... not home health sec­tor: group

Modern Healthcare - - MODERN HEALTHCARE - Beth Kutscher

Home health group urges tar­get­ing fraud “hot spots”

The home health in­dus­try is fight­ing back against Medi­care pay­ment cuts and re­stric­tions that pun­ish the sec­tor broadly for the billing fraud and abuse in home health claims. Most of the push has come from the 2-year-old Part­ner­ship for Qual­ity Home Health­care, a group that counts some of the largest for­profit home-care providers among its mem­bers. Mem­ber com­pa­nies in­clude Amedisys, Gen­tiva, Al­most Fam­ily and Sun­Crest Health­care, and the group says it rep­re­sents more than 1,500 home health agen­cies.

The Part­ner­ship has urged the fed­eral gov­ern­ment to con­sider re­forms that raise the bar­ri­ers to en­try for providers, pre­vent pay­ment of aber­rant claims and im­ple­ment qual­ity and out­comes bench­marks—rather than pay­ment cuts. It is also us­ing the gov­ern­ment’s own data to show, for in­stance, that only 25 of the coun­try’s 3,143 coun­ties are fraud “hot spots.”

“Cou­pled with MedPAC’s an­nual list of the 25 coun­ties in which ex­ces­sive home health­care episode uti­liza­tion is oc­cur­ring, Medi­care data analy­ses demon­strate that fraud and abuse can be pin­pointed and, thus, ef­fec­tively tar­geted,” Eric Berger, the Part­ner­ship’s CEO, wrote in a June 27 let­ter to the U.S. Se­nate Fi­nance Com­mit­tee. “We urge Congress to en­act a set of tough so­lu­tions to at­tack this tar­geted prob­lem, while safe- guard­ing pa­tients and the com­mu­ni­ties that hon­est providers serve.”

The HHS in­spec­tor gen­eral’s of­fice has long seen the rapidly grow­ing home-care space as vul­ner­a­ble to crim­i­nal ac­tiv­ity. A March re­port noted that Medi­care home health claims in­creased 84% from 2000 to 2007, to $15.7 bil­lion from $8.5 bil­lion, and con­cluded that in 2008 agen­cies sub­mit­ted 22% of claims in er­ror, re­sult­ing in $432 mil­lion in im­proper pay­ments.

In two high-pro­file cases this sum­mer, the owner of Will­sand Home Health, Miami, pleaded guilty to a $42 mil­lion fraud scheme, and the co-owner of Fam­ily Health­care Group, Hous­ton, was sen­tenced to nine years in prison for par­tic­i­pat­ing in a $5.2 mil­lion scheme.

“Over­all, there’s a per­cep­tion that there’s a good deal of fraud and abuse,” said Su­san Kayser, a New York-based at­tor­ney who spe­cial­izes in long-term care at Duane Mor­ris. “The en­force­ment agen­cies have sensed that there isn’t as much over­sight as there might be in an in­sti­tu­tional set­ting. At least to some de­gree, the home-care in­dus­try as a group is try­ing to pro­mote the sense that the home-care in­dus­try is as much against fraud and abuse as the gov­ern­ment.”

The mes­sage has be­come more press­ing as the CMS in July pro­posed 2013 pay­ment cuts to home health agen­cies that are expected to have an ef­fect of about 0.17% for ur­ban for-profit agen­cies and 0.61% for ru­ral for-prof­its, ac­cord­ing to the agency’s im­pact state­ment. The cuts are on top of a 2% across-the-board Medi­care rate cut un­der the Bud­get Con­trol Act (See story, p. 6).

The ef­fort has also pig­gy­backed on the Obama ad­min­is­tra­tion’s ac­tions to com­bat fraud, which it has made a top pri­or­ity. This sum­mer, for in­stance, the HHS and U.S. Jus­tice Depart­ment launched a pub­lic-pri­vate part­ner­ship with health in­sur­ers to pre­vent abuse in health­care billing.

In an in­ter­view, Berger ac­knowl­edged the link be­tween home health re­im­burse­ment and the ef­fort to com­bat crim­i­nal ac­tiv­ity as pol­i­cy­mak­ers have tried to make the space less prof­itable to bad ac­tors.

“Much of the fo­cus on cut­ting home health­care pay­ments has been driven by a de­sire to stem fraud and abuse,” he said. “We be­lieve tar­geted re­form is a bet­ter ap­proach be­cause it fixes the prob­lem where it ex­ists with­out hurt­ing in­no­cent se­niors and providers across the U.S.”

Kevin Camp­bell, an an­a­lyst at Avon­dale Part­ners who cov­ers the for­profit home health in­dus­try, said the Part­ner­ship was formed about 18 months ago to col­lab­o­rate with pol­i­cy­mak­ers.

“I think their view at the time was that (the Na­tional As­so­ci­a­tion for Home Care and Hospice) was not of­fer­ing enough so­lu­tions,” Camp­bell said, re­fer­ring to the in­dus­try’s ma­jor trade group. “Their hope is that they can re­place some of these across-the-board cuts with some of these tar­geted pro­grams.”

The Na­tional As­so­ci­a­tion of Home Care and Hospice did not re­spond to a re­quest for com­ment.

Both groups are among the back­ers of Fight Fraud First, a cam­paign to urge the gov­ern­ment to tar­get fraud­u­lent ac­tiv­ity as a way to save money be­fore go­ing af­ter in­dus­try pay­ments. Fight Fraud First’s other prom­i­nent mem­bers in­clude the AARP and Easter Seals.

The home health in­dus­try es­ti­mates that its rec­om­men­da­tions can save be­tween $15 bil­lion and $18 bil­lion over 10 years, Camp­bell said. “There is ev­i­dence that what they’re say­ing is res­onat­ing some­what,” he added.

The Part­ner­ship points to an Au­gust re­port from the in­spec­tor gen­eral’s of­fice that rec­om­mended many of the same re­forms the group has sup­ported, such as im­prov­ing the billing process, pre­vent­ing pay­ment of un­usual claims and putting a mora­to­rium on new providers in sat­u­rated ar­eas.

“Their rec­om­men­da­tions are con­sis­tent with the kinds of re­forms we’ve been talk­ing about,” Berger said.

Camp­bell noted that the pro­posed rate cut was sig­nif­i­cantly less deep than expected. The in­dus­try also has avoided other floated pro­pos­als such as ac­cel­er­ated rate ad­just­ments and co­pay­ments.

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