Department of Health and Human Services

Office of Inspector General -- AUDIT

"Review of Compliance With Billing Provisions Under The Prospective Payment System for Home Health Agencies' Therapy Services Connecticut Home Health Care, Inc.," (A-01-04-00507)

May 11, 2005

Complete Text of Report is available in PDF format (180 kb). Copies can also be obtained by contacting the Office of Public Affairs at 202-619-1343.


Our objective was to determine whether selected home health claims that included therapy services provided by Connecticut Home Health Care (CHHC) 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.  We selected 40 claims submitted by CHHC where the number of therapy services provided was 10, 11, or 12 per claim.  A medical record review performed by the Regional Home Health Intermediary (RHHI) determined that 19 of these claims contained therapy services that were not reasonable or medically necessary.  Therefore, because these claims no longer met the 10-visit threshold and were not eligible for the higher payment, CHHC was overpaid $41,940 for the 19 claims.  We recommend that CHHC work with the RHHI to reimburse the Medicare program $41,940 for unallowable therapy services; identify and submit adjusted claims for Medicare overpayments received subsequent to our audit period; and strengthen controls to ensure that the therapy services provided are reasonable and medically necessary.