CMS to Adopt a "Zero Tolerance" Position on Bad Home Care Actors

The Government Accountability Office (GAO) has issued a report that finds CMS lax in its controls to limit fraud and abuse in the Medicare home health payments. The report recommended that CMS:
1. perform criminal history background checks on key personnel listed on the HHA enrollment application.
2. Conduct post-payment medical review on claims submitted by HHS with high rates of improper billing identified through prepayment review;
3. Revoke an agency's Medicare billing privileges for a pattern of submitted claims that are falsified, for persons who do not meet coverage criteria or for services that are not medically necessary, and
4. Furnish the physician who certifies/recertified the plan of care wiht a statement of home care services furnished.

CMS has agreed to consider an additional ground for revokation of billing privileges and to contact physicians regarding home health claims with high therapy utilization and outlier claims as a check on high home health payments.

RAC in Minnesota

Congress passed legislation establishing a RAC program that is responsible for reviewing Medicare claims to assess if there have been improper payments (underpayments and overpayments) made to Medicare providers (physicians, all provider types, and suppliers). Home Care and Hospices are included among the providers that are part of this program.
An initial RAC three-year demonstration project (ended March 2008) conducted in 5 states (NY,MA,FL, SC, and CA) resulted in the RACs finding both underpayments and overpayments with 85% of those being for inpatient hospitals. The most common reasons for the overpayments were that the claims did not comply with Medicare coverage or with Medicare coding.
The RAC program is now being rolled out nationwide and Minnesota is among the first 19 states to be part of this roll-out beginning spring 2009. The RAC for Minnesota is CGI Technologies and Solutions of Fairfax, VA.
On April 7, there will be a "Meet Minnesota’s Recovery Audit Contractor(RAC)" meeting hosted by the Minnesota Hospital Association 2009 where a CGI representative will present information and updates on the focus for audits in Minnesota.
To find out more about the RAC program you can go to www.cms.hhs.gov/RAC.To find about more about the Meet Minnesota’s Recovery Audit Contractor meeting, you can go to www.mnhospitals.org and click on “events”