Recently, a "Whistleblower" report to the Department of Justice claiming a multi-state home healthcare agency submitted fraudulent bills for Medicare Home Health services.
After investigation, the organization settled the claim with the DOJ for $150 million. This story is not the first of this kind, however, the uniqueness stems from the setting... the Home Health Industry.
Each year, the CMS Office of Financial Management (OFM), under the Comprehensive Error Rate Testing (CERT) program, calculates the Medicare Fee-for-Service (FFS) improper payment rate. For the FY 2013 reporting period, the national Medicare FFS improper payment rate was calculated to be 10.1 percent. For that same reporting period, the improper payment rate for Home Health service was 17.3 percent, representing a projected improper payment amount of approximately $3 billion.
CMS concurred with the OIG recommendation, that as part of an effective Compliance Program, all Home Health Agencies should conduct regular audits to ensure charges for Medicare are accurately documented and billed. CMS instituted the PEPPER (report) to guide providers in identifying claims data that indicates higher than average billing. This report was initially released in July 2015, and is now generated on an annual basis. The report contains three years of comparative data specific to six pre-determined “target areas” collected via the UB-04 for each Home Health Agency. The report details Medicare claims data in certain targeted areas and compares the facility to other Home Health Agencies. PEPPER gives provider specific Medicare data statistics for services vulnerable to improper payments and allows providers to see how their agency compares to all other agencies across the State, Nation and Medicare Administrative Contractors (MAC) Jurisdiction. These comparisons and identifiable areas of target afford the organization a road map for compliance through the initiation of an internal audit process to assess variances and facility risk.
Harmony Healthcare International (HHI) offers a unique analysis to reveal how your organization compares to others within your state and across the country. The Harmony HealthCARE Specialists emphasize the fact that there is no “Good” or “Bad” PEPPER. Nevertheless, the report is a definite indicator of governmental audit risk. Therefore, the agency needs to gain a thorough understanding of the numbers and their relation to client’s medical records and service delivery. Providers utilize this invaluable analysis to determine risk for governmental audit and compliance program focus.
How can Harmony Healthcare International (HHI) help?
Harmony Healthcare International (HHI) can assist with the following:
- Retrospective and prospective audits to determine compliance with all aspects of Home Healthcare regulations
- Patient specific clinical case management strategies
- Education and Training for all clinical staff focused on regulatory guidelines to improve documentation practices and delivery of care
- Harmony Healthcare International (HHI) PEPPER Analysis specific to the Home Healthcare Agency
- Assistance with claims review while simultaneously identifying trends and triggers causing the probe
- Guidance with the Appeals process for denied claims through medical record preparation and composition of a Proper Reimbursement Explanation Paper (PREP) to submit to the Medicare Contractor