Medicaid Home Health

1. Medicaid Home Health Jim K. Hampton Office of the Medicaid Director Administrator/Fraud & Abuse Liaison July 30 � 31, 2008

2. 1 _____ ________ Recent Headlines �Florida�s Agency for Health Care Administration Unites with Federal Partners to Combat Home Health Fraud in Miami-Dade County� �Medicare Fraud Strike Force Cases Result in Long Prison Terms for Five Health Care Company Owners� �South Florida Labeled �Ground Zero� for Medicare & Medicaid Fraud� �Medicare Fraud Convictions Result in Prison Terms for Mother and Two Daughters�

3. Home Health: Visits Trends

4. Approved Visits

5. Aide w/o Associated Skilled Visit

6. Expenditures for Visits 

7. Utilization Trends

8. Private Duty Nursing/ Personal Care: Trends

9. Expenditures for Counties with Highest Medicaid Enrollment

10. Medicaid Home Health Program Home Health Services Coverage and Limitations Handbook EDS Website http://portal.flmmis.com/FLPublic/Provider_Home/tabId/36/Default.aspx

11. 10 Medicaid Home Health Program Purpose Provide medically necessary care to eligible Medicaid recipients whose condition, illness, or injury requires the care to be delivered in the recipient�s place of residence. Place of Residence Defined Private or foster home of recipient ALF or DS Group Home Home where unrelated individuals reside together Attending Physician Doctor in charge of the recipient�s medical condition that causes the recipient to require home health services.

12. 11 Medicaid Home Health Program Subcontracting A Medicaid home health agency cannot subcontract with a non-Medicaid home health agency for the provision or billing of Medicaid services. Fee-for-Service Medicaid Home Health Services include: Home Health Visits (includes services rendered by a licensed nurse or home health aide); Home Health Private duty nursing and personal care. Expenditures for these items in FY 2006-2007 were more than $190 million.

13. 12 _____ _______ _________ _______ _______ Dually-Eligible Recipients(Medicare & Medicaid) Medicaid cannot reimburse a home health agency for services that can be reimbursed by Medicare when a recipient is eligible for both Medicare and Medicaid services. Home health agency is responsible for retaining documentation in the recipient�s record that the service is not Medicare reimbursable.

14. 13 Medically Necessary Services The fact that a practitioner has prescribed does not, in itself, make the service(s) medically necessary or a covered Medicaid service. Appropriate and necessary for the treatment of a specific documented medical disorder, disease or impairment; Not for the convenience of the Medicaid recipient, the recipient�s caretaker, prescribing physician, or provider of service; Necessary to protect life, prevent significant illness or significant disability, or to alleviate severe pain; Individualized, specific, and consistent with symptoms or confirmed diagnosis of the illness or injury under treatment, and not in excess of the patient�s needs; Consistent with generally accepted professional medical standards as determined by the Medicaid program;

15. 14 ______ ________ ____________ Medical Necessity & Documentation Medicaid reimburses for services determined medically necessary and do not duplicate another providers services. If it is not documented; IT DIDN�T HAPPEN! If in doubt obtain guidance; Refer to Home Health Services Handbook; Seek assistance from local Medicaid office or Headquarters policy staff.

16. 15 Medicaid Home Health: Visits Face-to-Face contact with recipient at place of residence; Not limited to a specific length of time; Entry into the recipient�s place of residence, for the length of time needed, to provide the medically-necessary nursing or home health aide service(s). Does not include travel time; Administrative and not reimbursable by Medicaid. Limited to 4 visits per day; Although medically necessary situations requiring this level of care do exist, they are the exception vs. the norm. Pre-Certification required for services >60 in lifetime.

17. 16 Private Duty Nursing and Personal Care  Recipients that require more individual care than can be provided through a home health visit; Private Duty Nursing Services rendered in child�s home or other authorized setting. Support care required by child�s complex medical condition. Personal Care Medically necessary assistance with ADLs. Bathing; Grooming; Toileting; Oral Hygiene Minimum of 2 hours and up to 24 hours per day; <2 hours considered home health visit.

18. 17 Prior Authorization Requirements Physician writes an order for home health services; Home health agency submits the recipient�s medical information to the Medicaid peer review organization for review and authorization; Must meet established medical necessity criteria for approval of services. Home Health Visits; The home health agency submits a prior authorization request once the recipient has reached their 60 visit lifetime limit. Private Duty Nursing and Personal Care; Must be prior authorized prior to beginning services.

19. 18 Home Health Service Requirements To be reimbursed, home health services must also: Remain under the direction of the attending physician; Consistent with the individualized, written physician-approved plan of care; Provided by qualified staff; and Consistent with accepted standards of medical and nursing practice.

20. 19 In-Home Services Requirements Medicaid does not reimburse home health services solely due to age, environment, convenience or lack of transportation; Recipient requires, due to a medical condition, illness or injury, must be delivered at the place of residence rather than an office, clinic or other outpatient facility because: Leaving home is medically contraindicated and would increase the medical risk for exacerbation or deterioration of the condition. Requires services that are medically necessary and reasonable for the treatment of the documented illness, injury or condition; Require services that can be safely, effectively and efficiently provided in the home; and Live in a residence other than a hospital, nursing facility or intermediate care facility for the developmentally disabled (ICF/DD). (See exceptions for ICF/DDs in 42 CFR 483, Subpart I.)

21. 20 Physician Treatment Orders Written or verbal order from the attending physician is required to initiate or continue home health services. At a minimum, the order must include: Recipient�s acute or chronic medical condition or diagnosis that causes a recipient to need home health care; Documentation regarding the medical necessity for the service(s) to be provided at home; Home health services needed; Frequency and duration of the needed services; and Minimum skill level (nurse, home health aide) of staff who can provide the services. Physician orders must be signed and dated by the attending physician before submitting a request for pre-certification or prior authorization;

22. 21 ________ ________ _____ Physician Treatment Orders If pre-certification or prior authorization is not required, physician orders must be signed and dated by the attending physician before a claim for payment is submitted; Verbal orders must be put in writing and countersigned by the attending physician or validated prior to requesting pre-certification or prior authorization or submitting a claim for payment; Medicaid will reimburse home health services ordered by an ARNP or physician assistant only if the order has been countersigned by the attending physician.

23. 22 Assisted Living Facilities Cannot duplicate services an ALF provides to a resident. Home health agency is responsible for determining whether the provided home health service is being duplicated. Medicaid does not reimburse home health visit services provided to recipients living in an ALF when the following apply: The nurse or home health aide providing the service is an employee, directly or by contract, of both the home health agency billing for the service and the ALF; and The nurse or home health aide performs the home health visit service during a time period when also being paid or reimbursed for services by the ALF. Be sure the ALF is not being reimbursed under another program (i.e., ALE/ACS Waiver program) as assistance with ADLs are covered by this payment so aide services would not be eligible for reimbursement under home health!

24. 23 ___ __ ___ ___________ Plan of Care Requirements Description Individualized written program Collaborative attending physician and agency nurse Meets the needs of the recipient; Must identify the medical need for home health care, appropriate nursing interventions, and expected health outcomes; Home health agency must provide a copy of the initial and subsequent plans of care to the attending physician for inclusion in recipient�s medical record.

25. 24 Plan of Care Components Diagnosis(es), mental status, prognosis, rehabilitation potential, functional limitations, permitted activities, nutritional requirements, medications and treatments; Physician orders; Explanation of medical necessity for home health services; Nursing services, home health aide services or therapy to be provided; Medical supplies, appliances or durable medical equipment to be provided;

26. 25 ___ __ ___ _________ Plan of Care Components Start and end date, frequency, and level of staff necessary to perform the services; Safety measures to protect against injury; Discharge plan; Approval by the attending physician as evidenced by signature; Must be signed prior to submitting for pre-certification or prior authorization Expected health outcomes.

27. 26 _____ ________ ____ _____ __ ____ ___ ____ Agency Authority with Regard to Fraud and Abuse 42 CFR Part 455 Mandates state plans to have a method for identification, investigation, and referral of fraud & abuse. Section 409.913, F.S. �The agency shall operate a program to oversee the activities of Florida Medicaid recipients, and providers and their representatives, to ensure that fraudulent and abusive behavior and neglect of recipients occur to the minimum extent possible, and to recover overpayments and impose sanctions as appropriate.�

28. 27 __________ Definitions Fraud: The �intentional deception or misrepresentation� that an individual knows, or should know, to be false, or does not believe to be true, and makes, knowing the deception could result in some unauthorized benefit to himself or some other person(s). Abuse: Provider �practices that are inconsistent� with generally accepted business or medical practices and that result in an unnecessary cost to the Medicaid program or in reimbursement for goods or services that are not medically necessary or that fail to meet professionally recognized standards for health care. Overpayment: Includes any amount that is not authorized to be paid by the Medicaid program whether paid as a result of inaccurate or improper cost reporting, improper claiming, unacceptable practices, fraud, abuse, or mistake.

29. 28 _____ ___________ Strong Partnerships Medicaid ________ Program Integrity

30. 29 Fraud Landscape Two enabling factors: Patient population to exploit Services & treatments to bill Collateral Damage Corruption of patient medical histories Theft of patients finite health benefits Physical risk/harm to patients Draining of Medicaid funds Current fraud equation Low Risk/High Reward Information = Vital Commodity

31. 30 Examples of Health Care Fraud The Most Basic Healthcare Fraud Scheme Billing for services not rendered Medical services or procedures that were not actually performed Goods and/or supplies that were not provided Billing for nonexistent or unnecessary services Billing for more expensive products/services than were actually provided Paying kickbacks To recipients for use of Medicaid Number To providers for patient referrals Duplicate or double billing

32. 31 Home HealthFraud & Abuse Issues Misrepresentation of patients medical condition in POC Lack of medical necessity to justify service Aides working 18+ hours per day Physicians signing off on POCs without review Physicians never examining recipient Agencies being reimbursed for services aides are providing to relatives

33. Home HealthFraud & Abuse Issues POCs not being followed (i.e., 2+ visits per day billed, but only 1 rendered) Billing 100% for two or more recipients at same residence Home health aides recruiting patients Runners selling prescriptions Patients demanding payment

34. 33 Real Examples Nursing Notes & Assessments �Patient comatose� and later it says �patient is forgetful� �Patient suffers from unsteady gait�; Patient was a double amputee, in a wheelchair, does not own prosthetic limbs �Patient is four years old�.has dentures� Patient weight fluctuates +/- 20 lbs with every recertification Patient height fluctuates significantly between recertification

35. 34 Medicaid Program Integrity (MPI) Minimize fraud, abuse, and neglect of recipients Utilize advanced detection methods Utilize efficient auditing methods Pre & Post review of payments to providers Recover identified overpayments Impose sanctions Coordinate closely with Medicaid Fraud Control Unit and other state and federal partners

36. 35 Integrity Activities Conducts audits and investigations and refers cases to other regulatory and law enforcement agencies; Suspected provider fraud cases are referred to the Medicaid Fraud Control Unit within the Office of the Attorney General; Suspected recipient fraud cases are referred to the Florida Department of Law Enforcement; Suspected licensure violations are referred to the Department of Health or AHCA HQA (depending on type of license); Referrals are also made to Medicare, and other regulatory entities.

37. 36 Statutory, Administrative & Contractual Remedies Withhold of payments Reliable evidence of fraud or misrepresentation Pre-payment review Random & targeted Can last 60 � 180 days Requires provider to submit documentation & records to support billing prior to payment Sanctions Florida Administrative Code 59G-9.070 Require repayment Termination of provider contract

38. 37 Important Reminders for Medicaid Providers Maintain accurate documentation for the delivery of goods and services for a full 5 years; Keep provider enrollment information updated; Change of Address; Change of Ownership; Change of Officers, Directors, Managing Employees. Cooperate fully with MPI records requests; Better organized submission results in a more prompt review.

39. 38 Reporting Systems Hotline 1-888-419-3456 Internet Explanation of Medicaid Benefits (EOMB) Referrals

40. 39 AGENCY MEDICAID FRAUD AND ABUSE REPORTING CONTACT HORACE DOZIER Program Administrator/Intake Medicaid Program Integrity 2727 Mahan Drive, MS #6 Tallahassee, FL 32308 Telephone (850) 921-1802 Fax�(850) 922-3806 EMAIL: DOZIERH@AHCA.MYFLORIDA.COM

41. 40 ONLINE COMPLAINT FORM

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44. 43 Direct Link to Online Complaint Form http://ahcaxnet.fdhc.state.fl.us/inspectorgeneral/fraud_complaintform.aspx

45. 44 Altering the Fraud & Abuse Landscape AHCA Education & Monitoring Field Visits Education Acknowledgment Statements Revisions to policy Documentation of ordering physician with claim submission Mandatory pre-enrollment onsite visits Enrollment of aides Focused Home Health integrity and compliance projects Enhance fraud and abuse controls Increase pre & post payment reviews Increase use of sanctions

46. 45 Altering the Fraud & Abuse Landscape Aggressive Fraud & Abuse Controls Prevent Detect Deter Recover Prosecute Reverse the fraud equation High risk/low reward

47. 46 Altering the Fraud & Abuse Landscape Home Health Provider Community Engage Educate & Monitor Staff Reassess Medicaid Census Report Be A Partner Not A Contributor

48. Questions/Comments? Jim K. Hampton Administrator/Fraud & Abuse Liaison 2727 Mahan Dr., MS # 8 Tallahassee, FL 32308 (850) 414-8113 Office (850) 519-3527 Cell