OIG Report: CMS Needs to Provide More Oversight of HHA Program Integrity Efforts

On December 19, 2012, the US Department of Health and Human Services Office of the Inspector General’s (OIG) Office of Evaluation and Inspections (OEI) issued a report (OEI-04-11-00220) entitled “CMS and Contractor Oversight of Home Health Agencies”.

The OIG has consistently identified home health care as an area of concern and it believes home health care is “particularly vulnerable to fraud, waste, and abuse.” Additionally, the OIG has, in other studies it conducted, found vulnerabilities in CMS contractors’ efforts to identify and investigate potential fraud and abuse in home health, as well as limitations in CMS’s oversight of contractors. In order to evaluate contractor performance and CMS oversight, the OEI collected information and supporting documentation from CMS, selected Medicare Administrative Contractors (MAC), and selected Zone Program Integrity Contractors (ZPIC). OEI focused on geographic areas prone to HHA fraud, waste, and abuse to determine whether contractor activities focused on these areas. OEI also analyzed claims data to determine whether Medicare paid HHAs that were suspended or had their billing privileges revoked, and the timeliness with which CMS and its contractors acted on provider number revocation recommendations.

The results of its review of the program integrity efforts of CMS, the MACs and ZPICs were mixed. While OEI found that a substantial amount of improper payments were prevented, the efforts of the ZPICs varied widely and did not identify any HHA vulnerabilities. Additionally, CMS inappropriately paid five HHAs with suspended or revoked billing privileges and did not act on all revocation recommendations.

OIG’s recommendations in the report are what you would expect and essentially can be summed up as -> CMS you need to do more to address fraud in home health.  OIG recommends that CMS: (1) established additional performance standards for contractors relating to high-risk providers in fraud-prone areas; (2) develop a system to track revocation recommendations and respond to them; and (3) follow-up on and prevent inappropriate payments made to HHAs with suspended or revoked billing privileges.

The take-away from this report is that the OIG will continue to hound CMS on home health program integrity issues. Additionally  CMS concurred with all of OIG’s recommendations.  As a result, the industry can expect continued and increased scrutiny, particularly from the ZPICs and related MAC program integrity functions.

You can find a copy of the OIG report here —>   OEI-04-11-00220

For more information on the OIG Report, Medicare Program Integrity initiatives, home health fraud and abuse issues, or related issues, please feel free to contact Ari Markenson or any member of our health care practice group for a further discussion.

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