Increased OIG Interest in Home Health Agencies?

The U.S. Department of Health and Human Services' (HHS) Office of Inspector General (OIG) is responsible for investigating and combating waste, fraud, and abuse in HHS programs such as Medicare and Medicaid. Based on my personal experience in meeting with OIG representatives, let me tell you that they absolutely love recovering overpayments of taxpayer monies. Last year, investigators recovered a record-breaking $4.1 billion in health care fraud. Furthermore, the federal government reports that they have collected $7.20 for each $1 spent on fighting fraud. Given this climate, I can only assume that 2012 will see even more recovery of health care overpayments.

That's why it is my opinion that every health care entity should make an effort to be aware of the areas on which the OIG is focusing. If a provider can look into the mind of the OIG, the provider would be able to identify areas of increased scrutiny and, therefore, identify areas on which it should focus.

Fortunately, the OIG provides information to allow providers to do just that. In fact, the OIG is pretty good about staying transparent. They have even admonished health care entities to pay attention to OIG publications, case outcomes, and findings.

Each year (generally in October), the OIG prepares and publishes a Work Plan which sets forth the projects the OIG will be addressing for the upcoming fiscal year. These Work Plans can be important tools for health care providers because they essentially allow providers to look into the OIG's playbook.

By paying attention to OIG focus areas now,
HHAs can possibly avoid penalties
or other problems later.

As an example, in 2010, the OIG commenced a project identified as an Oversight of HHA Outcome and Assessment Information Set (OASIS) Data.  The OIG completed this project earlier this year and published its findings as Limited Oversight of HHA OASIS Data Report. In that report, the OIG found that HHAs failed to submit OASIS data for 6% of claims in 2009 and submitted late OASIS reports for 15% of claims. As a result of these findings, CMS will be applying a 2% payment reduction to HHAs who failed and fail to comply with OASIS submission requirements. An HHA who realized that the OIG would be looking into OASIS submission in 2010, could have made adjustments then to make sure it would not be subject to 2% reductions now.

In this year's Work Plan, the OIG will be targeting several projects related to Home Health Agencies operating under Medicare Parts A and B. You can find a list of the projects here. By paying attention to these OIG focus areas now, HHAs can possibly avoid penalties or other problems later.

In addition to the Work Plans, current cases can help an entity understand the OIG's focus. Just last month, the federal government uncovered a highly sophisticated HHA fraud scheme which resulted in approximately $375 million dollars in false claims. This scheme was reported by the HHS to be "the single largest fraud amount orchestrated by one doctor in the history of HEAT and Medicare Fraud Strike Force operations." Read about that case here.

I have no doubt that the OIG expects that there are other cases of fraud and abuse in Home Health similar to the one above. It seems that the OIG has alluded to this concern by noting several times in its most current Work Plan that HHA claims have increased more than 80% since 2000 and when it expressed concern that "the current system relies on self-reported data from the HHAs without further validation."

Given the fact that (1) the OIG has found that HHAs are not complying the OASIS submission requirement, (2) one of the largest fraud schemes in history involved HHAs, and (3) HHA claims have increased significantly while relying heavily on self-reporting, it seems almost inevitable that the OIG will be ramping up HHA investigations.

Thus, it would behoove HHAs to take measures now to ensure that they are playing by the rules and staying compliant with federal laws when it comes to participation in federal programs such as Medicare.

Top Ten Health Law Issues for 2012

In case you've never heard of it, the American Health Lawyers Association (AHLA) is "the nation's largest, nonpartisan, 501(c)(3) educational organization devoted to legal issues in the healthcare field." See AHLA's "about us" webpage. And in my experience, attorneys who are serious about health law are members and participants of this association.

For the past four years, AHLA has been publishing an annual list of the top ten issues it sees as the biggest issues for the upcoming year. This year, AHLA's staff identified the following issues as top issues for 2012 in the February edition of AHLA Connections, the official magazine of the AHLA:

A picture of my copy of AHLA Connections

1. Healthcare Reform/Supreme Court Ruling on the Constitutionality of the individual mandate.
2. Accountable Care Organizations
3. Fraud and Abuse Enforcement: Overpayments and Self-Disclosures
4. HIPAA Enforcement
5. Final Rule Issued on Medical Loss Ratio Requirements Under Healthcare Reform
6. The Responsible Corporate Officer Doctrine
7. State-based Health Law Initiatives
8. Retail Health Clinics
9. Community Benefit, Community Health Needs Assessment
10. Sunshine Act--Disclosure of Drug and Devise Manufacturers' Payments to Physicians

If you don't recognize what some of these issues are, I recommend googling them. Otherwise, you can ask your health law attorney if you can borrow a copy of their AHLA Connections. Better yet, you can join AHLA to help you stay abreast of current legal issues in health law. If you join, tell them that I sent you!

More important than these issues, though, is the fact that we can worry about these issues at all. Fortunately for everyone, NASA has determined that the world will not end in December 2012 as the ancient Mayans predicted. It turns out that the planet Nibiru is not going to slam into Earth -- at least so reports the Huffington Post in this article. I'm so relieved. If you read that article, you too can stop worrying about the end of the world and start worrying about micro loss ratios. Although frankly speaking, the planet Nibiru is a more exciting topic than micro loss ratios.