Home Health

Latest OIG audit suggests case-mix reductions a red flag for claim reviews

The U.S. Department of Health and Human Services Office of Inspector General (OIG) recently announced the results of an audit of Brookdale Home Health. The report came a familiar focus on ambulation, homebound and medical necessity. But there was another important note in the report that puts a fresh emphasis on case mix.

The review reportedly found $132,500 in overpayments after reviewing 100 claims from 2016 and 2017, and OIG estimated that would indicate $3.3 million in overpayments over the two-year audit period. Brookdale responded that it had addressed 16 claims that were paid in error, but it disputed the broader OIG findings and recommendations.

In its response to the draft report, Brookdale questioned why it was targeted for the audit and whether it was due to the size of the agency. OIG gave a response in the final report that could provide important information for other agencies reviewing their own billing and claims data.

“Prior to conducting this audit, we conducted a risk assessment at four Brookdale facilities in Florida based on our claim data analysis incorporating case mix,” OIG stated. “This analysis determined that Brookdale had one of the highest case-mix group paid rankings.”

According to the report, case mix is the largest single factor increasing reimbursements for an agency, and OIG reportedly identified a pattern where case mixes were later reduced significantly upon regrouping by CMS.

“We selected Brookdale for audit based on the case mix paid rankings and our risk assessment determinations and did not target it solely because it is a large Medicare biller,” according to the OIG report.

Read the OIG report and Brookdale’s response.