OIG Report: Medicare Overpaid HHAs $191.8 Million

In Home Health, News by Mary MadisonLeave a Comment

The Office of Inspector General released a report this last week of July that revealed overpayment of home health agencies. The OIG audit covered approximately $1.25 billion in Medicare payments to HHAs for 549,768 claims. These claims were for home health services provided in CY 2017. Because of the large increase in payment starting with the fifth visit, OIG focused the audit on claims for home health services with five, six, or seven visits in a payment episode. The report is 28 pages in length.

“Not all payments to HHAs for home health services with five to seven visits in a payment episode complied with Medicare requirements. Of the 120 sampled claims we reviewed, 91 complied with requirements, and for 4 claims there was no documentation available to make a compliance determination. However, the remaining 25 claims did not comply with requirements. As a result, Medicare improperly paid HHAs for a portion of the payment episode (14 claims) and for the full payment episode (11 claims), totaling $41,613. These improper payments occurred because the Medicare administrative contractors (MACs) did not analyze claim data or perform risk assessments to target for additional review those claims with visits slightly above the LUPA threshold of four visits. On the basis of our sample results, we estimated that Medicare overpaid HHAs nationwide $191.8 million for our audit period.”

If you’re not familiar with Home Health, the report provides good background information, including this table that shows payment methodologies for the past 20 years:

The Report in Brief as well as What OIG Recommends and CMS Comments are found on page 4 of the report.  Here’s a sneak peek at the latter:

“We recommend that CMS: (1) direct the MACs to recover the $41,613 in identified overpayments made to HHAs for the sampled claims; (2) require the MACs to perform data analysis and risk assessments of claims with visits slightly above the applicable LUPA threshold and target these claims for additional review; and (3) instruct the MACs to educate HHA providers on properly billing for home health services with visits slightly above the applicable LUPA threshold, which could have saved Medicare as much as $191.8 million during our audit period.
CMS concurred with our recommendations and described actions that it had taken or planned to take to address the recommendations.”


Mary Madison, RN, RAC-CT, CDP
Clinical Consultant | Briggs Healthcare

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