In August, the Office of Inspector General (OIG) of the U. S. Department of Health and Human Services released a report describing inappropriate and questionable billing by home health agencies.  The OIG conducted the study because recent investigations and studies showed that home health agencies are vulnerable to fraud, abuse, and waste.  The OIG identified inappropriate claims by examining claims data from home health, inpatient hospital, and skilled nursing facilities.  The OIG also looked at HHAs that billed unusually high amounts according to at least one of its six measures of questionable billing.  The report determined that Medicare inappropriately paid $5M for home health claims with three specific errors in 2010.  To read the report, click here.

Attorney Elizabeth Hogue prepared a concise, helpful summary of the report as follows:

The OIG issued Report OEI-04-11-00240 in August, 2012, entitled “Inappropriate and Questionable Billing by Medicare Home Health Agencies.” Unlike some other guidance published the OIG, this Report provides detailed information about inappropriate and questionable billing practices by home health agencies (HHA’s). Specifically, the OIG concluded that HHA billing is questionable or unusually high on the six measures below, if greater than the 75th percentile plus 1.5 times the interquartile range. The six measures are as follows:

 1. High average outlier payment amounts per beneficiary

According to the OIG, HHA’s with outlier payments above $403 per beneficiary have unusually high outlier payments and are likely engaging in questionable billing practices.

Earlier this month, the US Dept. of Health and Human Services Office of inspector General (OIG) issued a report regarding suspicious billing practices by community mental health clinics (CMHCS).  OIG scrutiny of CMHCs, particularly with respect to partial hospitalization programs (PHPs), is probably not a surprise to those in the Texas mental health provider community…

Recently, the United States Court of Appeals for the Second Circuit heard arguments on whether lawyers are allowed to bring whistleblower lawsuits against their employer and client (U.S. ex rel. Fair Laboratory Practices Associates vs. Quest Diagnostics Inc. et al.).  A U.S. District Court threw out the case in April of 2011, ruling that…

Last week, Paul Ryan accepted the nomination for Vice President.  In his acceptance speech, he cited “Obamacare” as the greatest threat to Medicare, but many hospitals view the expansion of coverage for low-income individuals positively.  More and more community hospitals are urging their state governments to accept payments for expanded Medicaid programs under the…

On August 10, 2012, HHSC-OIG posted proposed regulations that would expand the power and reach of the Office of Inspector General.  These regulations broaden the net so that persons who are affiliated with a provider can be sanctioned along with a provider as a result of such affiliation, and “affiliate” is broadly defined.  These regulations…

The FTC recently provided yet another warning to healthcare organizations that they must take the time to analyze potential antitrust implications when considering an acquisition or consolidation.  On August 6, the FTC  and Nevada Attorney General announced the filing of a lawsuit and proposed consent decrees settling litigation filed against Renown Health, the largest hospital provider in…

HHSC is performing certification/recertification review of all Durable Medical Equipment (DME) providers.  Over the past few weeks HHSC has been making site visits to Medicaid enrolled DME suppliers to verify operations and enrollment data.  Medicaid DME suppliers must cooperate with the HHSC investigators; a failure to do so may result in termination of a supplier’s…

On August 16, 2012, the U.S. Court of Appeals for the Fifth Circuit dismissed an appeal challenging the Patient Protection and Affordable Care Act’s (PPACA’s) restriction on expansion by physician-owned hospitals.  The lawsuit was initially filed in the Eastern District of Texas by the physician-owned hospital trade group (Physicians Hospitals of America) and a physician-owned

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A client recently asked me to review its fall policies and procedures as they relate to the standard of care.   Because that project was on my mind, the new training modules for nurse aides in long term care that were recently published by the Agency for Healthcare Research and Quality (AHRQ) caught my eye.  The three published modules are:

  1. Module 1: Detecting Change in a Resident’s Condition
  2. Module 2: Communicating Change in a Resident’s Condition; and
  3. Module 3: Falls Prevention and Management

Each module has an instructor’s guide and a student workbook that includes training materials, summaries and “Pearls and Pitfalls” to help staff become more aware of residents’ needs.   For example, the module on falls includes a mnemonic checklist “HEAR ME” to help prevent falls in the facility:

  • Hazards in the environment.
  • Educate residents.
  • Anticipate residents’ needs.
  • Round frequently.
  • Materials and equipment.
  • Exercises and ambulation.

Module 1 notes that the elderly do not exhibit the same signs and symptoms of illness that are seen in younger persons.  Therefore, identification of subtle changes can alert staff to a serious illness.  The AHRQ notes the top 12 changes in residents are:

A.  Physical Changes: Walking; Urination and bowel patterns; Skin; Level of weakness; Falls; and Vital signs.

B.   Non- Physical Signs: Demeanor, Appetite, Sleeping, Speech, Confusion or agitation, complaints of pain.

Our Insight. Your Advantage.   Much of the material will not be new to many providers.  However, use of the training modules developed, and following the steps advocated, by the AHRQ will provide strong evidence that the provider’s care was within the standard of care.   Long term care facilities that incorporate the AHRQ’s training standards into their care will be ahead of the game in number of areas such as:

  1. Regulatory compliance;
  2. Limiting exposure to civil malpractice;
  3. Reimbursement matters.

With the passage of the ACA, the voluntary nature of compliance programs is about to change. Smaller healthcare organizations and other ancillary providers who have previously not established compliance programs will now be required to adopt formal programs.  The ACA mandates providers and suppliers participating in federal health care programs to implement compliance programs with “core elements” as a condition of enrollment.

The HHS Secretary is responsible for setting a timeline to implement the new “core elements” for each health care sector and then setting a timeline for providers to adopt compliance programs.  Details regarding the extent of the program have not yet been described or published.  Skilled nursing facilities are the first providers required to implement an effective compliance program by March 23, 2013.

Our Insight.  Your Advantage.  By doing the work now, healthcare organizations can get ahead and avoid surprises when HHS eventually publishes the mandatory compliance program rules for other healthcare sectors. Many in the healthcare industry anticipate the OIG’s voluntary compliance program guidance will serve as an example to HHS as it determines which compliance program elements shall be required.  As you prepare your compliance programs,