Govt. Inspector Finds 25% of Home Health Agencies Make Inappropriate Medicare Claims

A Department of Health and Human Services Office of Inspector General (OIG) report released today finds that one in four Home Health Agencies (HHA) participated in questionable billing activity in 2010.

The report, titled Inappropriate and Questionable Billing by Medicare Home Health Agencies, breaks down the $5 million Medicare paid to HHAs for inappropriate health care claims in 2010. OIG also finds that  80% of HHAs with questionable billing are located in just four states.

The report uses data on home health claims to investigate why inappropriate claims were made and in what region of the country they originated. Texas and Florida lead the country with the highest number of questionable billings, making up 39% and 25% of the total number of questionable billings by HHAs in the U.S. respectively, according to the report. California and Florida follow in the three and four spots respectively. 

Because of the report’s reliance on collected data, and use of statistics, it has caught some flak from home health advocates.

“The report may add to dialogue and has done so in ways that are helpful and unhelpful,” said Bill Dombi, vice president for law for the National Association for Home Care & Hospice (NAHC). “The extrapolated data should not create presumptive guilt,  it should tell people: Let’s pause and look deeper.” 

Despite critiques of the report though, the NAHC does recognize that there are issues in states like Texas and Florida that need to be solved to protect the rest of the industry.

None of the top four states contributing to inappropriate health claims employ Certificate of Need policies that help regulate the number of unnecessary HHAs in the state. In addition, the report found that 97% of HHAs with questionable billing are are found in states without Certificate of Need policies.

One suggestion cited in the report to combat inappropriate billing is a regional or state wide moratorium on new HHAs in Texas and Florida. This would mean new HHAs would not be allowed to enter the industry, and a there would be a focus on analyzing the integrity of already established HHAs.

“Most of the problems are coming from providers of recent certification,” said Dombi. “A moratorium would be a short term approach while coming up with long term solutions for long term providers.” 

A moratorium must be approved by the Center for Medicare and Medicaid Services (CMS). According to Dombi, there is often reluctance to authorize moratoria. 

“We certainly believe a moratorium is long overdue, the chances of it happening though are lower because of a strange reluctance to impose moratoriums over the years,” said Dombi. “We’re going to continue to push for that to happen.”

Additional solutions listed to help combat potentially inappropriate claims include closer monitoring of home health claims that overlap hospital or skilled nursing claims, increased monitoring of billing for home health services, and enforcement and consideration regarding lowering the 10% cap on the total outlier payments an HHAs may receive annually.

Read the full report here

Written by Erin Hegarty

Erin Hegarty