HHS OIG Releases 2014 Work Plan
February 7, 2014 09:00 AM
On January 31, U.S. Department of Health and Human Services Office of the Inspector General (HHS OIG) released its Work Plan for Fiscal Year 2014 (the Work Plan). The National Council on Medicaid Home Care – a NAHC affiliate - reports on the focus areas and objectives of the Work Plan in the Medicaid home care space, found on pages 36 through 38 of the Work Plan. These focus areas and objectives are virtually identical to objectives from the Work Plan for Fiscal Year 2013. However, while the 2013 Work Plan contains twelve (12) focus areas and objectives relating to Medicaid home care, the 2014 Work Plan contains only five (5). Standards and contextual information from the 2014 Work Plan provide:
Billing and Payments
Home Health Services: Provider and Beneficiary Eligibility
[HHS OIG] will review HHA claims to State Medicaid programs to determine whether the billing providers met applicable criteria to provide home health services to Medicaid beneficiaries. [HHS OIG] will also determine whether the beneficiaries met the criteria to receive such services.
Context: Medicaid home health services providers must meet standards and conditions of participation, many of which relate to quality of care and safety of beneficiaries, such as a minimum number of professional staff, proper licensing and certification, review of service plans of care, and proper authorization and documentation of provided services. Services are provided to a beneficiary at the beneficiary's place of residence and on a physician's orders as part of a written care plan that the physician reviews every 60 days. The care must include intermittent (not full-time) skilled nursing care and may include physical therapy or speech-language pathology services. The related Federal standards and conditions for HHAs’ participation in Medicaid are at 42 CFR Â§ 440.70 and 42 CFR Part 484. (OAS; W-00-12-31304; various reviews; expected issue date: FY 2015; work in progress) (2014 HHS OIG Work Plan, p. 36-37)
Analysis: Provider eligibility: Home care providers should note that being a Medicare certified agency will automatically qualify the provider as being able to provide Medicaid “home health services” to Medicaid beneficiaries. However, a state may allow providers that are not certified by Medicare to meet alternative eligibility criteria set forth in 42 CFR Â§ 440.70 and 42 CFR Part 484. These criteria including meeting Medicare standards mentioned above as well as standards related to personnel qualifications, patient rights, compliance with Federal, State and local laws, professional standards, and others. For example, a state licensing standard may be considered by the State Medicaid program to be the equivalent of the Medicare conditions of participation. However, it is for the state to decide on such standards, not the providers. Home care providers should take note of these standards as a potential alternate route to eligibility.
Beneficiary eligibility: Under Medicaid, states may not restrict eligibility for Medicaid mandatory home health services to those that are “homebound.” Nonetheless, as a July 2013 OIG report confirmed, states continue to allow such a homebound standard in violation of federal Medicaid law and the Americans with Disabilities Act (ADA). This will undoubtedly be an ongoing concern for HHS OIG moving forward.
The Work Plan also contains two other billing and payments provisions. Standards and contextual information from the 2014 Work Plan provide:
Adult Day Health Care Services
[HHS OIG] will review Medicaid payments by States for adult day care services to determine whether the providers complied with Federal and State requirements.
Context: ”Adult day health care programs provide health, therapeutic, and social services and activities to program enrollees. Beneficiaries enrolled must meet eligibility requirements, and services must be furnished in accordance with a plan of care. Medicaid allows payments for adult day health care through various authorities, including home and community-based services (HCBS) waivers. (Social Security Act, Â§ 1915, and 42 CFR Â§ 440.180.) (OAS; W-00-12-31386; W-00-13-31386; various reviews; expected issue date: FY 2014; work in progress) (2014 HHS OIG Work Plan, p. 37)
Continuing Day Treatment Mental Health Services
[HHS OIG] will review Medicaid payments to continuing day treatment (CDT) mental health services providers to determine whether their claims were adequately supported. Our review will follow up on a State Commission’s findings of unsubstantiated claims.
Context: ”CDT providers render an array of services to people with mental illnesses. CDT providers bill Medicaid on the basis of the number of service hours rendered to beneficiaries. One State’s regulations require that a billing for a visit/service hour be supported by documentation indicating the nature and extent of services provided. A State commission found that more than 50 percent of the service hours billed by CDT providers in that State could not be substantiated. To be allowable, costs must be authorized, or not prohibited, under State or local laws or regulations. (Office of Management and Budget (OMB) Circular A-87, Cost Principles for State, Local, and Indian Tribal Governments, Att. A, Â§ C.1.c.) (OAS; W-00-12-31128; W-00-13-31128; various reviews; expected issue date: FY 2014; work in progress) (2014 HHS OIG Work Plan, p. 37)
The Work Plan also contains one provision on state claims for federal reimbursement, and one provision on quality of care and safety of beneficiaries. Standards and contextual information from the 2014 Work Plan provide:
State Claims for Federal Reimbursement
Room and Board Costs Associated with HCBS Waiver Program Payments
[HHS OIG] will determine whether selected States claimed Federal reimbursement for unallowable room and board costs associated with services provided under HCBS waiver programs. [HHS OIG] will determine whether HCBS payments included the costs of room and board and identify the methods the States used to determine the amounts paid.
Context: ”Medicaid covers the cost of HCBS provided under a written plan of care to individuals in need of such services but does not allow for payment of room and board costs. (42 CFR Â§Â§ 441.301(b) and 441.310(a).) HCBS are provided pursuant to the Social Security Act, Â§ 1915(c). States may use various methods to pay for such services, such as a settlement process based on annual cost reports or prospective rates with rate adjustments based on cost report data and cost-trending factors. (OAS; W-00-13-31465; various reviews; expected issue date: FY 2014; work in progress) (2014 HHS OIG Work Plan, p. 37)
Analysis: As the Council recently reported, the new HCBS rule clarified that room and board costs are unallowable under the HCBS 1915(i) state plan benefit, with limited exceptions such as temporary food and shelter in a facility providing respite care services. Similarly, the Council supports full compliance with HCBS waiver program payments, including not billing for unallowable room and board costs.
Quality of Care and Safety of Beneficiaries
Home Health Services: Screenings of health care workers
[HHS OIG] will review health-screening records of Medicaid home health agency (HHA) health care workers to determine whether they were screened in accordance with Federal and State requirements.
Context: Health screenings for home health care workers include vaccinations such as those for hepatitis and influenza. HHAs provide health care services to Medicaid beneficiaries while the home health care workers are visiting beneficiaries’ homes. HHAs must operate and provide services in compliance with all applicable Federal, State, and local laws and regulations and with accepted standards that apply to personnel providing services within such an agency. (Social Security Act, Â§1891(a)(5).) The Federal requirements for home health services are found at 42 CFR Â§Â§ 440.70, 441.15, and 441.16 and at 42 CFR Part 484. Other applicable requirements are found in State and local regulations. (OAS; W-00-11-31387; W-00-12-31387; various reviews; expected issue date: FY 2014; work in progress) (2014 HHS OIG Work Plan, p. 38)
Analysis: HHS OIG has recommended that CMS retroactively deny Medicaid claims to providers not meeting State screening requirements. In other words, HHS OIG is treating failures to screen or failure to maintain screening documentation as resulting in claims overpayments. This indicates that HHS OIG views proper screening as a condition for Medicaid payment eligibility in addition to standards for provider participation in Medicaid. Home care providers should note that the HHS OIG may be overreaching with their position that healthcare screenings are a condition of Medicaid payment. In many states, the Medicaid program includes such requirements only provider participation standards. As such, the Council advocates that HHS OIG should not recommend that provider payments be subject to federal and state recoveries in states where it is not fully clear that staff health screening is a condition of payment as well. Regardless, to be on the safe side, home care providers are advised to focus extra attention on screening compliance.
Stakeholders should actively engage in the process of regulatory and legislative reform through the forums for state advocacy. Home care companies are encouraged to keep abreast of federal and state compliance initiatives, and to contact the Council with any questions or concerns.