700 Club’ list angers home health providers
By Park Morgan
Editor, Hospital Home Health
For the beleaguered home care industry, the most recent news from Washington, DC in this case, the so-called "problem provider" list should cause widespread panic, outrage, and condemnation among home care providers.
And those are just the nice reactions.
Compiled by the OIG for the purposes of a study released in July 1997, Home Health: Problem Providers and Their Impact on Medicare (OEI-09-96-00110), the list, which became known as the "700 Club" throughout the industry, contains the names of 698 home care agencies based in the original Operation Restore Trust (ORT) states of California, Texas, Florida, New York, and Illinois. Including both hospital-based and freestanding agencies, all were classified as "problem providers."
The list first appeared in October when the Department of Health and Human Services responded to a Freedom of Information Act (FOIA) request filed by a California home care consultant. Shortly thereafter, the consultant wrote letters to unwary providers telling them of their inclusion on the list. Subsequently, the National Association for Home Care (NAHC) and the American Federation of Home Health Agencies (AFHHA) received copies, and the list hit the fan. Hospital Home Health newsletter also obtained a copy of the list through the FOIA in late November.
The OIG says the list was compiled only for statistical purposes and only as part of the study. Indeed, the report itself does not contain the list, but the report concludes that "more than 25% of the home health agencies in the ORT states are problem providers. Problem home health agencies received nearly 45% of Medicare home health payments in the ORT states."
Nonetheless, the "700 Club" membership roll has caused a firestorm of protest among the 698 providers whose names appear on it, bringing angry cries against what some call blatant abuse of federal power, and accusations that the OIG is going after industry leaders because of their high profiles a charge the agency denies.
Deputy Inspector General George Grob, who authorized the study, has tried to reassure home health providers that the list is not a blacklist or a hit list. "The list was never meant to be released or meant as a list to go after industry leaders. We do not maintain such a list. This was only [compiled] for the study."
Grob points out that the study (which was released on the same day as another study concluding that 40% of paid home health claims were unallowable under Medicare rules) was meant "to identify vulnerabilities in the program." He says the list would not have been released had it not been for the California consultant’s FOIA request. But once the OIG received the request, the agency could not, by law, prevent its dissemination.
"There is no system of maintaining a list where we go after people," Grob insists. "I cannot honestly say anyone on the list currently has a problem [with the OIG] or if someone not on the list doesn’t have a problem. This was limited to the five ORT states. It is not a universe of all providers."
The OIG report describes a "problem" agency as "one that has abused or defrauded Medicare or misappropriated Medicare funds through the cost report or claims process." The report states further that a problem agency was one identified by HCFA, a fiscal intermediary, the state certification and/or licensing agency, or the OIG as meeting one or more of the following conditions:
• has incurred significant uncollected overpayment;
• routinely submits cost reports with significant inappropriate and unallowable costs;
• files a cost report that is determined to be unauditable;
• routinely does not file cost reports within a reasonable time;
• has submitted multiple claims for services that are not medically necessary;
• has submitted multiple claims for services that were not rendered;
• continues to submit problem claims despite educational contacts;
• has significant certification deficiencies;
• has been referred to the fiscal intermediary’s program integrity unit;
• has been referred to the OIG by the fiscal intermediary.
Attorney William Dombi, director of the NAHC’s Center for Health Care Law, says NAHC doesn’t believe the OIG had sinister intentions, but the trade association nonetheless is unhappy about the bad impression left by the study and the list.
"[The OIG] developed extremely broad criteria," he says, "everything from fraud to multiple claims denials."
And those broad criteria, perhaps more than anything else, are the reason the storm of outrage continues to howl.
AFHHA executive director Ann Howard says it now appears that even a legitimate difference between a provider and a fiscal intermediary over Medicare reimbursement is reason enough to be suspected of fraud.
Howard fears that the list is a sign that government regulation is getting out of control. "The agencies I know who are being harassed by the government are the ones willing to fight for the rights of the beneficiary for the care they need."
Both Montefiore Home Health in Bronx, NY, and OSF Healthcare System in Peoria, IL, are in the 700 Club. Both agencies are hospital-affiliated provi ders and are considered industry leaders. Neither organization has ever been accused of defrauding Medicare. And both Susan Schulmerich, RN, MS, MBA, executive director of Montefiore, and David Baker, corporate director of home care services for OSF, serve on the NAHC’s Board of Directors.
Schulmerich says her agency made the list because Montefiore has had 43 billing disputes with its financial intermediary in the last few years. Yet "forty-two of forty-three claims [judgments] were found in our favor by the Administrative Law Judge," she says.
Most of these were daily wound cases, Schulmerich explains, in which it is difficult to determine when care will end, which is a requirement under current Medicare policy. Wound care patients, she says, tend to be chronic, long-term cases, but her intermediary, United Government Services, she says, "issues denials like clockwork, and then the Administrative Law Judge found in our favor in all but one case."
Schulmerich says her nurses started taking pictures of the wounds as evidence for the judge, and these proved to be powerfully persuasive.
Sara Speights, director of government and public relations of the Texas Association for Home Care in Austin, declares that "the OIG ought to disown that list. It’s faulty, sloppy, and it has no validity because, I tell you right now, the personal injury attorneys will use it. I think the OIG has a responsibility to be honest about it." Speights blames the fiscal intermediaries as well. "The FIs had an interest in making that list look large. We know they have been underfunded to do a difficult job. This was an opportunity to make that point."
For its part, the OIG just wishes the list would disappear. "I wish I could wish it away," Grob concedes. "But all I can do is tell you what it was intended for. If [providers] think badly of me, I can assure you, the feeling is NOT mutual."
In December, National Hospice Organization (NHO) chairman John Carney, MEd, announced the selection of NHO’s next president, Karen A. Davie, currently executive vice president and COO of United Way of America. She will assume the organization’s chief executive position Feb. 6, succeeding current president John J. Mahoney, who steps down Jan. 31. Mahoney, who has been at the organization’s helm since 1984 or approximately 70% of the organization’s history plans to remain active in a part-time role as president of NHO’s affiliated National Hospice Foundation.
Davie has worked as a medical social worker and was Chief of Staff to the Lt. Governor of Rhode Island from 1989 to 1991, and has served in a number of other positions at United Way of America. She became the second in command at the United Way just before the organization’s recent, widely publicized public relations problems. She also has a strong personal interest in hospice and end-of-life issues.
• • •
In Maine, Bill 116 proposing to legalize physician-assisted suicide was introduced last year and carries over to the 1998 Emergency Session. This is the fourth time the issue has come before the state’s legislature, and each of the previous attempts got farther in the legislative process, reports Kandyce Powell, RN, MSN, executive director of the Maine Hospice Council, which opposes assisted suicide.
At press time in mid-December, the Hospice Council was seeking funds for a public opinion survey that could shed more light on why the public feels the need to legalize assisted suicide, Powell adds. "We want to find out what the public sees as inherently problematic" in how the health care system now deals with end-of-life issues.
The council also has planned a January educational program on pain management for the state’s 200 legislators, local physicians, and others in Augusta, the state capital, and featuring James Cleary, MD, a pain expert from the University of Wisconsin. At press time, Powell was unsure how legislators would respond to this event, although the issue was important enough to influence Gov. Angus King’s decision to reschedule his state of the state address so it would not conflict with the council’s pain program.
• • •
The New Jersey Hospice Organization voted at its Nov. 21 annual meeting to broaden its mission by changing its name to the New Jersey Hospice and Palliative Care Organization. "We believe that palliative care is a right for all patients, at any point in their illness. No one else, in New Jersey at least, seemed to be taking that as a primary or even major responsibility," explains Don Pendley, MA, the organization’s president. "We also believe there has to be a greater focus in palliative care on psychosocial and spiritual needs. Palliative care specialists have a lot to learn from the success of hospice."
Palliative care will one day be a recognized specialty and a reimbursement stream in the American health care system, Pendley predicts. "We want to be sure we’ve built bridges, and we think it’s better to influence the process at its early stage than to be influenced by it later on." The organization hopes to draw in health professionals from other settings but also to inspire them with the expertise of hospice. "We want to be sure that the knowledge we’ve worked so long and so well at is available to other patients," he says.
"We’re looking at a year to 18 months to establish ourselves as recognized throughout the health care system." Pendley adds that his members are experiencing the same stresses and burnout as hospices in other states. "But what we’re doing with palliative care will help to deal with some of that. New bridges to the physician community will also help." The organization has a task force working on the latter goal and is expanding its program of awards to recognize physicians for their work in palliative care.
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NHO’s Committee on the Medicare Hospice Benefit and End-of-Life Care is continuing to sort out options for addressing barriers to access to hospice care, with a target of giving its report and recommendations for improving the hospice benefit to the NHO Board of Directors in April or May, says committee consultant Dorothy Moga.
"This group has met five times since last May, each time for an intensive working session, with another meeting scheduled for February," Moga says. "The committee has followed a structured planning process so we could go through this thoroughly and deliberately," identifying stakeholders, considering the concerns of those stakeholders, testing assumptions, identifying ideal characteristics of hospice care in the future, and compiling a list of the most common barriers.
"Now we’re working with Health Policy Alternatives, a public policy consulting firm, to come up with public policy strategies and alternatives," Moga says. Achieving legislative changes in Medicare may be difficult in the current environment, "but much of what could be done to overcome the barriers does not require an act of Congress. Some of the barriers are within hospice itself. If we focus only on public policy, we may not get to where we want to be."
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