OIG Cracks Down on Home Health Questionable Billing Practices

A few years back, as part of its Work Plan, the U.S. Department of Health and Human Services Office of the Inspector General (OIG) announced it was seeking to identify home health agencies, supervising physicians, and geographic areas whose Medicare claims had characteristics similar to those observed by the agency in cases of home health fraud. 

OIG noted in its brief that home health had long been recognized as a program area vulnerable to fraud, waste, and abuse and that previous reports raised concerns about questionable billing patterns, compliance problems, and improper payments in home health.

While cases of home health fraud investigated by OIG vary in nature, they generally involve HHAs that bill for services that are not medically necessary and/or not provided.

The OIG, in the last few weeks alone, announced the findings of investigations into three home health agencies whose billing practices were questionable, although the watchdog agency did not go so far as to suggest they were fraudulent.

The cases further illustrate the federal government’s commitment to taking a deep dive into home health billing practices nationwide.

On May 24, Metropolitan Jewish Home Care Inc. in Brooklyn, N.Y. was found to have failed to comply with Medicare billing requirements for 11 of 100 home health claims reviewed by the OIG. The OIG noted that Metropolitan received $34,514 in overpayments for services provided in 2013 and 2014. Specifically, Metropolitan incorrectly billed Medicare for beneficiaries that were not homebound or did not require skilled services. In addition, Metropolitan received reimbursement for claims for which the services were not supported by documentation.

OIG noted that the errors occurred “primarily because Metropolitan did not have adequate controls to prevent the incorrect billing of Medicare claims within selected risk areas.”

For its part, Metropolitan disagreed with the findings. OIG, in turn reviewed the additional documentation provided by the home health agency and revised its findings and reversed its determinations for nine of the 11 claims. The agency determined that the remaining two did not meet Medicare requirements.

Also on May 24, OIG announced its findings in a case against Excella HomeCare, whose headquarters are in Texas. The OIG determine that Excella did not comply with Medicare billing requirements for 41 of the 100 home health claims it reviewed. OIG determined that Excella received overpayments of $129,520 for services provided in calendar years 2013 and 2014.

Specifically, OIG noted that Excella incorrectly billed Medicare because beneficiaries (1) were not homebound or (2) did not require skilled services.

Excella disagreed with OIG’s findings and a re-review was conducted. OIG stated that based on these reviews, “our medical reviewer overturned, in part or full, 35 claims that it initially found in error.”

In the third case, announced on May 23, OIG said that it determined EHS Home Health Care Services Inc. of Illinois did not comply with Medicare billing requirements for 35 of the 100 home health claims that were reviewed. For these claims, EHS received overpayments of $55,303 for services provided in calendar years 2014 and 2015. Specifically, OIG noted that EHS incorrectly billed Medicare for beneficiaries who (1) were not homebound or (2) did not require skilled services. 

As with the other home health agencies, EHS disputed the OIG’s findings and after a subsequent review, OIG removed 6 of the claims originally found to be in error in its draft report and adjusted the findings for an additional 9 claims. 

Under the home health prospective payment system (PPS), CMS pays home health agencies a standardized payment for each 60-day episode of care that a beneficiary receives. The PPS payment covers intermittent skilled nursing and home health aide visits, therapy (physical, occupational, and speech-language pathology), medical social services, and medical supplies.

The OIG’s investigations are meant to root out fraud and abuse, but, as evidenced by the aforementioned cases some are simply billing errors which, when challenged, can result in a reversal of initial findings.

The Health Law Offices of Anthony C. Vitale can assist with all aspects of home health compliance and defense services including audits, overpayments and compliance programs. Give us a call at 305-358-4500, or send an email to info@vitalehealthlaw.com and let’s discuss how we might be able to assist you.

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