Medicare Compliance & Reimbursement

Waiver providers should expect more audits and fraud charges. The trend of more regulatory enforcement in Medicaid is about to reach home care, and the results may have providers leaving waiver programs in droves. Seventy percent of the Medicaid waivers for the elderly the General Accounting Office recently reviewed "documented one or more quality-of-care problems," the GAO says in a new report, "Federal Oversight of Growing Medicaid Home and Community-Based Waivers Should Be Strengthened" (GAO-03-576). The Centers for Medicare & Medicaid Services "does not adequately monitor" the rapidly growing state waivers, or "the quality of beneficiary care," the GAO maintains. Lack of federal and state oversight of the popular programs under home and community-based service (HCBS) waivers means the programs are prone to quality problems such as failure to provide authorized services, weaknesses in plans of care and inadequate case management, the federal watchdog charges. Other troubles such as a lack of complaint systems and enforcement tools also are a product of weak oversight, the report says. Every state but Arizona has a waiver program for the elderly, the GAO notes. The waivers allow Medicaid programs to furnish alternative care that keeps beneficiaries out of institutions and in their homes without all the requirements of the full Medicaid program. Usually that means offering the services to a limited population, such as the elderly that meet certain requirements. The programs often have waiting lists. Slim Profit Margins To Get Slimmer  While the report is an indictment of the federal and state governments, the criticism's impact will be felt at the provider level. "When the feds tighten up on the states, the states will tighten up on providers," warns William Dombi, vice president for law with the National Association for Home Care's Center for Health Care Law. Home health agencies and durable medical equipment suppliers that service waiver patients are in for a host of new activities under increased state scrutiny, predicts Burtonsville, MD-based attorney Elizabeth Hogue. Those include: increased reviews and audits; recoupment of monies; and fraud allegations of substandard care. "Recoupment of monies is likely to be reinforced by the need to balance state budgets that are bleeding red ink," Hogue forecasts. "The idea that monies can be recouped through retrospective audits and reviews will be very seductive for government regulators." That means waiver providers already operating under slim profit margins are likely to rethink their participation in the programs. "We may see a significant decrease in the number of agencies willing to participate" in waivers, Hogue says. The criticism of waiver programs comes at a time when the Bush Administration and CMS have been pushing consumer-directed care waivers, where beneficiaries manage their own services and hire their own caregivers, notes [...]