The Office of the Inspector General has released its annual focus through its work plan. Here is what the OIG will watch for the fiscal 2012 year in home health. Note the extremely strong emphasis on checking data, requirements, and regulations.
- States’ Survey and Certification of Home Health Agencies: Timeliness, Outcomes, Followup, and Medicare Oversight (New)
OIG will review standard and complaint surveys conducted by State Survey Agencies and Accreditation Organizations for the outcomes and the nature and followup of complaints against HHAs. CMS relies on the survey and certification process to ensure HHA compliance with Medicare Conditions of Participation (CoP). HHAs must be surveyed at least every 36 months.
- Medicare’s Oversight of Home Health Agencies’ Patient Outcome and Assessment Data
OIG will review OASIS data submitted by Medicare-certified HHAs, including CMS’s process for ensuring that HHAs submit accurate and complete OASIS data. Federal regulations require HHAs to conduct accurate comprehensive patient assessments that include OASIS data items and submit the data to CMS.
- Missing or Incorrect Patient Outcome and Assessment Data (New)
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.
- Questionable Billing Characteristics of Home Health Services (New)
OIG will review home health claims to identify home health agencies that exhibited questionable billing in 2010. Questionable billing refers to claims that exhibit certain characteristics that may indicate potential fraud. … “The home health benefit was originally intended for short-term, posthospital recovery for homebound beneficiaries, but it has been expanded to include other types of homebound beneficiaries.”
- Home Health Agency Claims’ Compliance With Coverage and Coding Requirements
OIG will review Medicare claims submitted by HHAs to determine the extent to which the claims meet Medicare coverage requirements. “We will assess the accuracy of resource group codes submitted for Medicare home health claims in 2008 and identify characteristics of miscoding.”
- Medicare Administrative Contractors’ Oversight of Home Health Agency Claims (New)
OIG will review fraud and abuse prevention and services performed by the home health benefit MACs. We will also review the reduction of payment errors by MACs.
- Wage Indexes Used To Calculate Home Health Payments (New)
OIG will determine whether Medicare home health payments were calculated using incorrect wage indexes and evaluate the adequacy of controls to prevent such inaccuracies.
- Home Health Prospective Payment System Requirements
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
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.
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