Corporate Compliance

OIG: Home health agency must repay $63,425

Healthcare Auditing Weekly, November 8, 2005

The OIG has recommended that Total Patient Care Home Health, LLC in Jacksonville, FL., repay Medicare $63,425 the home health provider billed for unallowable therapy services.

The OIG's objective was to determine whether selected home health claims--including therapy services provided by Total Patient Care Home Health (Total Patient Care), LLC--to Medicare beneficiaries met federal requirements and were appropriately paid.

Home health episodes with 10 or more therapy services result in an increased payment to home health agencies.

The OIG's review of medical records determined that 22 claims contained therapy services that were not reasonable.

In addition to repaying $63,425, the OIG recommended that Total Patient Care work with the regional home health intermediary to identify and submit adjusted claims for Medicare overpayments received subsequent to the audit period, and strengthen controls to ensure that the therapy services provided are reasonable and medically necessary.

To accomplish the audit the OIG

  • reviewed relevant rules and policies

  • selected a random sample of 100 claims from a universe of 192 paid claims submitted by Total Patient Care to Medicare for home health episodes with 10, 11, or 12 therapy services during the period October 1, 2002, through September 30, 2003

  • obtained Total Patient Care's medical records for each claim selected and provided those records to Palmetto GBA for medical review

  • obtained medical review data, which included a determination by medical reviewers of reasonableness, of medical necessity, and of adequate support and proper authorization of services billed, and summarized the results

  • interviewed a Total Patient Care's physical therapist and reviewed documentation supporting a therapist's time with selected patients

  • determined, with the assistance of medical reviewers, what the appropriate payment code and amount would have been for claims with unallowable services

  • quantified the Medicare overpayment for identified unallowable services billed by Total Patient Care

      Click here to read the audit report, "Review of Selected Paid Claims with Therapy Services Submitted to Medicare by Total Patient Care Home Health, LLC for the Period October 1, 2002, through September 30, 2003," (A-04-05-02000) issued September 20, 2005.

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