Home health agencies inappropriately paid $5 million for home health claims in 2010, found the Office of Inspector General in an examination of home health agencies' billing practices.
Citing the historic high levels of fraud and abuse in the home health sector, OIG analyzed home health claims from 100-percent paid claims data from the Center for Medicare & Medicaid Services' National Claims History Part A Standard Analytical File for 2010 as well as paid inpatient claims from hospitals and skilled nursing facilities.
[See also: OIG pressures CMS on home health agency sanctions.]
OIG identified 6.96 million Medicare claims for both full and partial home health episodes billed by 11,203 home health agencies (HHAs). OIG developed six measures of questionable billing based on results of past OIG analyses and home health services-related fraud investigations and from input from CMS staff and contractors.
The six measures of questionable billing developed by OIG were:
1. High average outlier payment amount per beneficiary.
2. High average number of visits per beneficiary.
3. High percentage of beneficiaries for whom other HHAs billed Medicare.
4. High average number of late episodes per beneficiary.
5. High average number of therapy visits per beneficiary.
6. High average Medicare payment amount per beneficiary.
OIG found that approximately one in every four HHAs had unusually high billing for at least one of its six measures. It also found that the HHAs with the highest rates of questionable billing were located mostly in Texas, Florida, California and Michigan.
OIG also identified three specific errors made by HHAs that lead to inappropriately paid claims: overlapping with claims for inpatient hospital stays; overlapping with claims for skilled nursing facility stays; and billing for services on dates after beneficiaries' deaths.
OIG noted in its report that the agency did not independently verify the accuracy of the data it used for the study and that it did not analyze medical documentation or determine whether the services were billed were inappropriate or fraudulent.
However, the limitations of its study do not diminish the findings, the agency asserts. "Collectively, these findings identify specific issues with Medicare payments for home health services that need to be addressed to properly safeguard the Medicare program," OIG wrote in the conclusion of its report.
Specifically, OIG recommended to CMS that CMS
1. implement claims processing edits or improve existing edits to prevent inappropriate payments for the three specific errors;
2. increase monitoring of billing for home health services;
3. enforce and consider lowering the 10 percent cap on the total outlier payments an HHA may receive annually;
4. consider imposing a temporary moratorium on new HHA enrollments in Florida and Texas; and
5. take appropriate action regarding the inappropriate payments that were identified and HHAs with questionable billing.
OIG's report noted that CMS agreed with its recommendations and acknowledged the sector's historic vulnerability to fraud, waste and abuse, and has begun taking steps to combat the issues raised by OIG. But CMS disagreed with OIG's $5 million price tag in inappropriate payments, saying that in the absence of individual claims analysis, "it is difficult to determine whether there was any financial impact from the submission of overlapping claims."