Review of Costs Claimed by Pro-Med Home Health, Inc.

EXECUTIVE SUMMARY:

This final audit report points out that 40 percent ($1.2 million) of home health claims submitted by Pro-Med Home Health, Inc. during the fiscal year ended December 31, 1993 did not meet Medicare guidelines in that: (1) 25 percent were for home health visits made to individuals who were not homebound; (2) 8 percent were for visits which in the opinion of medical experts were not reasonable or necessary; (3) 5 percent were for visits not made; and (4) 2 percent were for visits which physicians denied authorizing. In addition to recovering overpayments, we recommended that the Health Care Financing Administration (HCFA) require the fiscal intermediary (FI) to instruct Pro-Med on its responsibilities to monitor its subcontractors for compliance with Medicare guidelines, and monitor the FI and Pro-Med to ensure that corrective actions are effectively implemented. The HCFA agreed with our recommendations