An Office of Inspector General (OIG) audit of the Health Care Financing Administration (HCFA) revealed errors in 30 percent of all claims paid by HCFA in fiscal year 1996.  These findings remain relevant even today as observed during recent QA appointments.

The top three errors identified were:

1. Insufficient/No documentation.  In ~ 47% of all claims submitted, there was insufficient/no documentation and one-third of the documentation errors were associated with providers who failed to respond to repeated requests from auditors to submit documentation.
2. Lack of medical necessity.  In ~ 37% of all claims submitted, there was lack of medical necessity.  Hello Face-to-Face Encounter.
3. Incorrect coding.  In ~9 % of claims submitted, the coding was incorrect.  During recent QA appointments, our consultants have discovered there are agencies in which the individuals documenting & coding their OASIS have never attended an OASIS/Coding class. The Outcome Assessment Information Set (OASIS) is the tool that is in the driver’s seat in your agency when it comes to being appropriately compensated for the services you are providing.  Proficiency in documentation and coding is non-negotiable.

The errors identified during this audit accounted for a whopping $23.2 billion annually, or 14 percent of total Medicare fee-for-service payments, excluding managed care.  As a result of this audit and due to the rapid aging of America, the federal government has indeed made eliminating fraud and abuse from the Medicare System one of its top priorities.  The top three providers identified during this audit which will receive increased scrutiny by the federal government are:

a)      Inpatient PPS
b)      Physicians & yes, we made the cut
c)      Home Health Agencies

As providers, you can expect to see increased efforts by the federal government to prevent, identify, and punish healthcare fraud and abuse. HCFA developed an action plan to address the problems identified by the OIG audit and it includes the following measures:

1. Increased number of prepayment reviews.
2. Increased post payment reviews.
3. Overpayment recovery.
4. Target providers identified as submitting improper claims for more extensive    investigation.
5. Increase scrutiny of Management and Evaluation claims.
6. Increase in ADR’s.
7. Increased security measures to prevent submission of claims from improper providers.

So what does all this mean for you the provider? What can you do to reduce your chance of becoming a target of a fraud investigation, or if you do become a target, minimize the risk of assessment of maximum penalties? How can you assure and demonstrate that your organization has accurate medical record documentation that supports the diagnoses and services reported on the claim for reimbursement, and ethical coding practices?

1. Become familiar with the “Hot” Targets, i.e. OIG Fraud alerts; provider bulletins, etc…
2. Corporate compliance programs are seen as an effective mechanism to assure compliance with regulations and minimize risk of fraud.
3. Timely and accurate submission of OASIS  & CAHPS data
4. Face to Face Certification Requirements met
5. HIPAA 5010 compliant
6. Diversification of services
7. Multiple Referral Sources
8. Use the Complete Home Health Software Management Platform, Agencycore by Axxess.

Axxess prides itself on offering a platform that enables home health agencies to operate their agencies in full compliance with all regulations and payment criteria. Interested in becoming a highly effective HHA? Join the movement, and utilize the pre-eminent toolset for effectiveness in HHA operations: Axxess.

1. Article citation: Prophet, Sue. “Coding Compliance: Practical Strategies for Success.” Journal of AHIMA 69, no.1 (1998): 50-61.