Improper Home Health Payments Rising

With Medicare fraud proving to be a lasting concern for the home health industry, a new report offers fresh insight into the prevalence of improper Medicare payments this year.

Improper Medicare payments are increasing in prevalence, and medical necessity errors and insufficient documentation were the chief causes of improper Medicare payments during fiscal year 2015, according to the U.S. Department of Health and Human Services Fiscal Year 2015 Agency Financial Report.

Insufficient documentation was especially common for home health claims, the report says.


The improper payment rate for home health claims was 58.95% in fiscal year 2015, compared with from 51.38% in fiscal year 2014—rising due to the documentation requirements to support the medical necessity of the services.

Insufficient documentation also proved prevalent for skilled nursing facility (SNF) claims. The improper payment rate for SNF claims rose from 6.94% in fiscal year 2014 to 11.04% in fiscal year 2015, the report says.

Medicare Fee-For-Service utilizes the Comprehensive Error Rate Testing (CERT) program to determine the improper payment estimate. The CERT program considers any claim paid when it should have been denied or was paid in the wrong amount—including both underpayments and overpayments—to be an improper payment, the report says.


Written by Mary Kate Nelson