OIG Finds 20% Of Home Health Claims Coded Improperly, Resulting In $462M In Improper Payment

Some concerning news hit the home health community last week.

The Department of Health and Human Services’ (HHS) Office Inspector General (OIG) released a report that showed home health agencies submitted nearly 22% of claims in error because services were either not medically necessary (2.1%) or were coded improperly (20.2%).

This is the first time OIG has significantly addressed home health’s coding on claims. They stated that one of the factors for this review was the fast rise in Medicare home health spending—84% from $8.5 billion in 2000 to $15.7 billion in 2007—which “leads to concerns about the potential for improper payments due to fraud and abuse.”

More than 10 percent of claims (a value of $278 million) were considered up-coded, and 9.8% of claims (a value of $184 million) were found to be down-coded. This equates to a net loss of $94 million for the 
Medicare system.

While the report did not go into extensive details on scenarios that they found problematic, they did give an example of the frequent inappropriate use of GERD 530.81. We plan to discuss this further in our next blog post.

The results of this report are very significant and should be taken seriously by home health agencies. Whether the error is unintentional or not, agencies can get themselves into a lot trouble. CMS is cracking down and “has begun using technologies and analytic tools to prevent fraudulent payments and identify risky providers and claims.”

On the bright side, just 2% of claims did not show medical necessity. Agencies are doing a great job ensuring the services they provide are medically needed. 

Here at Daymarck, we have a very strict compliance stance. It is our first and foremost priority. We never up-code or use filler codes, and we code every agency the same. We also stay up to date with the constantly changing rules and regulations to ensure our clients are 100% compliant.

Now more than ever it’s critical that you are submitting accurate claims. If you’d like someone to give your agency an audit to see how you are doing, we can help. Contact us to discuss a coding “check up.”

To learn more about our view on compliance, visit here.

Non-Compliance: The Unintentional Kind

With instances of Medicare fraud fraught in the headlines, compliance has become a hot-button issue for our industry. Companies have faced fees of up to hundreds of millions and even jail time for being found in non-compliance.

US Assistant Secretary of Health and
Human Services, Ben Sasse

Just last week at the Home Care 100 Conference, keynote speaker, former US Assistant Secretary of Health and Human Services, Ben Sasse, said that fraud and self-policing should be our top concerns. He cited shocking estimates of widespread fraud and the devastating effects it has on us as an industry, especially in Washington.

We know we don’t have to preach to you about not being fraudulent. You are all ethical individuals. But, in a lot of instances, non-compliance can happen unintentionally. With the increasing amount of regulations (several resulting from health care reform) and differing interpretations of those regulations, many times it’s the “good guys” that are getting themselves into trouble. This is especially true for the small agencies who are stretched thin and doing what they can to survive. Can you imagine if one of them got into trouble? They would not be able to weather the storm.

At Daymarck, compliance is at the cornerstone of our business. It is our first and foremost priority. We never “up-code,” “re-sequence,” or use filler codes, and we code every single home care agency the exact same. We stay up to date with the constantly changing rules and regulations to ensure our clients are 100% compliant.

You should be able to keep all the hard work that you do. That’s why no matter if you are a home health provider, institution, clinician or biller, compliance needs to be your #1 priority.

Feel free to reach out to us to discuss ways you can ensure compliance, including setting up a policy and reporting structure.