Guest Column

Know how to avoid gaming the system

Stay on the right side of a very fine line

By Elizabeth E. Hogue, Esq.
Burtonsville, MD

Home health managers have responded admirably to an increasing emphasis on compliance in recent years. Routine compliance activities in home health agencies now include verification of data, pre-billing reviews, and reviews to identify inconsistencies, for example. These activities certainly should be continued and extended. Providers must, however, also recognize that there are limits on appropriate activities in this regard. It may be fair to say that there is sometimes a very fine line between a legitimate compliance activity and what constitutes an unacceptable "gaming" of the system.

Below are some activities that are likely to be considered appropriate:

1. Data verifications within an assessment in the form of basic Haven edits.

Most agencies have access to these edits in their MIS system or in their OASIS data-entry software. These systems usually include about 400 edits and help to identify significant errors in assessments.

2. Data verifications within an assessment that go beyond Haven edits.

These systems have additional edits beyond Haven to help identify logical inconsistencies and data errors within an OASIS assessment prior to submission to state agencies.

3. Patient-specific assessment trending.

These systems allow for desktop analysis so agencies can track patient progress across assessments and identify and address declines in patients’ clinical conditions. This analysis usually is performed after submission of data to state agencies as a part of ongoing quality improvement activities.

But some agencies want to move beyond the above types of analyses to data checks that, if used improperly, may cross the line from compliance into outright fraud or abuse. Specifically, some agencies have expressed a desire to perform assessment-to-assessment data checks prior to submission of data to state agencies using software that flags declines in patients’ clinical conditions or opportunities for increased reimbursement.

It’s all in how you use the data

Buyer beware! Use of such data should be handled very sensitively to avoid fraud or abuse. When agencies generate these types of data, managers must ask and answer a very crucial question: How is the agency using these data? It would be appropriate, for example, to use the data as a teaching tool to improve outcomes. It also would be appropriate to use these data to clinically manage declines in patients’ conditions. But it would be inappropriate for agencies to use these data to decide whether they want to submit them as a decline in patients’ conditions.

From a practical standpoint, there are two significant issues that managers must address regarding use of these types of data:

  • If the data are to be used appropriately as described, why is it important to have the data prior to submission to the state (i.e., a question of timing)?
  • If agencies generate the data, what controls will be established and implemented to help ensure they are not used inappropriately?

These two crucial questions should be asked and answered with the understanding that there are small but crucial differences among flagging declines prior to transmission to state agencies, verifications designed to maximize reimbursement, and appropriate compliance activities. Agency staff members easily can cross the line into the realm of fraud or abuse.

In view of the issues described, it is understandable, and perhaps prudent, that companies that develop and market software to home health agencies are reluctant to provide software that includes capabilities to produce data that may be used inappropriately.

Fraud and abuse have been such a hot and extremely sensitive area that possession and use of such software may raise suspicions on the part of regulators and enforcers, however unfair they may be.

Reimbursement on a prospective basis, periodic completion of OASIS assessments, and Outcome-Based Quality Improvement activities present new challenges for home health providers to achieve compliance without crossing the line into questionable activities. The key is undoubtedly vigilance with regard to what data are generated and how they are used.