OIG to Focus on Home Health Payments, Hospice in Senior Living in 2015

The Office of the Inspector General (OIG) has released its work plan for 2015, addressing various issues relating to home health care and hospice. 

Among the topics addressed are the home health prospective payment system, fraud, health screening, hospice patients’ length of stay in assisted living facilities and the appropriateness of hospices’ general inpatient care claims. 

“Work planning is a dynamic process, and adjustments are made throughout the year to meet priorities and to anticipate and respond to emerging issues with the resources available,” OIG writes. “We assess relative risks in the programs for which we have oversight authority to identify the areas most in need of attention and, accordingly, to set priorities for the sequence and proportion of resources to be allocated.”

Home health care

Previously, OIG reported that one in four home health agencies (HHAs) had questionable billing, and that since 2010, nearly $1 billion in improper Medicare payments and fraud relating to the home health benefit had been identified.

As a result, the agency says it will review compliance with various aspects of the home health prospective payment system (PPS), including documentation required in support of the claims paid by Medicare. The agency will determine whether home health claims are paid in accordance with federal laws and regulations. 

OIG will also determine the extent to which HHAs employed individuals with criminal convictions, given that nearly all states have laws prohibiting certain health care-related entities from hiring individuals with certain types of criminal convictions. 

With regard to Medicaid home health agencies, the OIG will review health screening records of these health care workers to determine whether they were screened in accordance with federal and state requirements. Health screenings for home health care workers include vaccinations, such as those for hepatitis and influenza. 

Hospice

Also addressed in its work plan for next year are issues relating to hospices in assisted living facilities and hospice general inpatient care. 

Next year, the agency will review the extent to which hospices serve Medicare beneficiaries who live in assisted living facilities (ALFs). The OIG will determine the length of stay, levels of care received and common terminal illnesses of beneficiaries who receive hospice care in this setting. 

ALF residents, the report notes, have the longest lengths of stay in hospice care, and the Medicare Payment Advisory Commission (MedPAC) has said that these long stays bear further monitoring and examination.

Finally, OIG will assess the appropriateness of hospices’ general inpatient care claims and the content of election statements for hospice beneficiaries who receive general inpatient care. 

While hospice care is palliative rather than curative, when a beneficiary elects hospice care, the hospice agency assumes the responsibility for medical care related to the beneficiary’s terminal illness and related conditions. 

Overview

Work planning for the fiscal year 2015 and beyond will consider quality of care, appropriate payments, and oversight of payment and delivery reform. 

With regard to quality of care, planned work will examine settings in which OIG has identified gaps in program safeguards intended to ensure medical necessity, patient safety and quality of care. OIG will also focus on access to care, including beneficiary access to durable medical equipment (DME), prosthetics, orthotics and supplies (DMEPOS) in the context of new programs involving competitive bidding. 

In addition, planning is ongoing to expand OIG’s portfolio examining inefficient payment policies or practices, including comparison among government programs to identify instances when Medicare paid significantly different amounts for the same or similar services or when less efficient payment methods were used. 

Finally, planning is underway to expand OIG’s work addressing changes to Medicare programs designed to improve efficiency and quality of care and to promote program integrity and transparency. 

To access the 2015 work plan, click here.  

Written by Emily Study

Emily Study

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