HHS Watchdogs: Home Health Smells

That review compared only billing codes to records and did not determine whether the records themselves were accurate, Levinson says.

To produce the research for the new report, investigators looked for agencies that scored substantially above the 75th percentile level on any of 6 measures indicating possible questionable billing.

The 6 measures used were:

• High average outlier payment amount per beneficiary.
• High average number of visits per beneficiary.
• High percentage of beneficiaries for whom other agencies billed Medicare for home health services.
• High average number of late episodes per beneficiary.
• High average number of therapy visits per beneficiary.
• High average Medicare payment amount per beneficiary.

“Acknowledging legitimate instances of unusually high billing is necessary, but it is equally necessary to examine [agencies] that bill unusually high amounts relative to other [agencies] to determine whether such billing is inappropriate or fraudulent,” Levinson says.

The investigators also used each beneficiary’s health insurance claim number to link inpatient hospital and skilled nursing facility claims to home health claims, and to link the claims with the beneficiaries’ dates of death.

The investigators found evidence that Medicare may have paid $5 million for home health claims that affected by 3 types of errors involving dates of service: 

• Claims for 2 or more overlapping inpatient hospital stays.
• Claims for home health services provided and skilled nursing home stays occurring on overlapping dates.
• Claims for services supposedly provided after beneficiaries’ dates of death.

Those kinds of errors appeared in 1,857 claims filed by 1,285 agencies, Levinson says.

About 80% of the agencies with high questionable billing scores were in Texas, Florida, California and Michigan. Those 4 states do not have a certificate-of-need policy that limits the number of home health agencies in operation, Levinson says.

The ratio of high scores on questionable billing measures to the number of home health agencies is much higher in Texas and Florida than in the rest of the country, Levinson says.

When considering whether to impose a Medicare home health agency enrollment moratorium in those states, “CMS should determine whether this moratorium should be imposed statewide or imposed in specific counties and/or metropolitan areas,” Levinson says.