneficiaries are receiving only reasonable and necessary skilled services,
- services are provided in accordance with beneficiaries' plans of care, and
- the correct HIPPS payment codes are billed.
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View full report at Xhttps://oig.hhs.gov/oas/reports/region3/31700009.pdf
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