OIG Says What?: Keeping your Agency up on Regulations

OIG Says What?: Keeping your Agency up on Regulations

Do you ever get the feeling that government regulators are not telling you the whole story regarding the standards to which your agency will be held?  Have you ever said to yourself, “If only I knew what the regulators and auditors were looking for, I could just give it to them?”  I know that I said that to myself many times over while I was the administrator of my home health agency.  

Fortunately, when it comes to Medicare home health, the chief regulatory agency, the Office of the Inspector General of the Health and Human Services Department (OIG) often tells us expressly what is on their mind and what their focus is.  Knowing what Medicaid and Medicaid waiver regulators want is not always so easy to discern.  Medicaid is a joint federal and state program with state agencies being the chief Medicaid regulators.  Some state regulators are somewhat transparent while other states’ regulators play it very close to the vest and reveal little until it is audit time.

The OIG publishes its work plan which lists its areas of focus and its current regulatory projects.  The work plan is updated regularly and can be found here.  The OIG also regularly publishes other reports and guidance documents for providers in Medicare, Medicaid and other federal health care programs.  One of the OIG’s publications that should be of special interest to Medicare home health agencies is a report that was made public in June of 2016.  The report is entitled Nationwide Analysis of Common Characteristics in OIG Home Health Fraud Cases.  A copy of the report can be downloaded here. The report lays out the findings of a study by the OIG of the most common characteristics found in instances of home health fraud.  This report is instructive for home health agencies and its findings should be used by home health agencies in their internal audit and monitoring program.

The report states that there are five distinct characteristics found in OIG-investigated cases of home health fraud.  Those five characteristics are:

  1. High percentage of episodes for which the beneficiary had no recent visits with the supervising physician;
  2. High percentage of episodes that were not preceded by a hospital or nursing home stay;
  3. High percentage of episodes with a primary diagnosis of diabetes or hypertension;
  4. High percentage of beneficiaries with claims from multiple HHAs; and
  5. High percentage of beneficiaries with multiple home health readmissions in a short period of time.

After the OIG identified the above characteristics, they then identified home health agencies and supervising physicians that were “statistical outliers with regard to those characteristics in comparison to their peers nationally.”  The report points out that just because a home health agency or physician was determined to be a statistical outlier, that did not necessarily mean that they were engaged in fraud.  The OIG identified 562 home health agencies, or about 5 percent of all home health agencies and 4,502 physicians, or about 1 percent of all physicians who supervise home health care, who were statistical outliers on 2 or more characteristics commonly found in OIG-investigated cases of home health fraud.  Again, these home health agencies and physicians were not necessarily engaged in fraud, but the OIG’s attention was drawn to them.

Neither a home health agency nor a physician who supervises home health care wants to draw the attention of the OIG.  Although you may be doing nothing wrong, dealing with an OIG investigation or audit of your agency can be very expensive and stressful.  Audits or enforcement actions also are disruptive of your business and can create negative opinions of your agency or practice.  Therefore, avoiding an audit or enforcement action starts with not drawing the OIG’s attention to your agency or practice.

With this guidance from the OIG in mind, Medicare home health agencies should audit a sampling of their home health patients to determine if their cases exhibit a high instance of any of the five characteristics listed above.  If the results of the audit reveal that the agency’s cases do involve a high instance of the five characteristics, an internal investigation into why is warranted.  If an internal investigation is conducted and there are legitimate reasons why the agency’s cases exhibit the listed characteristics, that will go a long way if the OIG comes knocking on the door.  If, on the other hand, fraud is detected during the audit, it is best to immediately involve outside counsel to get direction on how to proceed.

A proactive compliance program is vital for all health care organizations, large and small.  Even if a health care organization does not participate in any federal health care programs, there are still compliance risks that exist and must be addressed.  If your agency does not have a compliance program in place, this should be a very high priority for your organization.  

If you do not know where to start, I would be happy to help. Check out our compliance program options today and contact us to schedule your consultation

Reminder: These resources can help you make sure that you stay on track when it comes to compliance: