Homecare & Hospice News» Clinicians Among 30 Arrested for Home Health Fraud

Clinicians Among 30 Arrested for Home Health Fraud

Editor — Tue, 15 Dec 2009 18:48:26 +0000

Home care benes falsely documented as blind diabetics.

Last week we told you about an OIG report that raised concerns over the high number of outlier payments for diabetic Medicare benes in the Miami-Dade area. Today, federal agents arrested about 30 suspects in three states Tuesday for alleged Medicare fraud totaling $61 million, reports Associated Press.

Once again, diabetes and home care appear prominently in press reports. The fraud schemes involved fake patients and claims for medically unnecessary equipment, physical therapy and HIV infusions, according to AP.

Among those arrested were a Florida doctor and 14 of his staff, including nurses, reports AP. The doctor is alleged to have run a $40 million fraud scheme in which he falsely claimed that patients were blind diabetics so he could bill for home health nurse visits twice a day.

It’s not just the RACs out there auditing you. Are you ready for the MICs? Quick checklist says for sure.

Don’t Count On Outliers Forever

Editor — Wed, 09 Dec 2009 04:41:06 +0000

CMS still may eliminate the PPS payment option entirely.

Home health agencies smarting at the looming 10 percent cap on home health PPS outlier payments may face even bigger woes ahead. If abusive billing of the outlier option continues even under the 10 percent cap that begins Jan. 1, the Centers for Medicare & Medicaid Services may cut outlier payments from the prospective payment system altogether. So says CMS in a new question and answer about the outlier payment changes.

“If CMS finds that the new CY 2010 outlier policy is not effective and/or achieving our goals, an alternative … would be to eliminate the outlier policy altogether (in future rulemaking),” the agency warns in the Q&A.

Plus: In a separate Q&A, CMS clarifies that claims are subject to the new outlier cap if they are paid at the 2010 rate.

A link to the Q&As is online here.

OIG Report Links Miami-Dade Home Health Outlier Payments to Diabetes

Editor — Wed, 09 Dec 2009 04:16:15 +0000

Medicare officials suspect kickbacks to physicians, beneficiaries.

A new HHS Office of Inspector General report targets home health outlier payments in Miami-Dade County, and legitimate home care providers worry that the crackdown will hurt some of the patients who really need care, reports The Miami Herald.

Among the OIG’s findings:

“Miami-Dade County accounted for more home health outlier payments in 2008 than the rest of the Nation combined.”
“In Miami-Dade County, Medicare outlier payments for home health claims with a primary diagnosis related to diabetes were eight times the national average.”

Medicare officials, the FBI, and federal prosecutors think that crooked home care providers are paying $100 to physicians for each referral. In addition, the HHAs are paying patients cash to use their Medicare numbers, as well as bribing them with flat screen TVs, groceries and housekeeping, reports the Herald.

2010 PPS: More Cuts for Case Mix Creep Hit Home Health

Editor — Wed, 18 Nov 2009 05:00:26 +0000

Just how much the feds will dock your HHA for perceived upcoding may depend on the health reform battle.

Your home health agency will getting 2.75 percent less in Medicare reimbursement next year thanks to so-called “case mix creep,” and that cut may only get steeper in years to come.

CMS set the home health agency episodic payment rate at $2,312.94 for 2010 in its prospective payment system rate update notice published in the Nov. 10 Federal Register. That’s a net 1.75 percent increase over this year’s rate, because changes to outlier payments and an inflation increase offset the cut for case mix creep.

CMS has made similar case mix creep cuts the last two years and already has set a 2.71 percent cut for 2011. But don’t count on the 2011 cut being the last one, or even staying at that level.

“Given the continued growth in nominal case-mix, we expect to revise upward the 2.71 percent reduction … in next year’s rule,” CMS says in the rate update. Click ‘read more’ to see a table of this year’s cuts …

But the industry isn’t taking the cuts lying down. “Our disagreements with CMS over its case mix creep adjustments continue,” notes the National Association for Home Care & Hospice’s Val Halamandaris. “We have no doubt that agencies are seeing sicker patients and more patients with needs for therapy.”

As shown by patient outcomes, agencies “are doing the right things for their patients,” Halamandaris says. “And Medicare has seen the benefits through controlled home health spending and reduced hospital readmissions. This is not the result of abusive coding creep.”

But in the final rule, CMS fends off numerous commenters’ arguments against the adjustment. A common protest was that clinicians’ OASIS coding skills have merely gotten more accurate.

Rationale: “Improved OASIS implementation, staff education, and improvements in documentation are indications of coding change, not an actual change in patient case-mix,” CMS maintains.

“While they may represent a much-desired improvement in the accuracy of data used to manage the care of patients, they do not represent cost increases related to the health status of patients.”

Bigger Case Mix Creep Cuts Loom

CMS actually is maintaining the 2.75 percent 2010 cut even though data show that the case mix increase was higher than the agency originally calculated. Case mix continues to “creep” upward, CMS finds.

It’s surprising to see a continued increase in perceived upcoding, notes financial expert Mark Sharp with BKD in Springfield, Mo. “You’d like to think that the creep would start to level off after an initial significant jump following the implementation of a new payment system,” Sharp says.

More ahead: In fact, CMS may assess even steeper case mix creep cuts when it starts examining data dating after the 2007 PPS refinements rule. That’s because you’d expect to see coding changes sparked by the reimbursement structure change. The influx of new providers in the past few years may also contribute to higher creep determinations, Sharp predicts.

Whether CMS actually imposes higher case mix creep cuts in the future could depend heavily on the health care reform legislation working its way through Congress, notes financial expert Pat Laff with Laff Associates in Hilton Head Island, S.C. Some legislation under consideration would preempt CMS’s cuts, but impose even steeper ones, Laff warns.

Don’t Consider These Rates Set In Stone

Watch out: Agencies should realize that the pending reform legislation could also affect rates in 2010, with significant cuts proposed for next year, Laff warns.

Planning for 2011 is difficult because “it seems light years away,” Laff laments. Agencies are having enough trouble planning for next year with legislative changes hanging over their heads.

“To say that this situation is fluid is an understatement,” Laff tells Eli’s Home Care Week. “There is a lot in play right now,” Sharp agrees. Most likely, the “final form of health care reform will determine what ultimately happens with 2011 home health payment rates.”

CPA and home health financial expert Aaron Little prepares you for PPS 2010 in this audio training event.

Final 2010 Home Health Service Rates Available

Editor — Wed, 11 Nov 2009 05:14:30 +0000

Watch Out: Congressional action could cut rates in near future.

As we mentioned last week, CMS issued the final home health prospective payment system update on Oct. 30. This week, we’ve got some preliminary analysis and handy advice from OASIS Alert editor Marian Cannell.

What Marian wants you to know up front and center? “Make sure you have the latest — and most accurate — version of software and instructions,” she stresses.

Dollars & Cents Summary: The final rule implements a 2 percent market basket update, a scheduled 2.75 percent “case mix creep” subtraction, and a new outlier policy that adds 2.5 percent to the base rate. This sets the overall base rate increase at 1.75 percent for calendar year (CY) 2010. The base episode rate for 2010 will be $2,312.94. The low utilization payment (LUPA) add-on will be $94.72.

The PPS rule contains a number of other ‘heads up’ rules and measures, which Marian lists here …

OASIS submission will be a condition of payment. CMS will require providers, prior to submitting a final PPS episode claim, to have submitted an OASIS assessment, and require that the HIPPS code on the final claim match the HIPPS code on CMS’ OASIS validation report. CMS has “no intention that this proposed requirement would have an effect on long-standing direction associated with submitting RAPS, OASIS completion timeframes, and instructions associated with one-visit episodes” the agency assures providers.

Outlier changes will be effective for one year. Efforts to decrease fraud by reducing and capping outlier payments did not change from the proposed rule. “Few HHAs would be negatively impacted with the change,” the National Association for Home Care & Hospice predicts.

Quality data available on Home Health Compare will increase. In CY 2010, CMS “will publicly report 12 nationally accepted and approved quality measures plus 13 new process measures,” CMS announces.

The Consumer Assessment of Healthcare Providers and Systems Home Health Care Survey (HHCAHPS) will begin in 2010. But CMS will delay linking the data to the annual payment update from CY 2011 to CY 2012.

Note: For more information and analysis of the final PPS rule, check Eli’s OASIS Alert next month.

Prefer to listen to the HHA PPS changes for 2010? Aaron Little, CPA can brief your whole staff for one low price.

Home Health PPS 2010 Final Rule: 2 Percent Market Basket Update

Editor — Wed, 04 Nov 2009 16:12:35 +0000

Tis the season for red leaves, red tape.

We’ve got the link that gives you a preview before the rule hits the Federal Register.

It’s that time of year again. The fall leaves are fluttering down from the trees, and pages and pages of final health care reimbursement rules are falling out of Baltimore.

CMS has published it’s final rule updating payments and policies for home health care, according to this agency release.

Check It Out: Go here to get a sneak peek at the rule before it’s published Nov. 10 in the Federal Register. The rule takes effect Jan. 1, 2010.

Highlights about the rule, according to the CMS press release:

Outlier payments for 60-day home health episodes of care: “For CY 2010, CMS will cap home health outlier payments at 10 percent per HHA and target total aggregate outlier payments at 2.5 percent of all HH PPS payments,” the release notes. Currently, in 2009, you have a 5 percent target for total aggregate outlier payments, so the number for 2010 is going to be harder to hit.

2 percent home health market basket update.

The final rule also addresses OASIS-C and Home Health Compare.

Stay tuned to Home Care & Hospice News for a complete analysis of the final rule and what it means to YOUR bottom line.

And, dig deep into what the 2010 final rule does to your HHA’s finances in this audio learning event taught by Aaron Little, CPA.

Avoid These Hospice Eligibility Pitfalls

seank — Thu, 28 May 2009 20:48:25 +0000

If your hospice hasn’t taken a good look at how it determines–and documents–patients’ eligibility for the Medicare hospice benefit, you’re fair game for everything from payment recoupments to fraud and abuse investigations.

There’s no shortage of reasons for hospices to pay close attention to patients’ hospice eligibility, an issue that has moved to the front burner for payers and prosecutors.

First, there’s the specter of the $24.8 million SouthernCare qui tam lawsuit settlement involving allegations that the hospice kept patients on the benefit who didn’t need it.

Experts also predict the Recovery Audit Contractor program will likely target the hospice eligibility issue, which provides easy pickings.

Not only that: Providers that consistently have longer-than-average lengths of stay will likely prompt a medical review, if a hospice shows persistently higher-than-average LOS compared to what the CMS reported as the average, predicts consultant M. Aaron Little with BKD in Springfield, Mo.

AUDIO TRAINING EVENT: What every hospice should do at the onset of a probe edit – even if you aren’t in the wrong. With attorney Mary Michal.

“The longer lengths of stay are not only an issue from a medical review perspective,” adds Little. They “can also put a provider in a situation where it exceeds the per beneficiary cap, which is an average over the reporting year.”

And hospice eligibility is a favorite target for surveyors, experts point out.

One Trajectory Doesn’t Fit All Patients

Hospice teams tend to do “snapshot documentation”about the hospice visit where the interdisciplinary group members describe what they saw and did for the patient, says consultant Joy Barry with Weatherbee Resources in Hyannis, Mass. But that approach doesn’t provide “a good picture — painted in words – of the patient’s trajectory of illness over time,” Barry cautions.

Instead: The narrative documentation should include “clinically measurable” data points that show the patient’s decline is consistent with a six month or less prognosis.

Hospices also have to anticipate and address a terminal illness’ expected trajectory of decline. For example, “dementia typically has a long, slow, dwindling decline,” says Barry. By contrast, organ-system diseases, such as cardiac or pulmonary disease,tend to produce a “saw-tooth pattern” of exacerbations followed by slight improvements with periods of relative stability in between. But over time, the patient fails to recover his baseline and shows decline, she notes.

By knowing the expected trajectory, hospice providers can document accordingly. “Documenting decline in dementia, for example, could be as simple as noting the person needs increasing caregiver support with all ADLs,” says Barry.

You also have to know the local coverage decisions. For example, an LCD might have criteria for dementia spelling out how many ADLs the person can perform and a “whole list of elements” that would determine a prognosis of six months or less, says attorney Mary Michal, with Reinhart Boerner Van Deuren in Madison, Wis.

Terminal cancer usually has a rapid, downhill trajectory, Barry says. So if the hospice is seeing a saw-tooth pattern in a patient with cancer, the team should take a closer look, she advises. “Some cancers– pancreatic cancer or glioblastoma, for example – can be very aggressive” and cause the person to die in fewer than six months. By contrast, stomach cancer and certain lung cancers may not have such a “rapid downward trajectory.”

Ask key questions: “Hospice staff may not be able to discern one cancer from another – relative to eligibility requirements – without asking about the type of cancer, how widespread the cancer is, what the treatment plan has been to date, the patient’s response to treatment, etc.,” says Barry.

Home In On Outliers

If the patient lives longer than expected, the hospice has to determine whether it is a situation involving what’s called failure to die – or one where the patient should be discharged from hospice due to an extended prognosis, says Barry.

“Failure to die” is a real issue, however, she adds. “A patient can be very appropriate for hospice services and simply not die – and no one can explain why,” although the patient is declining. In such cases, the hospice documentation must speak to the “failure to die” issue – and the patient’s eligibility for continuing hospice care, Barry emphasizes.“The hospice should be proactive in getting physicians to make home visits to help document the patient’s eligibility.”

Also keep in mind that hospice patients fall on a bell curve, which includes outliers on both ends. “If you pay close attention to the latter part of the definition of terminally ill, it allows for outliers,” says attorney Connie Raffa with Arent Fox in New York, N.Y.

Raffa points to a study by a Harvard researcher published in the New England Journal of Medicine which concluded that if a hospice has 5 percent or less of its population living beyond a year from the date of admission, those are the outliers. And the outliers are permitted by the second part of the definition of “terminally ill” in 42 C.F.R. 418.3 “if the illness runs its normal course,” says Raffa.“That isn’t fraud.”