Review of Home Health Agency Costs Claimed By Niagara County Health Department For Calendar Year 1997

EXECUTIVE SUMMARY:

We estimate that, of the $2.5 million claimed by NCHD for calendar year (CY) 1997, at least $807,679 was for services which did not meet Medicare guidelines. Using the 90 percent confidence interval, we believe the overpayment is between $507,679 and S 1,358,3 19. We found that 70 of 100 home health claims reviewed, containing 780 of 1,562 services, were not reimbursable under Medicare. The 750 services were found to be unallowable for the following reasons:

• 455 services did not have valid physician orders;

• l 249 services which were not, in the opinion of medical experts, reasonable and necessary; 58 services which were rendered to beneficiaries who, in the opinion of medical experts, were not homebound;

• 13 services which we determined had not been rendered; and

• 5 services where there was no evidence that a medical service was performed.