Fraud, especially healthcare fraud, has been everywhere in the news recently. Last Wednesday, May 13, the Centers for Medicare & Medicaid Services (CMS) announced a six-month, nationwide, data-driven moratoria on new Medicare enrollment for hospices and home health agencies. This was done in coordination with Vice President Vance’s Anti-Fraud Task Force.
The moratoria will allow CMS to halt, temporarily, new providers entering these programs, which they identify as a “key source of fraudulent activity.” CMS Administrator Dr. Mehmet Oz noted that “this is about protecting patients, restoring integrity, and safeguarding taxpayer dollars.” In a joint news conference with Vice President Vance Wednesday afternoon, Dr. Oz noted that half of the fraud in the federal government programs could come from healthcare services. He also detailed that dealing with Medicare fraud expenditures could double the lifespan of the Medicare trust fund.
CMS noted in the announcement that they will “intensify targeted investigations, deploy advanced data analytics, and accelerate the removal of hospice and HHA providers from the Medicare program that are suspected of committing fraud.” CMS added that this will not impact current enrollments, and further stressed that existing providers can continue to deliver their services to Medicare beneficiaries. Using a nationwide approach, officials said, the moratoria is designed to stop bad actors from shifting across state lines in an effort to evade detection. Current providers are able to provide services and bill Medicare for reimbursement, as they always have.
The May 13 announcement further details an earlier moratorium focused on preventing fraudulent Medicare billing by durable medical equipment (DME) companies. It also detailed some recent anti-fraud action that has resulted in the suspension of $70 million in funds from hospice facilities and home health agencies in Los Angeles that were suspected of fraud. Oz has noted that data shows one-third of all the hospice providers in the United States are located in Los Angeles.
This is just the most recent announcement of audits and investigations into Medicare fraud. Back in February, I wrote about the first, in a series of U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) skilled nursing facility (SNF) audits. That first audit found that 99 out of 100 sampled claims did not comply with Medicare payment requirements, translating into estimated Medicare overpayments of at least $31.2 million. Having professional coders who accurately and ethically assign codes for appropriately documented conditions has never been more crucial.
In the post-acute care world, focusing on hospice and home health care, that is also the case. The Association of Home Care Coding & Compliance (AHCC) offers several coding certification credentials. For hospice coders, it would be HCS-H, or Home Care Coding Specialist – Hospice. For home health agency coders, it would be HCS-D, or Home Care Coding Specialist – Diagnosis. Coders with these specialized credentials assign ICD-10-CM codes for patient encounters in both of these areas. While there is some similarity in hospice and home health coding, it is important to note there are differences coders need to be aware of, just like inpatient and outpatient coders are. Spoiler alert: sepsis is an area of confusion here also.
Many home health and hospice facilities do not have professional coders, much less credentialed ones. I do, however, look for this to change. Since the change in how these facilities and agencies are reimbursed, we have seen a change in coding emphasis. With the increased scrutiny by the OIG and focus on fraud from CMS, this will only increase. If you are looking for a new career opportunity, consider hospice or home health coding. As professional coders, we must be there to meet the moment.
This is an exciting new moment in healthcare, where coding and data improvement professionals can demonstrate their expertise and value.
