The Office of the Inspector General is the governmental agency responsible for investigating compliance of entities conducting business with Medicare including home health agencies. In its effort to enforce applicable regulations, the Office of Inspector General has set forth guidelines for home health agencies. Accordingly, the Office of Inspector General recommends that agencies implement a compliant program.

The compliance program should include the following:

1. Development of written policies and procedures;
2. Designation of compliance officer;
3. Implementation of training program
4. Creation of a reporting process for fraud or other violations;
5. The use of audits and other evolutions techniques to monitor compliance; and
6. Investigation and remediation of systematic problems.

The Office of Inspector General has also identified several risk areas that they believe may create the potential for unlawful behavior within the home health care agency. Any agency concerned with preventing investigations should be sure that these risk areas are not present within their agency. These risk areas should be avoided so as to insure that the agency does not draw attention from the authorities.

One area of concern is the claim development and submission process. The preferred policy should enable the billing staff to communicate effectively and accurately with the clinical staff. The policies and procedures should provide for timely documentation of nursing and other services prior to the billing to ensure accurate and documented services are billed, claims should be submitted only when appropriate documentation supports the claim and when such documentation is maintained and appropriately organized, and the diagnosis and procedure codes for home health services should be reported. Compensation for billing department personnel should not offer incentives or reimbursement. Finally, there should be a review process to insure that billings are accurately submitted.

Another areas of concern are the anti-kickback and self referral concerns. Any agency entering into agreements with marketers or physicians should have their agreements reviewed to verify that they do not violate anti-kickback and self referral prohibitions. All health care agencies should consult with a professional to verify that they are in compliance with applicable federal guidelines.
Home health agencies are heavily regulated. All agencies should expect inquiries during routine surveys or OIG investigations as a part of conducting business. It is critical that your agency is prepared.

Should you have any questions relating to this article please feel free to contact Theodore M. McGinn at tmcginn@lavellelaw.com.