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Gov't audit insider: Home health reimbursement

Healthcare Auditing Weekly, March 23, 2004

Home healthcare providers often receive reimbursement at unnecessarily high service levels, according to an Office of Inspector General (OIG) audit of fiscal intermediary United Government Services. Home health agencies' (HHAs') Fiscal intermediaries, like United Government, match the level of service a beneficiary requires to the appropriate reimbursement amount using outcome and assessment information set, or OASIS codes.

A claim coded as a "K" claim represents a beneficiary who required fewer home health services (HHS), and therefore a lower reimbursement for the provider. An "M" claim represents high-service utilization and a higher level of reimbursement. The OIG found that patients who received home healthcare within 14 days of a hospital discharge should be coded at the lower "K" levels but are often coded as "M" claims, says the OIG.

This discrepancy prompted the OIG to examine United Government's home health reimbursement, and flush out overpayments due to FIs inappropriately coding claims for beneficiaries who received HHS preceding a hospital discharge. During its audit, the OIG performed the following:

·  Reviewed regulations and applicable laws

·  Identified United Government paid claims that did not designate a discharge within 14 days of receiving home healthcare services, and ran the claims through the National Claims History file to find claims with a discharge within 14 days prior to home healthcare

·  Selected a random sample from the claims with discharges

·  Recalculated the correct payment for the sample claims to determine overpayment amounts

·  Contacted HHA representatives involved to discuss possible causes of and solutions to noncompliance

·  Worked with four rehabilitation and skilled nursing providers to find out how these providers could aid in billing compliance related to this issue

·  Performed a stratified variable appraisal program to estimate overpayments to HHAs working with United Government

On top of dragging the HHAs under its jurisdiction into its audit-mess, United Government owes the OIG $55,762 for its lapse in home health billing. Your fiscal intermediary could be making the same mistake that United Government made, and it could cost you in the long run.

Click here read the audit report called "Review of payments made by United Government Services for home health services preceded by a hospital discharge."

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