Home Health Agencies: Understanding Fraud, Waste and Abuse

Understanding Your Impact
in Fraud, Waste & Abuse
Home Health Agencies
Presented by Ciara Lewin, Owner of Elite
Precision Consulting
December 2019

Objectives
ith the new PDGM effective January 1, 2020 along
with the scrutiny posed on HHAs, this training will
help you to understand the following:
W
What is FWA and how does it impact HHA
What you need to know about PDGM and your
agencies sustainability
Where you may be at risk today and how you
can mitigate
How to quickly assess the readiness of your
operations and coding/billing team
What steps should be taken before January 1st
is here and to prepare for continual success
This is tailored to stakeholders,
executives and management
responsible for the operations
of their HHA. This is not
clinical training or expertise.
www.eliteprecisionconsulting.com

Why Do We Care?
orking alongside physicians and healthcare
professionals for over 15 years, we've seen the
stress, frustration and anxiety behind running a
profitable business and ensuring quality care for
patients. We've built a foundation of excellence,
actionable education and quality outputs so the
providers can get back to their first love!
W
Home health agencies have had increasing scrutiny
over the decade but since 2015 we've seen more
agencies suffering rather than profiting and so we
wanted to help.
because of their in-depth, extensive knowledge of
the industry.
"I highly recommend
Elite Precision...
Ciara also is a woman of the highest integrity, professionalism and delivers results that
can be utilized immediately producing a very high return on investment."
- M. Kuechler, Chief Operating Officer

Let's Get to the Point
$760 B
With this focus, government agencies are expected to increase their FWA
resources by nearly 40% in the upcoming years.
IN WASTE IS ESTIMATED FOR ALL SPECIALTIES
>4.5Mpatients
receive home care services as of 2017.
>$18 B
spent
by Medicare and other payers for these
services per year
HHAs must focus on ensuring
timely and quality care,
maintaining operation efficacy
and ensuring profitability, yet
with heightened FWA resources
by CMS and other agencies,
many HHAs are unaware of their
level of vulnerability and what
precautions are necessary to
stay sustainable.

Why Home Health?
Announced in CY 2015
Announced in CY 2018
Even though Home Health accounts for less than 5% of Medicare
Payments, they have one of the highest error rates amongst all
specialties.

What Exactly is FWA?
Fraud
Waste
Abuse
Actions that may, directly or indirectly, result in unnecessary costs
to the Medicare Program... And involves paying for items or
services when there is no legal entitlement to that payment, and
the provider has not knowingly or intentionally misrepresented
facts to obtain payment.
Knowingly submitting, or causing to be submitted, false claims or
making misrepresentations of fact to obtain a Federal health care
payment for which no entitlement would otherwise exist..knowingly
soliciting, receiving, offering, or paying remuneration (e.g., kickbacks,
bribes, or rebates) to induce or reward referrals for items or services
reimbursed by Federal health care programs..and knowingly billing for
services at a level of complexity higher than services actually provided
or documented in the medical records.
Any practice that does not provide patients with medically
necessary services or meet professionally recognized
standards of care.

What Does it Mean for
HHAs?
Fraud
Waste
Abuse
Performing therapy services in excess to the care plan for the
patient.
Submitting claims for payment that are misrepresented in the
documentation
Performing and being reimbursed for services that is not
medically necessary for patient
Having monetary payouts or incentives to community, PCP or
hospitals in exchange for referrals to your HHA.
Prescribing or adminstering opoids or other drugs without
clear documentation in care plan.
Improperly reporting codes for services not
performed

Background Insight
Office of Inspector General is an organization tasked to audit and assess
the efficacy of healthcare programs.
For Home Health, this means ensuring quality patient outcomes,
appropriate reimbursement for services and optimizing claims data.
In the past years, OIG would make public what topics and specialties they
would target in their auditing processes.
Since 1997 OIG made this 600+ page document available until 2017 in
which they publish this annual report on a monthly basis.
' You can access
education on our
website or call our
attorneys for more
information.'
How does OIG
help educate
providers to
ensure they are
compliant?

Background Insight
Complaints OIG investigate include:
Complaints from HHS employees, grantees or contractors
about fraud, waste, abuse or mismanagement in HHS
programs (whistleblower complaints),
Crime, gross misconduct, or conflicts of interest involving
HHS employees, grantees or contractors,
Fraud, waste, or abuse relating to HHS grants or contracts,
False or fraudulent claims submitted to Medicare or
Medicaid,
Kickbacks or inducements for referrals by Medicare or
Medicaid providers,
Medical identity theft involving Medicare and/or Medicaid
beneficiaries,
Failure of a hospital to evaluate and stabilize an emergency
patient,
Abuse or neglect in nursing homes and other long-term-care
facilities
To OIG, ignorance is not
bliss. There is no free
pass due to lack of
awareness or
knowledge.

Here to Save the Day
We know that HHAs don't have the time nor patience
to sift through various articles, webinars and
podcasts. So we've provided what you need to know
now and in the future.
As we delve into the
various areas of risk,
PDGM and audit
targets, we will
provide an easy
visualization that tells
you to 'take note' as
this may be worth
exploring in your own
practice.

PDGM: What's
Important
Up until now, all HHAs are paid through Home
Health Prospective Payment System (HHPPS).
Beginning January 1, 2020, payments and all
operations will need to align to Patient Driven
Groupings Model.
The purpose of this new model according to CMS is
to better align payment with cost of treating
patients, provide access to care for more acutely ill
patients, improve quality by grouping patients into
clinically meaningful categories and to eliminate
therapy driven payments and incentives.
Patient Driven Groupings
Model

Let's Compare
Patient Driven
Groupings
Model
Current
HHPPS
Unit of Payment : every 60
days
National standard 60-day
payment rate $3,154
Admission Source from
OASIS data
Clinical Domain from OASIS
and up to 95K diagnosis to
chose from
153 Home Health Resource
Groups
Low-Utilization Payment
Adjustment (LUPA) is fewer
than 5 visits made during
60-day episode
All payers follow HHPPS
Unit of Payment : every 30
days
National standard 30-day
payment rate $1,864 w/
quality data
Admission Source from
Claims Data
Clinical Severity is Primary
Diagnosis only and only 43K
diagnosis are acceptable
432 Home Health Resource
Groups
Low-Utilization Payment
Adjustment (LUPA) varies
between 2-6 depending on
HHRG
Only Medicare and Tricare
have mandated PDGM; other
payers may still follow
HHPPS
Register for iQIES by December 23. All (HHAs) need access to
the upgraded Internet Quality Improvement and Evaluation
System (iQIES) to submit assessment data beginning January 1.
CMS will return claims that cannot be matched to assessments,
delaying your Medicare payments.

Why It's Important
Clinical Severity is Primary Diagnosis only
and only 43K diagnosis are acceptable
ICD-10-CM codes such as R62.0 and many other Signs & Symptoms
diagnosis will not be allowed under PDGM as primary diagnosis.
This means 3 things:
Clinical documentation must have specificity
Coders must be up to date on the new acceptable diagnosis
codes and utilize the CMS Grouper Tool for each claim
Failure to adhere to this could result in additional scrutiny for
your agency
Expected Issue Date: 2020
FollowUp Review for Post
Acute Care Transfers
Focus on accuracy of diagnosis codes from
Inpatient settings to post acute care such as home
health and SNFs

Why It's Important
432 Home Health Resource Groups
compared to current 153 HHRGs
Understanding the complexity
of properly categorizing the
HHRGs for the new PDGM will
require attentiveness to the
clinical condition, comorbidity
found from secondary
diagnoses and knowing the
severity threshold from each
clinical group.
Expected Issue Date: 2020
Home Health
Compliance with
Medicare Requirements
Focus on all levels of home health services to
identify improper payments.

Let's Dig Deeper
Audited in May 2019
Great Lakes Home Health
Services
Outcome: Refund of $10.5 Million
Purpose
CMS has shown that in previous years home health services had
significant over payments largely in part to the fact that the patients were
not homebound or in need of skilled services.
Findings
Great Lakes did not comply with 38 out of 100 sampled claims that were
reviewed. For those claims alone, resulted in $64,114 in overpayment
from 2014-2015. After extrapolating, the final refund amount due was
$10.5 million.
If you have not completed an internal audit to ensure
accuracy for necessity for skilled services and need for
confinement to home, now is the time.

Let's Dig Deeper
Audited in May 2019
Great Lakes Home Health
Services
Challenge
Great Lakes was one of the few organizations who were prepared for their
audit. Having expertise internally they were able to challenge OIG's
medical review decisions.
Result
After additional review, OIG removed 21 out of the 59 claims originally
found to be in error in their draft report.
Do you have an expert on your side to challenge when
CERT or OIG audit comes your way?

Let's Dig Deeper
Audited in May 2019
Metropolitan Jewish
Home Care, Inc
Purpose
CMS wanted to ensure this HHAs complied with Medicare regulations.
Again stemming from the initial investigation that began CY 2014.
Findings
Out of 100 claims reviewed, 11 were found to have improper payments
due to beneficiaries that were not homebound or didn't require services
and claims in which the services were not supported by documentation.
These 11 claims resulted in $34,514 overpayment and after extrapolating
a total refund due of $2.9 million.
accuracy in documentation to ensure it supports services
billed, now is the time.

Let's Dig Deeper
Audited in August 2019
Mederi Caretenders
Home Health
Purpose
Again stemming from the initial investigation that began CY 2014.
Findings
Out of 71 claims reviewed, 21 were found to have improper payments due
to beneficiaries that were not homebound or didn't require services,
claims in which the services were not supported by documentation and
incorrect billing code. These 21 claims resulted in $31,428 overpayment
and after extrapolating a total refund due of $1.26 million.
accuracy in billing codes , now is the time.

Let's Dig Deeper
Audited in December 2019
Palos Community
Hospital Home Health
Agency
Outcome: Refund of $680K
Purpose
Using a stratified random sampling that is triggered from internal
algorithms, they initiated this audit.
Findings
Out of 100 claims reviewed, 16 were found to have improper payments
due to beneficiaries that were not homebound or didn't require services,
claims in which the services were not supported by documentation and
incorrect billing code. These 16 claims resulted in a $22,428 overpayment
and after extrapolating a total refund due of $680,884.
If you have not completed an internal audit of a minimum
of 100 claims over the past 2 years, your risk is higher
than you think.

What's the Trend?
Due Diligence and Strength
What OIG Recommends: We recommend that agency exercise reasonable
diligence to identify and return overpayments in accordance with the 60-
day rule and identify any returned overpayments as having been made in
accordance with our recommendations. We also recommend that agency
strengthen its procedures to ensure that (1) the homebound statuses of
Medicare beneficiaries are verified and continually monitored and the
specific factors qualifying beneficiaries as homebound are documented
(2) beneficiaries are receiving only reasonable and necessary skilled
services and (3) reimbursement for services comply with Medicare
documentation requirements.
How would you rate your due diligence and procedure
resilience?

Technology or Tips
Patients Can Call Anytime
800-HHS-TIPS
Patient Complaints
While many HHAs have a system in place to address patient complaints
and dissatisfaction from a clinical perspective, most do not understand
the repercussions of dissatisfied patients.
Patients have the ability to contact OIG directly to report what they may
feel is fraudulent. This triggers the over 1600 OIG team members possibly
to investigate and ultimately audit your HHA.
'We receive nearly
115,000 tips yearly
from our Hotline.'

Where To Start?
ollecting and assessing your data can feel
overwhelming. However, using these tips below, you
can begin to bite a chunk in this FWA pie.
C
Use the guide to start assessing
where you feel your biggest area of risk may
be
Work very closely with your clinical team to
ensure the workflow of your HHA is
optimized for the new PDGM
Collaborate with your coding and billing
team to ensure they are up to par on the
new regulations
60- day rule: Once you identify a problem,
overpayment or improper payment, notify
payer immediately
Continue to show due diligence in educating
your HHA on Medicare regulations

Transferring Risk
any HHAs utilize coding and RCM vendors to ensure
their coding and billing is done properly. Sadly, many
organizations too are inept to provide the level of
expertise needed for the scrutiny and upcoming
changes for HHAs. Below is a guide to help you
assess your coding/billing team's readiness and
awareness of the PDGM and audit triggers.
M
Request: Please provide top 10 areas of
potential risk based on my claims data from
CY 2017-present
Educate: Please provide 1 hour training to
clinical and operation staff to ensure our
documentation is up to par with new
regulations
Visualize: Please share with me how you
have monitored our claims data on a
monthly basis to ensure our agency is not
exposed to unnecessary audits from our
payers
If this information cannot be provided to you within 24
hours, your coding/billing team is not ready and thus
putting you at risk.

How We Serve
ollating historical data over the past 7+ years from
federal agencies, clients, focused audits and various
federal-based educational tools, we've created a
easy to understand model in understanding your risk
vulnerability and gaps.
We understand how intricate home health services
can be and place value on patient safety along with
business goals realization.
C
Let Us Help!
bringing a proactive, professional approach
and ensuring our organization was complaint.
"They provided cutting edge
auditing & education...
Elite Precision Consulting has always educated us on potential
changes in medical claim coding, billing, compliance and
healthcare changes.'
- M McMeechan, Chief Operating Officer

How We Thrive
ollaborating with your teams, we house a group of
highly skilled global experts with deep roots and
expertise in vendor relationship primarily in US and
Asia countries to ensure your vendor can be brought
up to speed and proactive in communicating your
risk tolerance and vulnerability.
C
Let Us Help!
because of their in-depth, extensive knowledge of the
industry.
"I highly recommend
Elite Precision...
Ciara also is a woman of the highest integrity, professionalism and
delivers results that can be utilized immediately producing a very high
return on investment."
- M. Kuechler, Chief Operating Officer

Conclusion
They here to stay. So embrace the
change, prepare your agency for a
successful future and utilize the
expertise to bridge the gaps in
knowledge.
PDGM and OIG
$ 6 BILLION
IN RECOVERIES FOR CY 2019
Don't be their next target.

Resources
1. https://oig.hhs.gov/reports-and-
publications/archives/workplan/index.asp
2. https://www.cms.gov/Outreach-and-
Education/Medicare-Learning-Network-
MLN/MLNMattersArticles/Downloads/MM11536.pdf
3. https://www.cms.gov/center/provider-type/home-
health-agency-hha-center ICD grouper
publications/workplan/summary/wp-summary-
0000338.asp
publications/workplan/summary/wp-summary-
0000100.asp
6.
https://oig.hhs.gov/oas/reports/region5/51600057.asp
7.
https://oig.hhs.gov/oas/reports/region2/21601001.pdf
8.
9.

Questions?
Contact Us
Today for Free
Consultation
We Are Here to
Help
Phone: 800-674-3732
Email: info@eliteprecisionconsulting.com
Website: www.eliteprecisionconsulting.com

Home Health Agencies: Understanding Fraud, Waste and Abuse

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