Review of Costs Claimed by Eddy Visiting Nurse Association of the Capital Region

EXECUTIVE SUMMARY:

This final audit report points out the Eddy Visiting Nurse Association (Eddy) claimed Medicare payments of at least $1.1 million that were ineligible for Medicare reimbursement. The majority of the improper claims were for services which were not, in the opinion of medical experts, reasonable and necessary, services that did not have valid physician orders, services where there was no evidence that a medical service was rendered or performed, and services which were rendered to beneficiaries who, in the opinion of medical experts, were not homebound. In addition to a financial adjustment for $1.1 million, we recommended that the Health Care Financing Administration (HCFA) take steps to ensure home health services billed to Medicare by the Eddy have the proper authorization, appropriate supporting documentation, and are otherwise allowable for reimbursement. These steps should include requiring the intermediary to monitor more closely the claims submitted by the Eddy and to conduct subsequent periodic in-depth reviews of its claims. The HCFA concurred with our recommendations.