About $5 million of the $19.5 billion Medicare paid home health agencies in 2010 was the result of “inappropriate and questionable billing,” according to an Aug. 2 HHS Office of Inspector General (OIG) report.

The payments were for claims with three types of errors: overlapping with claims for inpatient hospital stays, overlapping with claims for skilled nursing facility stays or billing for services after patients’ deaths, the report stated.

The agencies with questionable billing were mostly in Texas, Florida, California and Michigan, the report stated.

OIG recommended that the Centers for Medicare and Medicaid Services improve or implement edits to prevent paying claims for the three common types of errors; increase monitoring of home health billing; enforce and consider lowering the 10-percent outlier cap agencies receive; put a temporary moratorium on new home health agencies in Florida and Texas; and “take appropriate action” for the inappropriate payments OIG identified.

CMS concurred with those recommendations but questioned OIG’s estimate of in appropriate payments for claims overlapping with inpatient hospital or skilled nursing facilities stays, the report stated. Home health claims are rejected when overlapping occurs, CMS noted.

Fraud News

  • Two ambulance company owners charged with fraud.

The owners of MedEx Ambulance in Feasterville, Pa., were charged with 41 counts involving healthcare fraud, false statements in connection with healthcare matters, wire fraud and conspiracy. The charges are in connection with allegations that they transported patients in ambulances who were able to walk and travel safely without ambulances, according to the U.S. Attorney’s Office in eastern Pennsylvania. Medicare paid $2.5 million for those medically unnecessary services.

  • Durable medical equipment company owner charged in 21-count indictment.

Between Dec. 1, 2008, and Sept. 30, 2009, the owner of S&S Medical Supply Etc. in Stafford, Texas, allegedly bought physician orders from recruiters and marketers that contained forged signatures then submitted almost $1.3 million in fraudulent DME claims to Medicare and Medicaid, according to the U.S. Attorney in southern Texas. The owner was paid more than $414,000 for those claims.

RAC news

No recovery auditors (RACs) posted issues last week.

About the Authors

Karen Long is the compliance product manager for DecisionHealth and oversees products that relate to fraud and abuse and HIPAA compliance for physician offices and home health agencies, and accreditation compliance for hospitals. In her almost four years at DecisionHealth, Karen also has been the compliance editor and a reporter for Home Health Line, nation’s leading independent authority on home healthcare business, regulation and reimbursement. Tina Irgang is the editor of Home Health and Hospital Solutions for DecisionHealth.

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Medically Unnecessary Setting: RAC Findings and CMS Guidance

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