Review of Costs Claimed by Dr. Pila Foundation Home Care Program in Ponce, Puerto Rico

EXECUTIVE SUMMARY:

This final report estimates that the Dr. Pila Foundation Home Care Program (Dr. Pila HHA) was paid Medicare funds totaling at least $857,208 in Fiscal Year 1996 for services that did not meet Medicare reimbursement requirements. A statistical sample of 100 claims involving 699 services disclosed 87 claims involving 502 services were unallowable for Medicare reimbursement because services; (1) did not have valid physician orders, (2) did not have evidence that a medical service was performed, (3) were rendered to beneficiaries who, in the opinion of medical experts, were not homebound, (4) were not, in the opinion of medical experts, reasonable and necessary, and (5) did not meet the intermittent criteria related to skilled nursing. We recommended that the Health Care Financing Administration (HCFA) instruct the regional home health intermediary to recover the estimated overpayments of $857,208. We also recommended that HCFA take steps to ensure home health services billed to Medicare by Dr. Pila HHA have the proper authorization, appropriate supporting documentation and are otherwise allowable for reimbursement. The HCFA concurred with our recommendations.