OIG Work Plan for FY00 sets an ambitious agenda for HH
By MATTHEW HAY
HHBR Washington Correspondent
WASHINGTON The Department of Health and Human Services’ (Washington) Office of Inspector General (OIG) released its FY00 Work Plan Oct. 5, and it includes five investigations in the area of home health. The OIG’s annual Work Plan is a blueprint of that office’s activities for the year ahead.
According to the Work Plan, the OIG will investigate how many home health agencies have implemented compliance programs since it issued its voluntary program guidance for home health agencies in August 1998. It also plans to examine which specific elements have been implemented and gauge the benefits and difficulties associated with their implementation.
Veteran healthcare attorney Elizabeth Hogue said this item may signal that compliance programs for home health are on their way to becoming mandatory. But she said that would not be unprecedented. The Health Care Financing Administration (HCFA; Baltimore) already requires managed care organizations that participate in Medicare+Choice to have a compliance program in place.
According to Hogue, HCFA has previously expressed interest in moving in this direction, but cited difficulty in demonstrating the effectiveness of these programs as an obstacle. She said this investigation may be designed to satisfy that concern.
Hogue also pointed out that HCFA could include this requirement in proposed conditions of participation for home health that have yet to be finalized. "It would be relatively easy for HCFA to include a revision that makes compliance programs mandatory when they publish the final regulations," Hogue said.
The OIG also plans to carry out a follow-up review to determine the current extent of physician involvement in approving and monitoring home care for Medicare beneficiaries. According to the OIG, earlier investigations found that physicians often did not have a relationship with their home health patients and instead relied extensively on home health agencies to determine the care needed.
Hogue said the OIG’s stated intention to "identify obstacles to physician involvement" seems to suggest that physicians are eager to become more involved in supervising home care. "If anything, my experience has been that physicians want less involvement with home care patients," Hogue argued. She pointed out that many physicians are already resistant to managing home care patients because the documentation requirements are viewed as too burdensome and reimbursement is seen as insufficient. "From their point of view, they are just not being paid," she said.
The OIG also plans to evaluate whether home health agencies are discouraging admission of "very ill" beneficiaries. According to the OIG, the new per-beneficiary limits based on historical visit rates are an incentive to keep visits and associated expenditures down. The OIG said it will determine whether home health agencies are "dumping" their sicker beneficiaries or are cutting off care before it is medically warranted.
In this area, Hogue pointed to previous claims by the General Accounting Office and Congressional Budget Office that savings under the new payment methodology have been larger than anticipated, in part, because agencies did not fully understand the new system. Hogue said there may be some truth to that argument. "I have seen agencies all over the country who are over their cost caps, but under their aggregate per-beneficiary limits," said Hogue. "There were a lot of misunderstandings about what the new system meant for taking care of patients whose cost of care would exceed per-beneficiary limits."
According to Hogue, one of the contributing factors is that agencies cut back their volume and then did not have enough volume over which to spread their costs. As a result, many of them exceeded their cost caps. But Hogue said now that agencies understand that IPS requires a balance of patient mix, she does not expect the OIG to find many problems in this area. She added that agencies will need to maintain the same understanding when operating under the prospective payment system.
The OIG also plans to evaluate the implementation of a 1997 requirement that pays for home health services based on the location of the patient’s home rather than where the service is billed, which is typically the urban location of the parent home health agency. But that item is a carryover from last year’s Work Plan and does not appear to be high on the OIG’s list of priorities.
Finally, the OIG said HCFA has requested an examination of 1998 data and computer error rates for Medicare payments to home health agencies in several states. According to the OIG, whereas prior reviews computed error rates for earlier periods, this review should assist in measuring the effectiveness of corrective actions on the part of providers.
"This one worries me," said Hogue, who points to a previous OIG review that produced a 40% fraud rate in home care. According to Hogue, that finding has been convincingly refuted, but a similar finding would force the home care industry to fight that battle all over again.
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