OIG audit 2023: What hospice and home health agencies need to know

Audits are typically based on red flags that come up during analysis of claims data. While these red flags are rarely identified outside of audit reports, the OIG often focuses on lack of documentation, eligibility issues and Medicare spending (most Medicare payments go to patients with a stay of more than 180 days). Red flags that suggest healthcare fraud include:

• Upcoding services to increase payment
• Submitting claims for patients who aren’t homebound
• Billing for visits that aren’t medically necessary or ordered by a physician
• Billing for visits a doctor ordered, but the patient didn’t receive
• Billing for services and equipment the patient didn’t receive
• Forged or fake signatures on medical forms and equipment orders
• Offers for free goods or services in exchange for Medicare numbers

Current OIG hospice audits appear focused on proper usage and documentation around the length of stay, based on a high incidence of fraud associated with stays of more than six months. In some cases, length of stay exceeded one year or more. The most common Additional Determination Request (ADR) denial reason is lack of documentation to support a prognosis of six months or less. To reduce your risk of audit, it’s important that your agency’s documentation supports the need for hospice intervention per the Centers for Medicare and Medicaid Services (CMS) audit protocols and regulatory guidelines, which require that patients receive a prognosis of six months or less to qualify for hospice care.

According to experts at Husch Blackwell, OIG Medicare and Medicaid audits look for specific errors that commonly occur in hospice and home health care. For instance, in 2021, OIG was looking to see:

• If patients met requirements for homebound status
• If patients were truly in need of skilled services
• Whether OASIS was submitted in a timely way
• If services were accurately documented

Based on reports released in 2021, it seems reasonable to assume the 2023 audit will be looking at many of these same recurring issues. Right now, home health is seeing an uptick in audits, including SMRC and UPIC audits like those being conducted in the hospice space. If these audits detect more problem areas, reviews may be expanded and could lead to new or revised policies, increased regulatory oversight, or payment changes for both home health and hospice.

The OIG plans to publish its reports on the public website in 2023. It’s likely these reports could generate a new round of audits, and it’s only then that we may be able to determine additional areas of focus.