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How to Avoid Government Audits Across the Continuum of Care

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A government audit may feature prominently in the nightmares of many continuum care organization leaders. To get an idea of the potential impact of such a situation, here’s what was involved in three recent enforcement actions:

  • A home health company paid more than $700,000 to resolve false claims liability.
  • A hospice provider paid $6 million to resolve false claims liability.
  • A skilled nursing facility agreed to pay $171,000 to settle allegations involving the employment of an excluded individual.

The U.S. Government is Paying More Attention to Providers

Government scrutiny of post-acute providers has not slowed down. In fact, the focus on this segment of the healthcare industry is keener than ever. In a presentation at the recent Health Care Compliance Association's Compliance Institute in Boston, Massachusetts, the post-acute risk areas getting the most attention were discussed. Providers are wise to thoroughly assess these within their own organizations before the government does.

A number of risk areas being audited by both government and private payers are common across all types of post-acute providers. These included but are not limited to

  • Medical necessity and meeting patient eligibility requirements
  • Insufficient documentation
  • Unsupervised services

Specific Care Areas Have Their own Unique Risks

Specific deficiencies were revealed based on the particular type of post-acute care. For hospice providers, live discharges can be a red flag to auditors, making documentation of patient eligibility based upon a terminal diagnosis with a six-month or less life expectancy important.

Home health audits honed in on medical necessity, especially for therapies, meeting The Centers for Medicare and Medicaid Service's definition of homebound status and obtaining timely face-to-face encounters with physicians. Complete and accurate documentation in these areas is essential in satisfying payers and auditors.

In skilled nursing facilities, the focus of audits is reportedly moving away from therapies and moving toward the medical necessity for, and quality of, nursing care.

Ensuring these risk areas are supported by effective documentation is vital, as well as the best strategy for avoiding government audits.

Learn how HCCS Compliance solutions can help your staff avoid government audits.