Home Health Agencies and Skilled Nursing Facilities Among Those Providers Included in the OIG’s Compendium of Priority Recommendations

The March 2014 edition of the Department of Health and Human Services Office of Inspector General (OIG’s) Compendium of Priority Recommendations lists the OIG’s 25 “priority recommendations.” Some of the provider types that are specifically mentioned in the report, and likely to see increased scrutiny from the OIG, include:

1. Home Health Agencies. The OIG alleges that one in every four home health agencies (HHAs) exhibited “questionable billing.” Recommendations include implementing and improving claims processing edits to prevent “inappropriate payments,” enforcing and possibly lowering the 10 percent cap on the total outlier payments on HHAs with questionable billing, and implementing a surety bond requirement on HHAs.

2. Skilled Nursing Facilities. The OIG alleges that in 2009, one quarter of all Skilled Nursing Facility (SNF) claims were billed in error resulting in $1.5 billion in inappropriate Medicare payments. Recommendations include increasing and expanding review of SNF claims, monitoring compliance with new therapy assessments, changing the current method for determining how much therapy is needed, improving accuracy of data submitted by SNFs and following up on SNFs that were found to have billed in error or are deemed to have “questionable billing practices.” The OIG also recommends adjusting SNF rates as necessary and strengthening the monitoring of SNFs that disproportionately bill for higher paying resource utilization groups (RUGs). Other recommendations include increased monitoring of SNF care planning, discharge planning and quality of care issues related to wound care, medication management, and therapy.

3. Community Mental Health Centers. The OIG recommends increasing monitoring of Medicare billing and taking appropriate actions against Community Mental Health Centers (CMHCs) with “questionable billing.” The OIG specifically recommends coordination of activities to deter CMHC fraud in Florida. The development of a system to track billing-privilege revocation recommendations and communications between CMS and its contractors related to such recommendations was another recommendation.

4. Personal Care Services. The OIG expressed concerns related to both cost of personal care services and qualifications/supervision of personal care attendants which are payable by state Medicaid programs. Recommendations include assisting the states with overpayment identification through provision of data, establishing minimum federal qualifications for attendants and requiring attendants to enroll and receive a unique identifier from the state Medicaid agency.

Other provider types mentioned in the Compendium include Clinical Laboratories, Critical Access Hospitals, Hospitals, Hospices and Pharmacies.

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