The United States Department of Health and Human Services Office of Inspector General (OIG) stated in a recent report that it has identified significant overpayments to home health agencies (HHAs). The agency states that these overpayments are primarily from improper billing involving one of two situations: a beneficiary that was not homebound or not in need of the provided skilled services.
As a result, the agency has increased the focus of its audits in this area.
How do these audits work?
In a recent example, the agency conducted an audit of over $13.9 million in Medicare payments to an HHA over the period of one year. During the 2016 – 2017 audit period, the agency states the HHA made over 3,512 claims to Medicare for services provided to patients. These audits are generally conducted by extrapolating a finding based on a sample. In this instance, the agency reviewed a sample of 100 home health claims filed during that period and found 46 were not in compliance with Medicare’s billing requirements. Based on this finding, the agency estimated the HHA received over $3 million in overpayments.
Upon conclusion of the audit, the OIG recommended the HHA refund Medicare, exercise reasonable diligence and strengthen its procedures to avoid future issues.
What can the HHA do if it disagrees with the results of the audit?
Upon review of the audit results, the HHA agreed that 16 of the 46 alleged erroneous claims were improper. The HHA agreed to repay these claims. However, the HHA disagreed with the remaining claims and additional recommendations.
The HHA can choose to appeal the audit. If successful, the appeals process can reduce or even eliminate the government’s demands.