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Where do you stand on these 6 risk factors?

In an unprecedented move, the OIG has revealed the benchmarks it's using to identify questionable billing in home health agencies. Now it's your turn to use that information to your advantage.

The HHS Office of Inspector General found that one in four home health agencies exceeded at least one of the thresholds the agency set for six questionable billing measures in 2010, it says in a new report. (For the measures and threshold figures, see box, p. 231.)

The six measures are interrelated, observes attorney Robert Markette Jr. with Benesch Fried-lander Coplan & Aronoff in Indianapolis. For ex-ample, high outlier payment amount and high number of visits are likely correlated.

HHAs can expect close scrutiny of these factors, if the measures aren't under the microscope already, advises attorney John Gilliland with The Gilliland Law Firm in Indianapolis. "All agencies, especially those in Texas, Florida, California and Michigan, should expect these issues to be looked at by auditors," Gilliland says.

Agencies that are above the thresholds "are clearly at greater risk for enforcement action," warns Washington, DC-based health care attorney Eliza-beth Hogue.

HHAs can be pretty sure that if they exceed any of the thresholds the OIG sets out, they are popping up on somebody's radar, Markette cautions.

New: Providing the specific stats is a switch for the watchdog agency-- one that Hogue welcomes. "This type of specific information from the OIG is immensely helpful as opposed to the broad, often vague, pronouncements that we often receive," she says.

Make The Most Of The OIG's Benchmarks

1. Run the numbers. Sometimes providers get caught up in auditing the details of claims and records. Now's the time to step back and take a look at the big picture, Markette suggests. HHAs "should be looking at themselves to make sure they're not throwing up any red flags" by exceeding the OIG thresholds.

"Now we have something in which agencies can 'sink our teeth' and really get down to the business of making sure that they meet applicable requirements for compliance," Hogue cheers. "The information in the report is enormously helpful."

2. Get the full story. If you do find that you exceed one or more thresholds, figure out why. Remember, "there may be legitimate reasons for an HHA to have unusually high billing on any of our six measures," the OIG allows in the report.

For example: "A beneficiary receiving home health services may live in a state with a colder climate most of the year and spend the winter in a warmer state. If this beneficiary receives home health services throughout the year, then at least two different HHAs would legitimately bill Medicare for services provided to this beneficiary," the OIG explains. If you serve many such patients, then your percentage of patients served by more than one HHA may exceed the OIG's threshold.

But don't assume the reason for your numbers is legit, experts warn. Do some deep digging to figure it out -- before auditors or law enforcement authorities beat you to it.

3. Take action. Once you see where you stand, you must take steps to minimize your risk. If you determine that you are exceeding one or more thresholds due to legitimate reasons, then be prepared to defend yourself via the medical record and other documentation, Markette recommends.

For example: If you routinely pick up pa-tients recently discharged from other agencies be-cause you feel their goals haven't truly been met, "you'd better have compelling evidence of that" in the record, Markette advises.

On the other hand, this report "points out to agencies the kinds of errors agencies should make a special effort to avoid," Gilliland notes. Take a long hard look at your practices and determine if you need to make a course correction.

HHAs "that are above any of the thresholds included in the report must take immediate action to get below the thresholds," Hogue counsels. Other-wise, be prepared to face enforcement heat.

4. Implement or enforce your compliance plan. "All agencies should have a compliance program to lessen the likelihood that any of these questionable practices occur in their agency," Gilliland advises. "If they don't already have a compliance program, they should develop one."

Resource: The OIG's guidance for a home health compliance program is at http://oig.hhs.gov/ authorities/docs/cpghome.pdf. "Although it is more than 10 years old, it still is a helpful roadmap to put together a compliance program," Gilliland offers.