GAO: Home Health Referral Sources Need Documentation Lessons

Home health agencies that are fed up with referral sources not providing proper documentation have an ally in Washington, D.C.: the Government Accountability Office (GAO).

The GAO has elicited a promise that the Centers for Medicare & Medicaid Services (CMS) will begin requiring more education for referring providers about home health documentation.

After reviewing oversight efforts to reduce improper billing in Medicare, GAO concluded that these efforts “need improvement.” In a report released Monday, the agency outlined various problem areas, including the issues involving home health referring providers.


A home health claim can be denied if a referring provider’s medical record documentation is not sufficient—however, these referring providers often are not educated about what documentation is required, the report states.

“This education gap is problematic because insufficient documentation is the most common reason for improper payments for home health services…which have high improper payment rates,” according to the report. “As reported for fiscal year 2016…home health services had a 42% improper payment rate with the [Medicare] program paying an estimated $7.7 billion improperly.”

CMS should require Medicare Administrative Contractors (MACs) to work together to provide the needed education to referring providers, GAO recommended. CMS’ parent organization, the Department of Health and Human Services (HHS), concurred with this recommendation.


“HHS will work with the … MACs to ensure they work together to educate referring providers on documentation requirements for … home health services as part of their regular training and education efforts within existing funding limitations,” HHS wrote in response to the GAO report.

This type of education is not currently being provided because “it has not risen to a level of significant concern,” CMS officials told GAO investigators.

Even with this education in place, there may still be problems, the report notes. That’s because the home health provider loses the payment if a claim is denied due to insufficient documentation, while there is no repercussion for the referral source.

Written by Tim Mullaney

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