In August, the Office of Inspector General (OIG) of the U. S. Department of Health and Human Services released a report describing inappropriate and questionable billing by home health agencies.  The OIG conducted the study because recent investigations and studies showed that home health agencies are vulnerable to fraud, abuse, and waste.  The OIG identified inappropriate claims by examining claims data from home health, inpatient hospital, and skilled nursing facilities.  The OIG also looked at HHAs that billed unusually high amounts according to at least one of its six measures of questionable billing.  The report determined that Medicare inappropriately paid $5M for home health claims with three specific errors in 2010.  To read the report, click here.

Attorney Elizabeth Hogue prepared a concise, helpful summary of the report as follows:

The OIG issued Report OEI-04-11-00240 in August, 2012, entitled “Inappropriate and Questionable Billing by Medicare Home Health Agencies.” Unlike some other guidance published the OIG, this Report provides detailed information about inappropriate and questionable billing practices by home health agencies (HHA’s). Specifically, the OIG concluded that HHA billing is questionable or unusually high on the six measures below, if greater than the 75th percentile plus 1.5 times the interquartile range. The six measures are as follows:

  1. High average outlier payment amounts per beneficiary

According to the OIG, HHA’s with outlier payments above $403 per beneficiary have unusually high outlier payments and are likely engaging in questionable billing practices.

  1. High number of visits per beneficiary

HHA’s that bill for 91 or more visits per beneficiary are engaging in questionable billing practices.

  1. High number of late episodes per beneficiary

HHA’s that bill for more than two late episodes per beneficiary are likely engaging in inappropriate billing practices.

  1. High number of therapy visits per beneficiary

According to the OIG, 24 therapy visits per beneficiary is probably too many.

  1. High payments per beneficiary

The OIG’s threshold for unusually high payments is $11,653 per beneficiary.

  1. High average number of therapy visits per beneficiary

HHA’s with at least 61 percent of beneficiaries for whom other HHA’s billed Medicare are also likely engaging in questionable billing practices.

The OIG went on to say in the Report that in 2010, 25 percent of HHAs exceeded the above thresholds for at least one of the above six measures.

There is good news and bad news! The good news is that HHA’s now have specific information about what the OIG views as questionable, inappropriate billing practices. If you are one of these HHA’s, you know you are in the “crosshairs.” Fix it right now! The bad news is that the OIG thinks that at least one fourth of all home health agencies are engaging in billing practices that deserve further scrutiny. Enforcement actions hurt everyone, including patients. Fix it right now!

Our Insight.  Your Advantage.  Home health agencies should compare their billing practices with those described in the OIG’s report to avoid what the OIG considers inappropriate and adjust their practice if necessary.   Home health agencies, as with other health care providers, are obligated to report and refund over payments.