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Medical Coding News Archives

GAO Releases New Report on Improper Payments in Home Health

 
March 24, 2009:

Upcoding and other fraudulent and abusive practices contributed to an alarming increase in overutilization of and Medicare spending on home health services between 2002 and 2006, according to a study completed by the Government Accounting Office.

Concerned over a 44 percent rise in Medicare spending for home health services between 2002 and 2006, the Centers for Medicare and Medicaid Services turned to the GAO for help. The GAO then examined growth in home health spending—approximately $12.9 billion in 2006—and utilization, and assessed CMS’s potential vulnerability for improper payments.

The GAO focused its efforts on states with the highest growth in home health spending or utilization between 2002 and 2006. California, Florida, Louisiana, Nevada, Oklahoma, Texas, and Utah were identified as states experiencing the highest growth in home health spending or utilization during the study period. These states ranked among the three highest in one or more of four spending and utilization areas. Texas, Florida, and Nevada had the highest percentage growth during the 2002 through 2006 period than all the others—more than twice the national spending growth rate of 44 percent.

The agency also found that inadequate screening, monitoring, investigative, and enforcement procedures left the home health benefit area open and vulnerable to improper payments.

Recent CMS and contractor initiatives revealed that revalidation and targeted enforcement efforts being adapted to local billing practice reduce the incidence of home health fraud and abuse. Examples of such efforts include requiring all home health agencies (HHAs) to undergo revalidation by resubmitting enrollment applications for screening. Those who fail to resubmit their applications are subject to having their billing privileges revoked.

As a result of this study, the GAO provided CMS with four recommendations of which two are currently being considered. The four recommendations are:

  1. Assess the feasibility of verifying the criminal history of all key officials named on an HHA enrollment application.
  2. Provide physicians whose identification number was used to certify or recertify a plan of care with a statement of services the HHA provided to that beneficiary based on the physician’s certification.
  3. Direct CMS contractors to conduct postpayment medical reviews on claims submitted by HHAs with high rates of improper billing identified through prepayment review.
  4. Amend current regulations to expand the types of improper billing practices that are grounds for revocation of billing privileges. Grounds for revocation could include a pattern of submitting claims that are falsified or those that are for persons who do not meet Medicare’s coverage criteria, or for services that are not medically necessary

The two recommendations CMS is considering are items 2 and 4. On item 2, CMS is suggesting an alternate or revised approach. For more information and to read the report in its entirety, visit: http://www.gao.gov/new.items/d09185.pdf.

Karen M Prescott, CMM, CPC, CPC-I, CCS-P, PCS
Clinical/Technical Editor

 

 
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