Remember that sinking feeling you got when your teacher announced a pop quiz?
Now multiply that a few billion times to get the stomach-knotting sensation of a home healthcare agency audit. The stakes are infinitely higher — fines, criminal penalties, or termination from Medicare and Medicaid.
Surveys and audits are built into the home healthcare system and can’t be wished away. To prepare agencies for the inevitable, the CHC (Community Health Care Services Foundation) recently hosted a webinar called “Home Care Audits – Facts & Trends.”
(The CHC is the educational affiliate of HCP, the New York State Association Of Health Care Providers.)
The following are key takeaways from that session.
Increased audits and surveys
Presenter Patricia Tulloch, a Senior Consultant at RBC Limited, Healthcare & Management Consultants, said it straight: “This will be a heavy year for surveys and audits.”
Why?
First, she pointed to the COVID staffing shortages that agencies are experiencing. With so many aides out, it’s not always possible to replace them. Disgruntled patients or families, annoyed at not getting care, then file a complaint with the DOH. And complaints always trigger investigations.
The second reason traces Medicare and Medicaid oversight back to its roots in Washington. The OIG (Office of Inspector General) is a federal agency that fights Medicare and Medicaid fraud and abuse. It conducts studies and reports to Congress.
In its latest work plan, OIG recommends increased auditing, investigations, and inspections of all healthcare providers. OIG doesn’t perform audits, but its directive sets the agenda for the state agencies that do.
Audit and survey priorities
The OIG recommendation isn’t arbitrary. The government has specific concerns, and it’s directing state agencies to focus on those areas:
- COVID19 fraud – It was inevitable that the unscrupulous would take advantage of government COVID funding. Some common examples of fraud include billing for fake tests, vaccines, or remedies, using COVID-19 as a hook for identity theft, or billing Federal healthcare programs for unnecessary services. The few corrupt providers cast suspicion on everyone. It’s imperative to keep 1000% complete records to prove the legitimacy of your every COVID19 service.
- COVID19 safety – It’s no surprise that this is also big. Whether or not an agency agrees with the government’s COVID politics or policies, it risks losing its license by not following them. This category includes infection control training, COVID screens, vaccinations, tracking, medical exemptions, and return-to-work policies.
- Wage parity – New York State tightened the screws on wage parity in the 20-21 State Budget, and it means business. Annual Compliance Statements are now due by June 1st each year, bringing a new level of accountability and oversight. Every wage parity hour of care, episode of care, and employee wage payment must be carefully documented.
Getting into details, there are two routine investigations that New York HHAs face:
- NYS OMIG (Office of the Medicaid Inspector General) audits
- NYS DOH (Department of Health) surveys
Forewarned is always forearmed, so here’s what to expect from each audit:
OMIG Audits
Purpose:
OMIG audits save the state money by preventing Medicaid fraud and recovering improperly spent funds. They also generate money from penalties. In 2020 alone, OMIG recovered $215 million from audits!
OMIG audits will flag agencies for discrepancies such as
- Missing or insufficient documentation of hours billed
- Incorrect procedure code billed
- Missing medical orders/plan of care
- Billing for services in excess of ordered hours
You can download the complete list of LHCSA audit protocols from OMIG’s website.
For 2022, audits will also focus on
- Wage parity law, as mentioned above
- Compliance with new EVV (Electronic Visit Verification) protocols
Process:
OMIG audits are thorough, long-term investigations. After setting up an initial conference call, the auditors select and review 100 clinical records from the past three years. In 2022, they’ll look at 2017-2019. They also examine:
- Service documents to support billing (such as timesheets)
- Personnel records
When they’re done, the auditors conduct an exit conference summary. They give you a Preliminary OMIG Report listing all your missing documents and giving a timeframe to submit them. Then they’ll review the information again and produce a Final Report.
As mentioned above, OMIG’s chief objective is to find and correct Medicaid overpayments. If the auditors find an error in the 100 records, they extrapolate those findings and compound it by your total Medicaid billing.
So, for example, an agency might bill $50 million a year to Medicaid. If the OMIG auditors find a 5% error rate in their sample, they’ll extrapolate 5% of $50 million. That’s $2,500,000 that the agency may owe!
However, there is a settlement process. It’s crucial to have legal counsel throughout the audit and especially during the settlement to negotiate lower penalties.
NYS DOH Surveys
Purpose:
The DOH is the government body that licenses New York’s home healthcare agencies. After the initial state licensure survey, the DOH performs periodic surveys to ensure the agency follows all state and federal regulations.
The DOH focuses on your policies and procedures, with an emphasis this year on infection control and COVID19. Practically speaking, they’ll be looking at your:
- COVID screening policies (a random two weeks’ worth)
- List of employees with medical exemptions
- Infection control training
- PPE policies
- Return to work policies
- Aide replacement policy
- And lots more!
Process:
DOH surveys are unannounced, happening approximately every three years for LHCSAs. During COVID, they conducted virtual surveys, but they’re back to in-person visits.
When the surveyors come, they’ve already done considerable remote surveillance, using data mining to access your documentation. They will check that information against reality!
Beyond the COVID policies mentioned above, they’ll request extensive documentation:
- HCR & CHRC policy & processes
- personnel files
- clinical records
- emergency disaster plan
- And more!
(To see the HCP’s very helpful sample survey, click here.)
Within two weeks of the survey, the Department sends you an Inspection report, identifying any deficiencies. You then have ten days to send back a written, detailed corrective action plan. The DOH reviews the plan and later comes for a follow-up visit.
For serious deficiencies, an agency may be fined or have to terminate its Medicaid participation.
Tips for audit and survey success
Countless details go into an audit, but the webinar noted some general best practices that can help you successfully pass your audits.
- Regulations are constantly changing, especially regarding COVID. To stay compliant, you must stay current. You can go to source websites such as CMS, CDC, and OIG to sign-up for email updates.
- Make sure all your policies are documented and up to date. COVID policies, in particular, should match or exceed NYS standards. This is very tricky since NYS keeps changing the rules! See #1 above about staying up to date.
- Don’t be caught by surprise! Go through the audit protocols and survey checklist to compile a documentation packet. Update it regularly and let everyone in the office know where it is.
- Keep a cover list of waivers for both clinical and personnel records. For example, in 2020 and 2021, agencies were allowed to delay annual health assessments and in-service hours. Without a reminder, an auditor or surveyor might not remember that waiver and flag you for not doing assessments those years.
“It all comes down to record-keeping,” says Shaya Sternhill, Melody Benefits Head Of Business Development & Sales. “If your records are in order, you can feel confident about being audited.”
That’s why Melody is meticulous about tracking data. We do the work for you, sending you a monthly report on your:
- Total wage parity spend
- Spend broken down by wage parity benefit
- Complete benefits usage report for each employee.
“Audits are time-consuming and intimidating,” says Shaya. “Let us give you one less thing to worry about.”
