Review of Home Health Services Billed During An Inpatient Stay - Home Health & Hospice Care of Whidden Memorial Hospital

EXECUTIVE SUMMARY:

This final report provides the results of our review of home health services billed by Home Health & Hospice Care of Whidden Memorial Hospital (Whidden HHA) under the Medicare program. The objective of our review was to determine whether procedures were established to ensure that home health agency (HHA) services were not billed to Medicare while a beneficiary was an inpatient at a hospital.

Under current Medicare regulations, Medicare does not cover home health services furnished while a patient is an inpatient at a hospital. Moreover, to be covered, home health services must be properly supported. The Whidden HHA generally has adequate controls in place to ensure that services billed are rendered, properly documented, and supported in the medical records.

A computer match of the calendar year 1994 inpatient and home health agency paid claims data identified 519 home health claims submitted by Whidden HHA in which the home health dates of service overlapped an inpatient stay. Our review of a random sample of 100 claims representing 1,717 home health visits, identified that only 27 home health visits were billed in error (1.6%). We found that 4 home health visits were billed while the beneficiary was an inpatient at a hospital and 23 home health visits did not have supporting documentation in the medical records to show if the services were rendered. As a result of reviewing a random sample of claims, we estimate that the Medicare program visits and costs reported in Whidden HHA's fiscal year 1994 cost report may be overstated by 140 home health visits at a cost of approximately $9,000. In addition, we noted isolated instances in which the physician did not authorize home health aide services, yet, the home health aide services were billed to Medicare contrary to Medicare regulations.

To improve the documenting and supporting of home health visits in the medical records, Whidden HHA developed policies and procedures for tracking the flow of home health aide paperwork. We recommend that Whidden HHA continue to strengthen procedures to ensure that services are rendered and supported in the medical records. A listing of the claims with these errors was provided to Whidden HHA during our review.

In response to the draft report, the Whidden HHA stated in its letter dated June 14, 1996 that "We are not in dispute with any of the stated findings and continue the improvement practices described by the agency that are in place to eliminate any error".

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