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How can HHA avoid allegations of Medicare overpayment?

| Apr 6, 2021 | Medicare Overpayment |

The government has increased its focus on Medicare overpayments to home health agencies (HHAs). These healthcare facilities can reduce the risk of these allegations by avoiding the most common complaints. The United States Department of Health and Human Services (HHS) often pushes back when it finds the HHA requested payment without proper justification in these two situations.

Situation #1: Confined to the home

Although the HHS does not require the patient be bedridden to qualify for home services, it does have strict requirements in order for the HHA to justify these payments as defined within section 1814(a)(2)(C) and 1835(a)(2)(A) of the Affordable Care Act. Essentially, the HHS considers the beneficiary “confined to the home” for Medicare payment purposes when the illness or injury restricts the ability to leave the home without the aid of another individual or medical device like a walker or cane or if leaving the home is medically contraindicated.

The HHS uses the following criteria to make this determination:

  • The patient must need the aid of supportive devices, special transportation, or the assistance of another to leave the residence; or have a condition that makes it medically contraindicative to leave the home; and
  • There must be a normal inability to leave the home and leaving the home must require considerable and taxing effort

Again, the agency generally requires both criteria to meet the “confined to the home” definition.

Situation #2: Skilled services

The agency will expect the billed service require specialized judgement and skills to maintain the patient’s current condition or prevent or slow further deterioration. These services must be “reasonable and necessary” to justify payment. To meet this expectation, the agency generally requires the following:

  • Complex. As noted above, the service must require administration by trained individuals. If relatively simple to complete by a lay person, the agency will likely challenge the claim.
  • Consistent. The service must make sense for the patient’s condition. If other patient’s with similar conditions are not receiving this coverage, it is unlikely to survive a challenge.
  • Proper. The care must be inline with accepted medical standards for this patient’s treatment plan.

An HHA needs proper documentation to survive government allegations of Medicare overpayment. Keep proper documents, ideally with physicians signing of on the medical necessity of the proposed care plan, to help defend the claim.

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