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OIG 2011 Work Plan Home Health Issues

Home Health Care Issues In OIG 2011 Work Plan

We are a little late at reporting this, but a couple of months back, the OIG released its Work Plan for Fiscal Year 2011. This publication provides brief descriptions of activities that the Office of Inspector General (OIG) plans to initiate or continue with respect to the programs and operations of the Department of Health & Human Services (HHS) in fiscal year (FY) 2011.  I will be posting several smaller articles of interest as a continue my more detailed review of the OIG Work Plan for 2011.  You can access the entire 2011 OIG Work Plan at the following link:

This particular article will focus on some of the 2011 Work Plan issues that apply to home health providers.  The 2011 OIG Work Plan identified several key areas of focus for home health agencies.

Part B Payments for Home Health Beneficiaries

The OIG will be reviewing Part B payments for services and medical supplies provided to beneficiaries in home health episodes. Most services and non routine medical supplies furnished to Medicare beneficiaries during home health episodes are included in the home health agency (HHA) prospective payments. Normally payment for  home health services furnished under a plan of care of an HHA are made to the home health agency.  This includes payment for services and supplies provided under arrangements by outside suppliers. The OIG will be focusing on the identification of  Part B payments to outside suppliers for services and medical supplies that are included in the HHA prospective payment.  OIG will be conducting examinations concerning the adequacy of controls that the home health agency established to prevent inappropriate Part B payments for services and medical supplies.

Claims for Medicare Home Health Resource Groups

In order to receive home health services a patient must meet certain coverage requirements including:  (1) the patient must be homebound; (2) the patient must require intermittent skilled nursing care, physical or speech therapy, or occupational therapy; (3) the patient must be under the care of a physician; and (4) have a physician established and periodically reviewed plan of care.  The Work Plan states that the OIG will continue to perform reviews to assure compliance with these conditions of coverage.

Medicare reimburses for home health services on a prospective basis based on categories that are grouped based on the patient’s need for care and resources.  These categories are referred to as Home Health Resource Groups.   HHRGs are assigned based on an assessment of each patient.  The OIG  Work Plan will target the assignment of HHRG codes assigned to patients.

Home Health Agency Outcome and Assessment Information Set Data

Federal regulations require home health agencies to conduct  comprehensive patient assessments.  These examinations must include OASIS data items which must also be submitted to CMS.  The OASIS data is used by CMS in the home health prospective payment system. OASIS quality data is also used in CMS’ Home Health Compare web site.  The OASS data contains information on the performance of the home health agency in assisting patients to regain and maintain functioning and the activities involved with daily living.  The 2011 Work Plan states that the OIG will be reviewing CMS’s process to assure that the data being reported by home health agencies is complete and accurate.

PPS System Controls For Home Health Agencies

The OIG expresses concern with the rapid increase in home health expenditures since PPS was implemented in 2000. As a result of this concern, the OIG will be examining many aspects of the home health PPS.  Some of the areas specifically mentioned include whether the billing is for an the appropriate location, an analysis of trends in home health activities, visit frequency, ownership arrangements and arrangements with other providers and facilities.

Examination of Home Health Profit Margins

Again stating a concern over the growth in home health spending since PPS was implemented, the OIG states an intention to examine home health profitability. The OIG will examine cost report data to determine trends in profitability of home health providers since home health PPS was implemented.

Medicare Home Health Agency Enrollment

The OIG highlights DME suppliers, that it claims are often associated with home health agencies, who have been found to have provided innacurate information in their enrollment documentation.  The OIG states that it will be reviewed CMS and state agency program integrity efforts during the enrollment process to be certain that complete and accurate applications are provided.

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John H. Fisher

Health Care Counsel
Ruder Ware, L.L.S.C.
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