by Michael McGowan
Since the beginning of November, twelve Florida Medicare home health agencies, roughly one per day, have received notices from a Zone Program Integrity Contractor that they are suspected of, at best, waste or abuse, at worst, Medicare fraud. Their patient records will be examined and a determination as to the dollar amount of their claims payment reversals and fines will be made sometime in the future. Similar upticks in ZPIC activity are being reported nationwide.
What is the cause of this increase in ZPIC activity? Instructions from CMS to crack down? Or widespread HHA misunderstanding of CMS expectations? Eighty percent of the clinicians and providers I encounter still have little to no understanding of Medicare’s Conditions of Payment.
Compliance and billing errors in the home health industry have not significantly improved over the years, leaving providers’ contracts in jeopardy. Recent activity indicates ZPIC’s are reopening initial investigations (see sidebar). Continuations of what providers thought were finalized investigations are being reopened, sometimes only months, or even weeks, before the four year legal limitation expires. Agencies failing to realign themselves with CMS contract expectations are at the top of this list.
From MLN Matters® SE1524
CMS is implementing a "Probe and Educate" medical review strategy to assess and promote provider understanding and compliance with the Medicare home health eligibility requirements. CMS has issued guidance to MACs about how to select home health claims for review during the program, which will focus on home health episodes that began on or after August 1, 2015. MACs began sending Additional Documentation Requests after October 1, 2015; the first round of claim reviews and provider education will conclude in approximately one year.
Claims Subject to Review as Part of the Probe and Educate Process
If You Are A Minor Concern
If You Are A Major Concern
It is critical to understand that a MAC or ZPIC or RAC contractor’s determination is not the closure of a case. Rather, it is the quiet transition to behind the scenes monitoring of a provider previously identified as "at risk." Any cessation of ADR requests may temporarily continue but the ZPIC is spending that time evaluating the provider’s performance with each claim submitted until it has enough information to resume or close the investigation. Federal law governing the ZPIC states:
Think of it this way. You transmit information a ZPIC needs to justify reopening your investigation every day in your OASIS and claims data. Every component of data generated, managed, and then submitted by your agency belongs to you and tells the ZPIC how well you understand compliance requirements. If you have previously been through a ZPIC survey and did not realign your practice patterns from what caused those ADR requests, you continue to be at risk to the extent that you continue to deliver "toxic data" to the contractor.
CMS benchmarks the results of its auditing on a quarterly basis and has done so for more than a decade now. When your MAC or a ZPIC demands charts from a suspect HHA, denial rates routinely exceed 80%! Most HHA owners and clinicians are found to be insufficiently educated regarding CMS Conditions of Participation and Conditions of Payment.
From BID Insulin to therapy
Once upon a time, some HHAs discovered there was a lucrative profit to be made by serving diabetes patients unable or unwilling to administer their own daily or twice-daily insulin injections (or simply willing to state they are unable or unwilling to inject). In 2007, the entire Medicaid outlay for this service nationwide was $550 million, of which about $277 million was paid into Miami-Dade county.
When CMS finally ended this practice, and the revenue stream these types of agencies had relied upon dried up, therapy visits became the new revenue boosting survival strategy.
When therapy thresholds were at 10 visits for a payment bump, many HHAs got themselves in trouble by enhancing their revenue through reporting too many episodes that exactly hit that threshold. When the thresholds moved to 6, 14 and 20, some of those same agencies got into deeper trouble — including being dragged before a Senate committee hearing — by immediately beginning to report too many episodes that hit the new thresholds and too few that just missed. Many more HHAs than were caught were equally guilty of this practice.
Recerts as the new therapy
When the therapy crackdown came, hundreds, perhaps thousands, of HHAs adjusted their therapy visits to match patient need rather than payment thresholds but once again saw their revenue drop as much as it had when they had to stop all those 5-minute insulin visits. Many of them turned to other methods to replace that lost revenue, two methods in particular. Some focused on boosting their sales and marketing efforts, arming sales reps with data about their high patient outcomes and low hospital readmission rates. Others, who may not have had impressive data to brag about, turned to the practice of increasing consecutive PPS recertifications. Can't win new patients? Keep the old ones.
Benchmarking of re-cert rates is prominent in today’s environment. While re-certifications are necessary to provide long term in-home care to high acuity patients, reports from benchmarking services show that many agency owners are recertifying essentially healthy people, perhaps demanding of their clinical staff 30% to 40% re-cert rates regardless of regional differences, socioeconomic factors, chronic disease processes, and patient acuity.
Fraud, Waste, and Abuse predictive modeling started more than 25 years ago. Vendors supporting ZPIC contractors track, trend and report provider behaviors, instantly informing the enforcement agencies of suspicious wasteful or fraudulent practices. Providers usually get away with this for years. When the ZPIC catches up with them, and they do catch up with them, payment takebacks can erase 100% of the revenue gain, or more when penalties are imposed.
I’ve never found a clinician unable to find something beneficial to provide to a patient. When administration tells them to target a specific re-cert rate, regardless of patient acuity, they can find a clinical justification for doing so. But, will the ZPIC’s radar gun affirm the clinician’s rationale? It is a risky strategy, considering today's enhanced ZPIC aggressiveness, but it is resorted to when sales and marketing efforts fall short. Increasing referrals and partnering with ACOs is the safer, more honorable alternative strategy.
Recertifications do keep census figures up but the question must be asked, "How long can HHAs engage in this practice?? It has been dubbed toxic census syndrome" and it is never more than a temporary fix. It always ends in fines or expulsion from Medicare participation, or both.
Providers resort to toxic census syndrome when the proper way to keep census figures up, strong sales and marketing efforts using impressive outcome and readmission data, has failed. This occurs either when your Home Health Compare data are not good enough to be shared with referral sources or when your sales and marketing teams are ineffective. The answer is to fix one or both problems, not to risk initiation, or re-initiation, of a ZPIC audit with excessive recerts. Improve clinical practices so that outcomes improve and readmissions decline. If your scores are already good and you are still short on referrals, re-train and re-incentivize your sales team instead of clinging to healthy patients.
There are software solutions available to help you with both fixes. More and more HHAs are investing in Customer Relationship Management software and in sending representatives to home health-oriented sales training. Some forward-thinking owners are tapping social media for marketing. Others are re-examining the science and methodology they use to determine which patients are appropriate for another 60-day episode. Often it is as simple as learning how ADRs and audits are generated. What is in your chart room?
Michael McGowan is the former OASIS coordinator for the state of California and a longtime Medicare appeals consultant. He is the designer of OPERA, a software system that supports clinical compliance. He lives in New Mexico with his wife and daughters and can be reached at email@example.com.
In coming weeks, HCTR will examine all of these strategies and recommend some new technologies to help HHAs legally increase patient census:
©2015 by Rowan Consulting Associates, Inc., Colorado Springs, CO. All rights reserved. This article originally appeared in Tim Rowan's Home Care Technology Report. homecaretechreport.com One copy may be printed for personal use; further reproduction by permission only. firstname.lastname@example.org