Pay them now, or pay them later: The real ORT
Pay them now, or pay them later: The real ORT
What is HCFA’s new approach to surveys?
(Editor’s note: This is the second part of the two-part series regarding Operation Restore Trust (ORT). Last month, Home Infusion Therapy Management focused on the facts about ORT. This month, HITM takes a look into the future.)
Many agencies are wondering what the real deal is regarding Operation Restore Trust. (See HITM, September 1996, p. 113.) It turns out, you might not want to know. This month, HITM speaks with an agency that underwent an ORT survey and shares the specifics of its ordeal, which resulted in its being asked to pay back nearly $100,000 in disallowed claims. Because it is considering alternatives to HCFA’s settlement offer, the agency requests anonymity.
In last month’s look at Operation Restore Trust, the Health Care Financing Administration (HCFA) told HITM that agencies can be selected at random and do not necessarily have to meet high utilization ratios or other criteria. This agency can attest to that.
"They just walked right in, and we were only told that it was a lottery of some kind," our source tells HITM. "We have had two previous annual inspections and were below the state average utilization, so we don’t think it was over-utilization that brought on the survey."
The agency’s administrator immediately phoned a Medicare attorney who advised the administrator that the agency had the same rights as those that applied during an annual inspection. The surveyor said this was not true, and the agency was given 30 minutes to provide 15 patient files, with the specific patients having already been selected by the surveyor.
The agency noted that the patients for which HCFA requested files had required services for longer than the normal amount of time, typically longer than three months.
The administrator insisted that the agency would comply only if the standard survey rules applied, in particular, that a staff member be present when turning the files over to the surveyors, who would in turn, photocopy the files. There was a reason for this important step.
"We had heard from other agencies that HCFA would say certain things were missing from the files that weren’t missing, so we had the surveyor photocopy the files in front of us and make one copy for them and one copy for us."
No one-stop shop
But the surveyors’ work was not done. After picking up the patient files over two days, the surveyors spent the remainder of the week visiting patients.
"Then they wanted to go out and see each of those 15 patients, and during a regular survey you are allowed to let your nurse or somebody go with the surveyor," according to the agency. But the surveyors would have no part of it and appeared to be less than truthful to prevent that from happening.
"They would not allow the nurse to go. They told us they were quitting early for the day, but within a couple of minutes of their leaving, one of our patients called very frantic because they were at her front door," the source says.
The patient visits were all completed within 24 hours of the surveyors picking up the patient files. The quick work then dragged on, as nearly two months went by before the agency heard anything from HCFA. Even though the agency was confident that it was not involved in filing fraudulent claims, the staff weren’t without their worries.
"We weren’t too scared because we’re not fraudulent, and we are very aware of the Medicare conditions of participation and make every effort to adhere to them, but we had heard that HCFA looked until it found something. We had not heard of any agency receiving a letter that said You’re OK.’"
Agency owed $100,000
Its trepidation awaiting the results wasn’t unfounded, as the letter requested the agency pay back nearly $100,000 in disallowed claims.
"In the 15 charts they had taken, they found six errors," notes the source. "They then extrapolated that ratio of the visits they were denying to our entire Medicare bill for the year, and they came up with we owed them [nearly $100,000]."
It wasn’t just the total that was shocking. Equally alarming were the reasons some of the visits had been disallowed. Consider the following:
• A doctor had ordered a venipuncture to be drawn every two weeks. In one instance, the venipuncture was drawn after 13 days instead of 14.
• A doctor’s partner had signed off on a plan of treatment, rather than the doctor whose name was on it. The surveyors visited the practice and asked the doctor, whose name was on the plan, if it was his signature at the bottom. The doctor answered no but was not given the opportunity to explain that the signature was his partner’s.
Of the several disallowed visits, the agency concedes one in which a patient was going to social day care rather than a medical care center. As a result of finding the woman was not "homebound" per Medicare regulations, HCFA denied all the visits the agency had provided for the two months it had been treating the patient.
It appears that providers’ rights in regular surveys have not applied to agencies undergoing surveys under the ORT pilots. At least that was this agency’s experience.
"In a normal Medicare denial, you are able to go before a judge and present your case," notes the source. Not so with the visits denied under ORT. According to HCFA figures for 1996, 620,000 claims were denied. A total of 20,000 were reversed on appeal, totalling $23 million. Under ORT, don’t plan on getting a piece of the appeals pie, though.
"You have no rights to appeal at all," she says. "They give you two choices."
1. Pay up. The first choice is for the agency to sign the letter. This admits guilt and sets forth that you agree to pay the fine.
2. Do it again. "You don’t have to sign it, but you then are going to be subjected to another audit in which they go through a more representative sample, which is a larger sample than the 15 charts they took the first time. And in that case, you do have appeal rights, but you still have to pay the fines while you’re waiting for the larger sample and the appeals."
This agency has talked to "just about every Medicare attorney in the business, and most have said you’re crazy not to sign it," which this source says doesn’t seem fair at all.
"The government is being allowed to extort money from providers who truly are trying to do a good job. Most providers are going to sign and pay just to get them out of here, but you feel robbed like someone has come in with a big elephant gun and held it to your head and said Pay this or else.’"
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