Review of Costs Claimed by Visiting Nurses Association of ..., Lecture notes of Medical Records

Download Review of Costs Claimed by Visiting Nurses Association of ... and more Lecture notes Medical Records in PDF only on Docsity! P . *’ -. J . � DEPARTMENT OF HEALTH & HUMAN SERVICES OWceof hsDector General 1 -. .4, *+9., U‘4 c MAY 24 1= Memorandum Date +&44+­ From & ‘Une ‘ibbs ‘rown /“ - Inspector General %bjecl Review of Costs Claimed by Visiting Nurses Association of Dade Coun~, Inc. (A-O4-95-O11O3) To Bruce C. Vladeck Administrator Health Cam Financing Adminisuation Attached are NO copies of our finalreport entitled, Revi~ c!!CUWSCZCZi~ed@ Visiting k Nurses AmcJck@m of Dade County, Inc- The audit objective was to determine whether [ the home health care services claimed by the Visiting Nurses Association of Dade County Inc. (VNA) in Miami, Florida, met Medicare reimbursement guidelines. We randomly selected for review 100 claims submitted by VNA for Medicare reimbursement during the fiscal year (FY) ended December 31, 1993, These clams represent 1,856 home health services. Our review showed that 32 claims or 32 percent of our sample contained 403 services (22 percent of the total semices) th:t did not meet Medicare guidelines, as follows: b 9 percent of the claims were for 129 services provided to beneficiaries who, in their own opinion, or in the opinion of medical experts were not homebound; F 16 percent of the claims were for 208 services which, in the opinion of medical experts, were not reasonable or necessary; � 4 percent of the claims were for 18 se~ices not provided; and . � 3 percent of the claims were for 48 semices which physicians either denied authorizing, or authorized improperly. Cases in the latter two categories concern us and should be closely reviewed by the Medicare fiscal intermediary (FI). During the FY ended December 31, 1993, VNA claimed $11.1 million in 8,606 claims representing 187,197 semices. Based on our review, we estimate that at least $1.3 million did not meet the reimbursement guidelines and using the 90 percent confidence interval, we believe the overpayment is between $1.3 million and S2.6 million. I .- Page 2- Bruce C. Vladeck Although we found documentation that VNA monitored its own employees and subcontractors, it did not follow its own policies and procedures to emure that claims submitted were for services that met Medicare reimbursement guidelines. Nevertheless, the guidelines make contractors, such as VNA, responsible for the acticms of their subcontractors, We recommend that the HeaIth Care Financing Administration (HCFA) requk=-tie FI to instruct WA on its responsibilities to properly monitor its subcontractors for compliance with the Medicare regulations and HCFA guidelines, monitor the FI and VNA to ensure that corrective actions are effectively implemented, and recover all overpayments, We also recommend that HCFA direct the FI to investigate all cases of possible fraud and refer them as necessary to the Office of Inspector General’s office of Investigations. In its written response to our draft report, HCFA agreed with our recommendations. The complete text of HCFA’S response is presented as Appendix E to this report. We would apprecia~e your views and the status of any further aclion taken or contemplated on our recommendations within the next 60 days, If you have any questions, please call me or have your staff contact George M. Reeb, Assistant Inspec~or General for Health Care Financing Audits, at (410) 786-7104. Copies of this report are being sent to other interested Department officials. To facilitate identification, pIease refer to Common Identification Number A-04-95-01 103. Attachments Page 2- Bruce C. Vladeck During the FY ended December 31, 1993 VNA claimed $11.1 million in 8,606 claims representing 187,197 services. Based on our review, we estimate that at least $1.3 million did not meet the reimbursement guidelines and using the 90 percent confidence interval, we believe the overpayment is between $1.3 million and $2.6 million. .=-. . Although we found documentation that VNA monitored its own employees and subcontractors, it did not follow its own policies and procedures to ensure that claims submitted were for services that met Medicare reimbursement guidelines. Nevertheless, the guidelines make contractors, such as VNA, responsible for the actions of their subcontractors. We recommend that the Health Care Financing Administration (HCFA) require the FI to instruct VNA on its responsibilities to properly monitor its subcontractors for compliance with the Medicare regulations and HCFA guidelines, monitor the FI and VNA to ensure that corrective actions are effectively implemented, and recover all overpayments. We also recommend that HCFA direct the FI to investigate all cases of possible fraud and refer them as necessary to the Office of Inspector General’s (OIG) Office of Investigations (01). In its written response to our draft report, HCFA agreed with our recommendations. The complete text of HCFA’S response is presented as Appendix E to this report. BACKGROUND Visiting Nurses Association of Dade County Inc. The VNA is a Medicare certified home health agency (HHA) with a principal place of business in Miami, Florida. The VNA is a voluntary nonprofit Florida corporation that directly and indirectly employs nurses, aides, therapists, and administrative personnel in Dade County. ~ A Medicare certified HHA, such as VNA, can either provide home health services itself or make arrangements with other certified or non-certified providers for home health services. Most of the services claimed by VNA were provided under contract with non- Medicare certified nursing groups. During FY 1993, VNA was reimbursed under the periodic interim payment (PIP) method. Payments under PIP approximate the cost of covered services rendered by the provider. Interim reimbursement from Medicare totaled $10.9 million. Interim payments I --- Page 3- Bruce C. Vladeck The VNA submitted a costare adjusted to actual costs based on amual cost reports. report for FY 1993 claiming costs totaling $11.1 million .. Authority and Kequlremenls Jor Home fieaan awvuxs .-.. r r rr - -1. r. 0. —.:--,..,. The legislative authority for coverage of home heal~ services is contained in sections 1814, 1835, and 1861 of the Social Security Act; governing regulations are found in title in the Medicare HHA Manual. 42 of the Code of Federal Regulations (CFR); and HCFA coverage guidelines are found Intermediary Responsibilities f The HCFA contracts with fiscal intermediaries, usually large insurance companies, to assist them in administering the home health benefits program. The FI for VNA is AEtna Life and Casualty Insurance Company (AEtna) in Clearwater, Florida. The FI is responsible for: [ � processing claims for HHA services, ! F performing liaison activities between HCFA and the HHAs, 1 � making interim payments to HHAs, andI i [ F conducting audits of cost reports submitted by HHAs. I I SCOPE The objective of the audit was to determine whether the home health care services claimed by VNA met Medicare reimbursement guidelines. The audit was performed [ 1 1 under the auspices of Operation Restore Trust and was initiated by a request from HCFA’S Atlanta regional office and its regional home health intermediary. The individuals who participated in this audit are shown on Appendix D. The VNA claimed 187,197 services on 8,606 claims for FY 1993. We reviewed a statistical sample of 100 claims totaling 1,856 services for 99 different individuals (1 individual appeared twice in the sample). We are reporting the overpayment projected from this sample at the lower limit of the 90 percent confidence interval. The claims were submitted by VNA during the period January 1, 1993 through December 31, 1993. Appendix A contains the details on our sampling methodology. Appendix C I Page 4- Bruce C. Vladeck contains the results and projection of our sample. We used applicable laws, regulations, and Medicare guidelines to determine whether the services claimed by VNA met the reimbursement guidelines. In addition to using the sample to determine the amount of overpayment, we used the sample to determine the percentage of certain characteristics. Appendix B contains the.=. details of the results of these projections. Generally, for each of the 100 claims, we interviewed: � the beneficiary or a knowledgeable acquaintance, b the physician who certified the plan of care, and � the beneficiary’s personal physician. Our interviews included validation of beneficiaries’ and physicians’ signatures when necessary. We interviewed 86 of the 99 beneficiaries. We were unable to interview 13 of the beneficiaries or a close acquaintance because they were either deceased or had moved out of the area. We were not able to interview 21 physicians because they were either deceased, had moved out of the area, or refused to talk to us. We reviewed supporting medical records maintained by VNA for all of the claims in our sample. The records were also reviewed by AEtna medical personnel to determine whether the medical records for the claimed services met the reimbursement requirements. We conducted a review of VNA’S internal controls, but we did not place reliance on them. Specifically, we reviewed quality control work performed by VNA to monitor services provided either by their own staff or subcontractors. Our field work was performed at the VNA’S administrative office in Miami, Florida, and the FI’s office in Clearwater, Florida. Interviews were conducted in the beneficiaries’ residences and the physicians’ offices. Our field work was started in January 1995 and completed in October 1995. Our audit was conducted in accordance with generally accepted government auditing standards. DETAILED RESULTS OF REVIEW Our audit showed that 32 percent of the claims submitted by VNA during FY 1993 did not meet the Medicare reimbursement requirements. Page 7- Bruce C. Vladeck Services Claimed But Not Provided� Ourreview showed that 40fthe 100claims were for18services that were not provided. The medical records maintained by VNA contained the required documentation including signatures of the beneficiaries indicating that the services were provided. However, the physicians who purportedly signed certifications for two of these claims did not have any records to support the homebound status for the beneficiary, and did not know of the homebound requirements for home health services. During the initial interview of the beneficiaries, they told us that they had not received the services on the dates that were on the sampled claims. A review of the medical records indicated that the beneficiaries had signed for the services. We reinterviewed three of the four beneficiaries and showed them the signatures on the visit logs and one beneficiary stated that her signature was forged; a second beneficiary said that some of the signatures appeared to be hers, however she insisted that she did not receive the services; the third beneficiary refused to validate her signature. The fourth beneficiary died before we could validate her signature. We also interviewed the four physicians who signed the plans of care for the four claims. Two of the physicians had no record to support the homebound status of the beneficiaries, and were not familiar with the homebound requirements for home health services. Physicians Did Not Properly Authorize The Sewices� Our review showed that 3 of the 100 claims were for 48 services not properly authorized by a physician. Two of the claims were for services where the physicians said their signatures were forged. We interviewed the two physicians who purportedly signed the plans of care for the claims. The physicians advised us that they did not sign the plans of care. Furthermore, one physician told us that she did not know the beneficiary or have any medical records indicating that the beneficiary had been seen by her. The second physician recognized the beneficiary as his patient, but stated that she was not homebound. The third claim was for services where the physician did not sign the plan of care until after the bill was submitted to the intermediary for payment. The laws, regulations and guidelines recognize that the physician plays an important role in determining the utilization of services. The legislation specifies that payment for services may be made only if a physician certifies the services were required because the individual was homebound and needed skilled nursing care. The regulations (42 CFR 424.22) state that Medicare pays only if a physician certifies the services were needed. In addition, the regulations at 42 CFR 424.22 require all care to follow a physician’s -- m.. Page 8- Bruce C. Vladeck plan of care. The Medicare HHA Manual states that the patient must be under the care of a physician who is qualified to sign the certification and the plan of care, and that the plan of care must be signed by the physician before the bill is submitted to the intermediary for payment. We discussed these cases with AEtna officials and they advised that claims not duly authorized should be denied. Effect� Our audit showed that 32 percent of the FY 1993 claims submitted by VNA were overstated. We projected the sample overpayment amounts to the sampling frame. The 90 percent confidence interval is $1,325,105-to $2,629,965 with a midpoint of $1,977,535. Using the lower limit of the 90 percent confidence interval, we are 95 percent conildent that VNA was overpaid by at least $1,325,105 for unallowed home health services. VNA Did Not Properly Monitor Subcontractors� The VNA did not follow its own policies and procedures to monitor its subcontractors. The VNA stated that the subcontractors provided documentation which indicated visits were made and services were provided. The VNA had procedures for monitoring subcontractors to ensure that beneficiaries met the homebound and medical necessity criteria to receive HHA services. However, VNA had no explanation as to why their monitoring did not disclose the problems that we found. The HHA coverage guidelines issued by HCFA, provide that the HHA has essentially the same responsibilities for services provided by subcontractors as for services provided by their salaried employees. During reviews of the beneficiaries’ medical records maintained by the HHA, we found documentation that showed VNA did monitor subcontractors. However, in two instances, the documentation showed that the services were no longer reasonable or necessary, yet no action was taken to discontinue the services. In another instance the physician’s signature was not obtained until after the claims had been submitted to the FI for payment. -- r . ,, Page 9- Bruce C. V1adeck RECOMMENDATIONS We recommend that HCFA: 0 Require the FI to instruct VNAonits responsibilities to properly monitor its subcontractors for compliance with Medicare regulations and HCFA guidelines. o implemented. Monitor the FI and VNA to ensure that corrective actions are effectively o Recover all overpayments. o Direct the FI to investigate all cases of possible fraud and refer them as necessary to the OIG’S 01. In its written response to our draft report, HCFA agreed with our recommendations. The complete text of HCFA’s response is presented as Appendix E to this report. APPENDIX B Page 1 of2 AUDIT OF VNA OF DADE COUNTY INC. ATTRIBUTES PROJECTIONS -. REPORTING THE RESULTS: We used our random sample of 100 claims out of 8,606 claims to project the occurrence of certain types of errors. The lower and upper limits are shown at the 90 percent confidence level. The results of these projections are presented below: CLAIMS THAT DID NOT MEET THE REQUIREMENTS Quantity Identified in the Sample Point Estimate Lower Limit Upper Limit SERVICES CLAIMED BUT NOT PROVIDED Quantity Identified in the Sample Point Estimate Lower Limit Upper Limit 32 32.0% 24.3% 40.5% 4 4.0% 1.4% 8.9% SERVICES PROVIDED TO BENEFICIARIES THAT WERE NOT HOMEBOUND Quantity Identified in the Sample 9 Point Estimate 9.0% Lower Limit 4.8% Upper Limit 15.2% SERVICES THAT WERE NOT PROPERLY AUTHORIZED BY PHYSICIANS Quantity Identified in the Sample 3 Point Estimate 3.0% Lower Limit 0.8% Upper Limit 7.6% - - APPENDIX B Page 2 of 2 AUDIT OF VNA OF DADE COUNTY INC. ATTRIBUTES PROJECTIONS REPORTING THE RESULTS: SERVICES THAT WERE NOT REASONABLE OR NOT NECESSARY Quantity Identified in the Sample 16 Point Estimate 16.0% Lower Limit 10.3% Upper Limit 23.3% , 1 APPENDIX C AUDIT OF VNA OF DADE COUNTY INC. VARIABLES PROJECTIONS REPORTING THE RESULTS: - - We used our random sample of 100 claims out of 8,606 claims to project the value of claims that did not meet the requirements. The lower and upper limits are shown at the 90 percent confidence level. The results of these projections are presented below: CLAIMS THAT DID NOT MEET THE REQUIREMENTS Identified in the sample Number of Claims Value Point Estimate $1,977,535 Lower Limit $1,325,105 Upper Limit $2,629,965 $22~79 Health Care Financing Administration (HCFA) Comments cm OffIce of kspector General (OIG) Draft Report: “Review of Costs Claimed by Visiting Nurses Association of Dade CountY.” (A-04-95-0 1103) OIG Recommendation .= - HCFA should require Fiscal Intermediaries (FI’s) to (VNA) on its responsibilities to properly monitor its instruct Visiting Nurses Association subcontractor for compliance with Medicare regulations and HCFA guidelines. HCFA Response We concur. HCFA will instruct the FI to conduct focused medical review on future claims submitted by VNA and ask the Medicare survey and certification agency to review the subcontracting arrangements. OIG Recommendation HCFA should monitor the FI and VNA to ensure that corrective actions are effectively implemented. HCFA Response We concur. HCFA will monitor Aetna Life and Casualty Insurance Company’s compliance with our instructions to review VNA. OIG Recommendation HCFA should recover all overpayments. HCFA Res~onse We concur. We will take the appropriate actions necessary to recover from VNA those payments made for home health visits failing to meet Medicare reimbursement guidelines. If the OIG, Office of Investigation collects sufficient evidence, we will support the imposition of Civil Monetary Penalties. [it t’I’>Iv 1)1 ‘m Page 3 A 1~, Qf 3 , Page 2 OIG Recommendation HCFA should direct the FI to investigate all cases of possible fraud and refer them as necess~ to the OIGS, Office of Investigations. .= - HCFA Response followed by the FI. We concur. This procedure is already outlined in our contractor mamxd and is being