Health Care Compliance Association (HCCA)

Report on Medicare Compliance 30, no. 17 (May 3, 2021)

In a new provider compliance audit,[1] the HHS Office of Inspector General (OIG) said Visiting Nurse Association of Maryland (VNA) received overpayments of $2.1 million in 2015 and 2016. OIG audited a stratified random sample of 100 claims and found errors on 19 of them. As a result, VNA received overpayments of $25,295 for services provided in 2015 and 2016. “On the basis of our sample results, we estimated that VNA received overpayments of at least $2.1 million for the audit period,” according to OIG, which noted all the claims are outside the reopening period. OIG said VNA billed for services provided to beneficiaries who weren’t homebound or delivered services that were inconsistent with the plan of care, among other errors. VNA disagreed with most of OIG’s findings. In a letter to OIG, the home health agency said, “VNA stands firm that it was providing covered services,” and “the error rate does not support extrapolation.”

◆ CMS said in a final rule announced April 29 that it’s extending the Comprehensive Care for Joint Replacement (CJR) model for three years and making some changes to it.[2] “Under the CJR model, all related care within 90 days of the [lower extremity joint replacement] procedure is included in the episode of care,” according to the CMS Center for Medicare and Medicaid Innovation.[3] According to the rule, outpatient hip and knee replacements will now be included in the CJR episode of care. The final rule is expected to be published in the May 3 Federal Register.

1 Amy J. Frontz, “Medicare Home Health Agency Provider Compliance Audit: Visiting Nurse Association of Maryland,” HHS Office of Inspector General, A-03-17-00009, April 2021, https://bit.ly/2RdmsKb.
2 CMS, “Medicare Program: Comprehensive Care for Joint Replacement Model Three-Year Extension and Changes to Episode Definition and Pricing; Medicare and Medicaid Programs; Policies and Regulatory Revisions in Response to the COVID-19 Public Health Emergency,” final rule, accessed April 30, 2021, https://bit.ly/3gQPFW5.
3 CMS, “Comprehensive Care for Joint Replacement (CJR) Model Three-Year Extension and Changes to Episode Definition and Pricing (CMS-5529-F),” fact sheet, accessed April 30, 2021, https://bit.ly/332oSht.

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