Home Health Care News: Addressing OIG’s Characteristics of Home Health Fraud — Without Toppling the Whole System

January 9, 2017| Blog, Health Care, Homecare, Payer, Provider
Posted by Home Health Care News; contributed by Tom Meyer, HHAeXchange

The numbers don’t lie.

After more than 10 years serving in the New York Office of the Medicaid Inspector General, including as the Acting Inspector General, I can attest firsthand to the unfortunate instances of fraud, waste and abuse that occur with too much regularity in home health care and home care.

Between 2011 and 2015 alone, investigations from the national Office of the Inspector General (OIG) resulted in more than 350 criminal and civil actions and $975 million in receivables. In fact, the OIG estimates more than $10 billion in improper payments in the 2015 fiscal year.

In spite of the numbers that point to the need for improvements, home health and home care play a vital role in the broader healthcare ecosystem, and increasingly, states are relying on managed care organizations (MCOs) to deliver efficient and effective Medicaid programs. For MCOs and state Medicaid programs alike, the balance between preventing fraud and continuing to provide quality care is a delicate one.

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CURES Act’s EVV Mandate for Home Care is the First Step

December 16, 2016| Blog, Compliance, Homecare, Payer

In an industry where issues of mistrust and system abuse often rule the headlines, family and friends want reassurance that their loved ones are being provided with proper care. Government programs, like Medicaid, need accountability for the money they pay out, and proof positive that members are receiving proper care and caregivers are being held accountable. Electronic visit verification (EVV) alone doesn’t solve all problems, but implementing an EVV system is the first step to combatting fraud and abuse to ensure program integrity.

Signed into law this week by President Obama, the 21st Century CURES Act mandates, among other actions, that EVV be used for in-home visits for home care and personal care visits.

While EVV is an effective monitoring tool for tracking arrivals and departures – thereby reducing false claims of time spent with a member – it only goes so far. Capturing and tracking data from an EVV solution won’t help Medicaid payers reduce readmissions unless they actively manage the process and consider a collaborative and transparent home care platform.

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Ensuring Compliance

September 29, 2016| Blog, Compliance, Payer, Provider

Solving the Most Common Compliance Problems

HHAeXchange’s web-based software platform dynamically links payers and providers — creating a shared environment to effectively interact in real-time allowing increased operational efficiency.

Benefits include: Read More

The EVV Bill, helping to reduce FWA

September 23, 2016| HR Bill 2446, Payer, Uncategorized

The EVV Bill proposed to reduce FWA while improving patient care

The Office of the Inspector General of Health & Human Services has identified that personal care services provided in Medicaid are at high risk for fraud, waste and abuse.  By using an electronic visit verification (EVV) solution, State Medicaid Agencies, Managed Care Organizations (MCOs) and homecare providers can reduce the level of fraud and improper payments, while ensuring that some of the most vulnerable Medicaid beneficiaries receive the care they need.  Read More

How does a Verification Organization benefit you?

September 21, 2016| Blog, Payer, VO

Verification Organizations (VOs) have helped to reduce fraud, waste, and abuse in New York State. HHAeXchange achieves this by employing an integrated, shared-platform that allows full visibility to your provider and MCOs’ activities.

More specifically, you could view processes such as:

  • Electronic Visit Verification (EVV) Processing
  • Scheduling  vs Confirmed or Unconfirmed Visits
  • Billing Read More

Status of House of Representatives Bill 2446

September 6, 2016| Blog, HR Bill 2446, Payer

HR Bill 2446 was rolled into section 207 of HR 2646 and passed the House by a vote of 422-2 on July 6, 2016.

  • There were some Medicaid provisions in the Mental Health bill and therefore, to incorporate the following items
    • EVV vendor neutrality clauses were added
    • The scope was expanded from PCA services only to include home health services as well

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What is a Verification Organization?

August 23, 2016| Blog, Payer, VO

In 2011, the New York Office of the Medicaid Inspector General (OMIG) passed into law a measure that required home health providers who exceeded $15 million in Medicaid and/or Medicaid Managed Care reimbursements to utilize a Verification Organization (VO). A VO is an entity that analyzes data captured by Electronic Visit Verification (EVV) software to verify that services billed to Medicaid are legitimate and were provided to an eligible Medicaid beneficiary.  In addition, the VO utilizes this data to prepare an assessment of each selected provider to ensure that their processes are compliant with CMS and state guidelines. This also educates organizations on how to improve their compliance processes.  Read More

Shared Platform Approach Most Effective Way to Manage MLTSS

August 15, 2016| Payer, Provider, White Paper

Real-time Oversight and Connectivity Needed to Reduce MLTSS Risk for Medicaid Payers, Home Care Providers

Rapidly shifting market forces have strained the delivery of Managed Long Term Services and Supports (MLTSS) in the United States to the point where spending may continue to outpace inflation, even as demand increases. Budget-strapped Medicaid payers, including state Medicaid programs and managed care organizations, must deliver high quality outcomes and hold the line on increased expenses. New Medicaid members flooding into the system without standard treatment protocols and a scalable infrastructure create gaps in quality and multimillion-dollar vulnerabilities related to fraud, waste and abuse. MLTSS requires a different approach to remain sustainable – a technology enabled ecosystem of care coordination, case management and billing where Medicaid payers and home care providers work together throughout the entire spectrum of home care delivery. This includes, but is not limited to, referrals and authorizations, plans of care, scheduling, caregiver compliance, visit verification and claims submission. Automation must be deployed and centralized to improve timeliness and service delivery at reduced cost. This white paper demonstrates how a shared platform approach will reduce MLTSS risk and improve operational efficiencies so Medicaid payers and home care agency providers aren’t left behind.

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Americare Scales its Business After Implementing HHAeXchange’s Shared Platform Solutions

July 5, 2016| Case Study, Payer, Provider

A Case Study with Americare Companies’ CIO, Michael Mayer

When Michael Mayer, Chief Information Officer with Americare, joined the organization, the company was managing clients and employees with both paper and an older software system for the Licensed Agency. These systems required a tremendous amount of manual intervention which was both labor-intensive and inefficient.  As an organization that not only provides short term care themselves, they also have a large network of contracted providers to deliver long term home care services. Because of this, they act as a payer, case manager, and provider. Americare’s environment is further complicated by the fact that additional programming logic is necessary because the episodic payment requirements for Medicaid differ from that of Medicare.

In order to provide the best patient care and stay competitive within the marketplace, Mayer and the executive team recognized the need to strengthen its visibility and oversight to the delivery of services by agencies within the network. Their strategy included enterprise-wide improvements in the key areas of clinical and operational automation, home care visit verification and claims management. Mayer and the Compliance team saw this strategy as the most expeditious way to prevent fraud, waste and abuse (FWA) and drive more profits into the business. What they didn’t realize was the additional tangential benefits this key initiative provided to the organization, the provider network and the patients being serviced.

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HHAeXchange Announces Senior Vice President of Payer Business Solutions

March 31, 2016| Health Care, Homecare, Payer, Press Release, Technology

Long Island City, New York, March 31, 2016 –  HHAeXchange (HHAX), a leader in home care software solutions, announced today that Ms. Mary McMichael has joined the executive leadership team as Senior Vice President of Payer Business Solutions. McMichael brings prior experience in electronic visit verification (EVV) where she was responsible for EVV product and relationship management for clients in several states.

“Over time, as I studied this market space, I realized that HHAeXchange has a very unique value proposition that can be used in so many ways to enable organizations – whether state Medicaid agencies, Managed Care Organizations, or home healthcare provider agencies – to improve member outcomes and cost efficiencies,” said McMichael. “It was this type of innovation that lead me to the decision to join the HHAX team.”

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