A new report issued by the OIG should place some agencies on alarm. The report indicates that claim data from 2014-2015 was used to detect patterns of potential fraud and abuse. This time though, OIG is making the data personal with visits to agencies themselves. Unlike previous reports where OIG issued the reports and then left it to CMS to act on the findings, OIG is moving forward with combatting potential fraud issues themselves.
The 500 agencies that were identified by the OIG for potential fraud, waste, and abuse are going to be personally contacted. A plan of correction will be implemented along with mandated education by CMS on the proper usage of home health. The agencies were identified through claim data and consistent geographic areas that have shown strong tendencies towards fraud, abuse, and waste.
Using the claim data, OIG determined that the 500 selected agencies all shared the following 5 characteristics which made claims stand out.
- High percentage of episodes for which the beneficiary had no recent visits with the
supervising physician.
- High percentage of episodes that were not preceded by a hospital or nursing home stay.
- High percentage of episodes with a primary diagnosis of diabetes or hypertension.
- High percentage of beneficiaries with claims from multiple HHAs.
- High percentage of beneficiaries with multiple home health readmissions in a short
period of time.
Agencies should also be aware that OIG is reviewing arrangements between physicians and agencies for any improper dealings. For agencies who receive a bulk of their patients from one or two physicians, and those physicians may also be paid medical directors, you might want to consider increasing your referral base.
As time goes on, agencies will be coming under greater scrutiny. The best defense is to do it right from the start – no shortcuts. Proper documentation, clinical education of staff, and engaged management will all drive the effort towards compliance. Without a focus on strong compliance you are wrong in thinking that you aren’t going to be touched, and the consequences are going to be devastating to your agency.