Home Health Agencies OIG Work Plan 2009
Part B Therapy Payments for Home Health Beneficiaries We will review Part B payments for therapy services provided to beneficiaries in home health episodes. Therapy services furnished to Medicare beneficiaries during home health episodes are included in HHA prospective payments. The Social Security Act, §§ 1832(a)(1) and 1842(b)(6)(F), require that, in the case of home health services furnished under a plan of care of an HHA, payment for those services be made to the HHA, including payment for therapy services provided under arrangements by outside suppliers. We will determine whether payments made to HHAs are correct and supported for the service level claimed. We will identify Part B payments made to outside suppliers for therapy services that are included in the HHA prospective payment and examine the adequacy of controls established to prevent inappropriate Part B payments for therapy services. (OAS; W-00-09-35418; various reviews; expected issue date: FY 2009; new start) Accuracy of Coding and Claims for Medicare Home Health Resource Groups We will review Medicare claims submitted by HHAs to determine the extent to which the home health resource group (HHRG) billing codes that are used in determining payments to HHAs are accurate and supported by documentation in the medical record. The Social Security Act, § 1895, governs the payment basis and reimbursement for claims submitted by HHAs including a case-mix adjustment using HHRGs. Medicare pays for home health episodes based on a PPS that categorizes beneficiaries into groups, referred to as HHRGs. Each HHRG has an assigned weight that affects the payment rate. We will assess the accuracy of HHRG assignment and identify patterns of coding by HHAs. (OEI; 01-08-00390; expected issue date: FY 2009; new start) Physician Referrals for Home Health Agency Services We will review Medicare payments for home health claims to identify potential aberrant billing by referring physicians. Medicare home health expenditures were approximately $14.2 billion in 2007. The regulation at 42 CFR § 484.18 includes as a condition of participation for HHAs that a physician establish a plan of care. The instruction in CMS’s “Home Health Agency Manual,” Pub. No. 11, Ch. II, § 204.5, requires that a physician certification be included in the plan of care. CMS’s “Medicare Claims Processing Manual,” Pub. No. 100-04, ch. 10,
§ 40.2, requires home health claims to include an attending/referring physician identifier to receive Medicare reimbursement. We will examine trends in utilization patterns and Medicare reimbursement for services ordered by referring physicians. (OEI; 00-00-00000; expected issue date: FY 2009; new start) Medicare Home Health Payments for Insulin Injections We will review the incidence of Medicare home health services outlier payments for insulin injections. Insulin is customarily self-injected by a patient or is injected by a family member. However, CMS’s “Medicare Benefit Policy Manual,” Pub. No. 100-02, ch. 7, § 40.1.2.4.A.2, states that when a patient is either physically or mentally unable to self-inject insulin and no other person is able and willing to inject the patient, the injections would be considered a reasonable and necessary skilled nursing service under the Medicare home health benefit. The unit of payment under the home health PPS is a national 60-day episode rate with applicable adjustments. The law requires the 60-day episode to include all covered home health services, FY 2009 OIG Work Plan 10 Centers for Medicare and Medicaid Services including medical supplies, paid on a reasonable cost basis. When cases experience an unusually high level of services in a 60-day period, Medicare systems will provide additional “outlier” payments to the episode payment. Outlier payments can result from medically necessary high utilization of home health services. CMS makes outlier payments when the cost of care exceeds a threshold dollar amount. We will examine billing patterns in geographic areas with high rates of home health visits for insulin injections to determine the appropriateness of services billed. (OEI; 00-00-00000; expected issue date: FY 2009; new start) Comprehensive Error Rate Testing Program: Fiscal Year 2008 Home Health Agency Claims Error Rate We will review certain aspects of CMS’s Comprehensive Error Rate Testing (CERT) methodology for determining the 2008 HHA error rate. The Improper Payments Information Act of 2002 (IPIA) and the Office of Management and Budget’s (OMB) implementation of that act in memorandum M-06-23 require Federal agencies to annually develop a statistically valid estimate of improper payments made under programs with a significant risk of erroneous payments. To accomplish our objective, we will review HHA claims that were selected for review by the FY 2008 CERT program. Our review will consist of a statistical subsample of claims from the CERT’s sample of HHA claims. For the sampled claims, we will obtain medical records and other supporting documentation used to determine whether payments for services and items such as skilled nursing, therapy, home health aides, and medical
supplies were adequately documented, medically necessary, and coded correctly. We will obtain additional information for the sampled claims by conducting site visits to the HHAs that submitted the claims, the referring physicians, and the beneficiaries. We will also determine whether the beneficiaries met the requirements for “homebound.” We will engage independent medical reviewers to determine the medical necessity and sufficiency of documentation for these claims. (OAS; W-00-09-40034; expected issue date: FY 2009; new start)