Transcript for audio podcast on the following report:
CMS and Contractor Oversight of Home Health Agencies
From the Office of Inspector General of Department of Health and Human Services
Jaime Durley, Atlanta Deputy Regional Inspector General, sits down with David Samchok, Program Analyst for the Office of Evaluation and Inspections (OEI) in Atlanta, to discuss the recent OEI report titled CMS and Contractor Oversight of Home Health Agencies.
[Jaime Durley] I'm Jaime Durley, Deputy Regional Inspector General for the Office of Evaluation and Inspections. And, I'm speaking with David Samchok, a program analyst in our office, about a report called CMS and Contractor Oversight of Home Health Agencies. David, could you tell us about home health agencies?
[David Samchok] Sure. In 2010, the Medicare program paid more than $19 billion to over 11,000 home health agencies. These agencies provide care, such as physical therapy, for over 3 million patients.
[Jaime Durley] And what is the Centers for Medicare & Medicaid Services, or CMS's, role in home health agencies?
[David Samchok] CMS and Medicare contractors oversee agencies to ensure that they work within Medicare's guidelines. CMS works with contractors to process claims, prevent improper payments, and prevent, detect, and deter fraud. They investigate potentially fraudulent agencies and may recommend administrative actions to CMS or refer cases to law enforcement. Administrative actions may include suspensions or revoking an agency's billing privileges so they may not receive Medicare payments.
[Jaime Durley] So tell us about the focus of the report.
Our report looked at CMS, and CMS contractor oversight, of home health agencies in 2011. We looked at CMS's and its contractors' effectiveness in preventing improper payments and deterring fraud among agencies. The report also identified how Medicare paid agencies with suspended or revoked billing privileges.
[Jaime Durley] So why did the report focus on CMS and contractor oversight of these home health agencies?
[David Samchok] Well, home health services are historically vulnerable to fraud, waste, and abuse. Also, Federal investigators and analysts have targeted their efforts in fraud-prone areas, such as Dallas, Houston, Miami, Los Angeles, and Baton Rouge.
[Jaime Durley] And, what's been the impact of these targeted efforts?
These efforts have resulted in criminal charges against agency owners. For example, in October 2012, a Dallas Home Health owner pleaded guilty for his role in a $374 million dollar fraud scheme in which he and others billed Medicare for unnecessary services that were never performed.
[Jaime Durley] Wow! What about OIG's past work in the area of Home Health?
[David Samchok] A 2012 OIG report found that one out of four agencies had questionable billing, and eight States had high percentages of questionable billing.
Past OIG studies have also found vulnerabilities in Medicare contractors' efforts to identify and investigate potential fraud and abuse.
[Jaime Durley] David, tell us how you did the current study and what you found.
[David Samchok] We reviewed the home health oversight activities that CMS and its contractors performed in 2011.
We found that in 2011, two contractors we reviewed prevented $275 million dollars in improper payments and referred 14 home health agencies to law enforcement. Contractor efforts to detect and deter fraud varied greatly. For example, we had two contractors that recommended administrative actions, and referred cases to law enforcement, nearly eight times more than two other contractors - even though both sets of contractors worked in fraud-prone areas.
[Jaime Durley] And, what about payments to agencies with suspended or revoked billing privileges?
[David Samchok] Well, in 2011, we found that Medicare inappropriately paid five agencies with suspended or revoked billing privileges; and, CMS did not act on all revocation recommendations.
[Jaime Durley] Now based on these findings what did the Office of Inspector General recommend to CMS?
[David Samchok] Based on our findings, we recommended three things to CMS. First, create more contractor performance standards for high-risk providers in fraud-prone areas. Second, develop a system to track revocation recommendations and respond quickly. And third, follow up on and prevent future inappropriate payments made to agencies with suspended or revoked billing privileges.
[Jaime Durley] And, what's been CMS's response to our report?
[David Samchok] CMS agreed with all of our recommendations and acknowledged that home health services have been vulnerable to fraud, waste, and abuse. CMS also shared information on its new Fraud Prevention System, which uses predictive analytic technology on claims. This should help identify suspicious claims so CMS can take administrative action if necessary.
[Jaime Durley] David Samchok, a program analyst for the Office of Evaluation and Inspections. Thank you so much for sharing this important work on CMS and contractor oversight of home health agencies.
[David Samchok] Thank you.
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Priority recommendations summarized.
FY 2016 Work Plan
OIG projects planned for 2016.
Significant OIG activities in 6-month increments.