CORPORATE INTEGRITY AGREEMENT BETWEEN THE OFFICE OF INSPECTOR GENERAL OF THE DEPARTMENT OF HEALTH AND HUMAN SERVICES AND LHC GROUP, INC.

 

a.

Overpayment:  The amount of money LHC has received in excess of the amount due and payable under any Federal health care program requirements.

 

b.

Paid Claim:  A claim submitted by LHC and for which LHC has received reimbursement from the Medicare program.

 

c.

Population:  The Population shall be defined as all Paid Claims during the 12-month period covered by the Claims Review.

 

d.

Error Rate:  The Error Rate shall be the percentage of net Overpayments identified in the sample.  The net Overpayments shall be calculated by subtracting all underpayments identified in the sample from all gross Overpayments identified in the sample.  (Note:  Any potential cost settlements or other supplemental payments should not be included in the net Overpayment calculation.  Rather, only underpayments identified as part of the Discovery Sample shall be included as part of the net Overpayment calculation.)

 

e.

Internal Compliance Audit:  LHC’s internal home health medical record compliance audits are conducted by the Compliance Department.  LHC audits by provider number.  Provider numbers may or may not be used by multiple home health facilities.  The Compliance Department reviews at least

a)  

the name of the home health facility, its location (city, state), and its affiliated Medicare provider number(s);

b)  

the total dollar amount of Paid Claims per home health facility;

c)  

the Medicare payor mix per home health facility;

d)  

if subject to an Internal Compliance Audit during the preceding 12 months, the date the Internal Compliance Audit was completed by the Compliance Department; and

e)  

a list of those home health facilities not subject to an Internal Compliance Audit during the preceding 12 months.

 

b.   Full Sample.  If necessary, as determined by procedures set forth in Section A.4a above, the IRO shall select an additional sample of Paid Claims from that home health facility (Full Sample) using commonly accepted sampling methods.  The Full Sample shall be designed to: (1) estimate the actual Overpayment in the population with a 90% confidence level and with a maximum relative precision of 25% of the point estimate; and (2) conform with the Centers for Medicare and Medicaid Services’ statistical sampling for overpayment estimation guidelines.  The Paid Claims selected for the Full Sample shall be reviewed based on supporting documentation available at LHC or under LHC’s control to determine whether the medical record documentation supports homebound status and the medical necessity of the home health services furnished.  For purposes of calculating the size of the Full Sample, the Discovery Sample may serve as the probe sample, if statistically appropriate.  Additionally, the IRO may use the Paid Claims sampled as part of the Discovery Sample, and the corresponding findings for those Paid Claims, as part of its Full Sample, if:  (1) statistically appropriate and (2) the IRO selects the Full Sample Paid Claims using the seed number generated by the Discovery Sample.  OIG, in its sole discretion, may refer the findings of the Full Sample

 

c.   Systems Review.  If the Discovery Sample for any home health facility identifies an Error Rate of 5% or greater, LHC’s IRO shall also conduct a Systems Review for the applicable home health facility.  The Systems Review shall consist of the following:

 

i.

a review of LHC’s policies and processes for determining a patient’s home bound status and the medical necessity of home health care services furnished to the patient; and

 

ii.

for each claim in the Discovery Sample and Full Sample that resulted in an Overpayment, the IRO shall review the system(s) and process(es) that generated the claim and identify any problems or weaknesses that may have resulted in the identified Overpayments.  The IRO shall provide its observations and recommendations on suggested improvements to the system(s) and the process(es) that generated the claim.

 

           d.

 

i.

Supplemental Materials.  The IRO shall request all documentation and materials required for its review of the Paid Claims selected as part of each Discovery Sample or Full Sample (if applicable), and LHC shall furnish such documentation and materials to the IRO prior to the IRO initiating its review of each Discovery Sample or Full Sample (if applicable).  If the IRO accepts any supplemental documentation or materials from LHC after the IRO has completed its initial review of each Discovery Sample or Full Sample (if applicable) (Supplemental Materials), the IRO shall identify in the Claims Review Report the Supplemental Materials, the date the Supplemental Materials were accepted, and the relative weight the IRO gave to the Supplemental Materials in its review.  In addition, the IRO shall include a narrative in the Claims Review Report describing the process by which the Supplemental Materials were accepted and the IRO’s reasons for accepting the Supplemental Materials.

ii.         

Paid Claims without Supporting Documentation.  Any Paid Claim for which LHC cannot produce documentation sufficient to support the Paid Claim shall be considered an error and the reimbursement received by LHC for such Paid Claim, net of the reimbursement received by LHC for which it has supporting documentation, shall be deemed an Overpayment. Replacement sampling for Paid Claims with missing documentation is not permitted.

 

iii.

Use of First Samples Drawn.  For the purposes of all samples (Discovery Sample(s) and Full Sample(s)) discussed in this Appendix, the Paid Claims selected in each first sample shall be used (i.e., it is not permissible to generate more than one list of random samples and then select one for use with the Discovery Sample or Full Sample).

 

      e.

Repayment of Identified Overpayments.  LHC shall repay within 30 days any Overpayment(s) identified in any Discovery Sample or the Full Sample (if applicable), regardless of the Error Rate, to the appropriate payor and in accordance with payor refund policies.  LHC shall make available to OIG all documentation that reflects the refund of the Overpayment(s) to the payor.

 

a.

 

i.

Claims Review Population. A description of the Population subject to the Claims Review.

 

ii.

Claims Review Objective.  A clear statement of the objective intended to be achieved by the Claims Review.

 

iii.

Source of Data.  A description of the specific documentation relied upon by the IRO when performing the Claims Review (e.g., medical records, physician orders, certificates of medical necessity, requisition forms, local medical review policies (including title and policy number), CMS program memoranda (including title and issuance number), Medicare carrier or intermediary manual or bulletins (including issue and date), other policies, regulations, or directives).

 

iv.

Review Protocol.  A narrative description of how the Claims Review was conducted and what was evaluated.

 

v.

Supplemental Materials.  A description of any Supplemental Materials as required by A.4.d.i, above.

 

b.

 

i.

A copy of the printout of the random numbers generated by the “Random Numbers” function of the statistical sampling software used by the IRO.

 

ii.

A copy of the statistical software printout(s) estimating how many Paid Claims are to be included in the Full Sample, if applicable.

 

iii.

A description or identification of the statistical sampling software package used to select the sample and determine the Full Sample size, if applicable.

 

c.

 

i.

 

d.

Recommendations.  The IRO’s report shall include any recommendations for improvements to LHC’s processes for determining and documenting homebound status and for establishing the medical necessity of home health care services.