In September 2019, the US Department of Health and Human Services Office of Inspector General released the result of an audit report, “The Centers for Medicare & Medicaid Services Could Use Comprehensive Error Rate Testing Data To Identify High-Risk Home Health Agencies”.
The OIG noted, as the report title suggests, CMS could use CERT data to identify high-risk home health agencies (HHAs) as a part of a multifaceted approach that includes targeted probe-and-educate reviews as well as aspects of its Fraud Prevention System to further reduce improper payments and the error rate for claims paid to HHAs. “Using nationally reported CERT program data for fiscal years (FYs) 2014 through 2017, [OIG] identified 87 high-risk HHAs, which in the CERT sample had an improper payment rate of about 78 percent and approximately $1 million in actual improper payments. Using Medicare program data during this same period, we determined that Medicare paid these 87 HHAs more than $4 billion for services.”
According to the OIG, “In written comments on our data brief, CMS recognized that HHA claims are a major source of improper payments and described past and future corrective actions that address this issue. These corrective actions include identifying high-risk HHAs by using CMS's Fraud Prevention System, probe-and-educate reviews and targeted probe-and-educate reviews, and a new Home Health Review Choice Demonstration in Illinois. CMS stated that these sustained efforts have decreased the home health improper payment rate from 59 percent in FY 2015 to 17.6 percent in FY 2018 and are reliable and effective.
“CMS stated that it does not believe that our methodology for identifying high-risk HHAs is valid, as the CERT data are not designed to be precise at the provider level. CMS stated that providers with a higher number of claims billed are much more likely to be selected by the CERT review.”
The OIG report noted, “We disagree with CMS that our method for identifying high-risk HHA providers is misleading and ineffective.” The OIG further noted, “We continue to maintain that CMS can use CERT data as an additional tool in its targeted enforcement and education efforts to effectively reduce improper payments and CERT error rates.”
For more: https://bit.ly/2kox8FT
Complete report: https://bit.ly/2mjuPVk
