Mission Home Health of San Diego Inc. was overpaid $61,718 in 2015 and 2016, which was extrapolated to $5.9 million, according to the latest Medicare home health agency (HHA) provider compliance audit. The HHS Office of Inspector General (OIG) recommended the HHA refund the portion of the money within the reopening period and hunt down additional overpayments in accordance with Medicare’s 60-day overpayment refund rule, the audit report[1] said.
Mission Home Health disagreed with virtually all of OIG’s findings and recommendations, and before the report was finalized, OIG said it “reduced the sampled claims incorrectly billed from 38 to 32 and revised the related findings and recommendations.” Otherwise, “We maintain that our remaining findings and recommendations are valid, although we acknowledge Mission Home Health’s right to appeal the findings.”
OIG audited a stratified random sample of 100 claims worth $415,271 for compliance with certain billing requirements, and an independent medical review contractor evaluated whether the services met coverage, medical necessity, and coding requirements. OIG’s conclusions: 32 claims were noncompliant because services were provided to Medicare patients who weren’t homebound or didn’t require skilled services; claims had the wrong Health Insurance Prospective Payment System codes; and documentation was insufficient to support the services provided.[2]
OIG recommended Mission Home Health return to Medicare the portion of the $5.9 million in overpayments that are within the reopening period and to “exercise reasonable diligence to identify and return overpayments in accordance with the 60-day rule.”
In a written response on behalf of Mission Home Health, the law firm Bass, Berry & Sims said no response was necessary for three of the four areas because OIG found the compliance rate was at least 97%. In the fourth area, homebound status, the letter said OIG’s medical reviewer focused on how far the patient could walk, “which is not only clinically inappropriate but also directly contrary to Medicare guidance.” The law firm also disagreed with the recommendations. For example, refunding money under the 60-day rule is “premature” during the appeals process, as CMS has acknowledged, the letter said.
Other HHAs Are Under the Microscope
OIG has released several provider compliance audits of HHAs in the past few months. For example, in April, OIG said Residential Home Health, a for-profit home health care provider with locations throughout the Midwest, received overpayments of $16,927 in 2014 and 2015. “On the basis of our sample results, we estimated that Residential received overpayments of at least $2 million in CYs 2014 and 2015,” OIG said in the report.[3] Although the incorrectly billed claims are outside the reopening period, OIG recommended the HHA “exercise reasonable diligence to identify and return overpayments” consistent with the 60-day rule.
On Aug. 12, OIG posted a report[4] that said Condado Home Care Program Inc., in San Juan, Puerto Rico, was overpaid $13,771 during a two-year audit period, which OIG extrapolated to $97,210.