OIG Reports Reliance on HHA Patient Lists Creates Survey Vulnerabilities and Recommends CMS Action

In March 2018, the Office of Inspector General (OIG) issued a Risk Alert, noting that some home health agencies (HHAs) provide Medicare surveyors with patient lists that are missing active Medicare beneficiaries at their locations. Because Medicare surveyors rely on patient lists generated by the HHAs to select patients for review, HHAs could alter patient lists in an effort to exclude certain beneficiaries from review or conceal fraudulent activities and health and safety violations. In response, OIG recommended that the Centers for Medicare and Medicaid Services (CMS) adopt new strategies to mitigate the risk of survey manipulation.

To ensure compliance with Medicare standards, HHAs must undergo onsite surveys prior to enrolling in Medicare, and then at least every 36 months thereafter. Medicare surveyors select a sample of patients to review based on patient lists that are issued by the HHA. These lists generally are intended to include a roster of all active patients and an admissions list. However, the OIG report revealed that, under the current system, the surveyors cannot authenticate whether the patient lists are complete and accurate at the time the survey is conducted. Therefore, HHAs could alter patient lists to exclude certain beneficiaries from review or conceal fraudulent activities and health and safety violations.

OIG analyzed a sample of 28 patient lists supplied to Medicare reviewers across five states (California, Illinois, Florida, Michigan, and Texas) from recertification surveys conducted between 2014 and 2016. The OIG report revealed that of the 28 lists, 19 were complete and 9 were incomplete. Of the incomplete lists, 2 lists were missing more than 10 beneficiaries and 1 list was missing more than 150 beneficiaries, equaling nearly 90% of active beneficiaries. OIG did not determine why beneficiaries were missing from the lists and noted that the survey results should not be generalized because of the small sample size. However, OIG did voice concerns that, under the current system, providers have the ability to intentionally omit beneficiaries from the lists or discharge beneficiaries on the roster date only to readmit them shortly after, in an effort to avoid surveyor scrutiny.

OIG recommended that CMS consider implementing multiple new strategies to verify lists and reduce survey vulnerabilities. These included creating OASIS-based reports for surveyors, conducting retrospective reviews, monitoring the HHA staff when they retrieve patient lists, or interviewing randomly selected HHA employees to confirm the patient list includes a certain subset of active patients.

The OIG report is of consequence for HHA providers. HHAs could face increasing oversight regarding their patient lists, and CMS may issue new survey rules or procedures. This response would align with CMS’s 2018 strategic initiative. On January 16, 2018, the Principal Deputy Administrator for Operations for CMS, Kim Brandt, J.D., M.A., discussed CMS’s goals and initiatives for 2018 at the Health Care Compliance Association annual Regional Conference in Atlanta, Georgia. Brandt noted that CMS would focus on program integrity and pay particular attention to home health, lab, and hospice providers due to their high error rates and billing irregularities. In addition, HHAs generating incomplete patient lists to CMS surveyors could face serious consequences. The OIG report noted providers that do not provide accurate records or other information necessary to verify compliance with Medicare’s terms and conditions of participation could face termination from the Medicare participation.

For more information, please contact Charmaine Mech. To read the full OIG report, click here, and to read more about CMS’s 2018 strategic initiatives, click here.