Medicare Home Health Agency Provider Compliance Audit: Guardian Home Care, LLC

Why OIG Did This Audit

• In calendar year 2023, Medicare paid home health agencies (HHAs) about $16 billion for home health services provided to about 2.8 million people enrolled in traditional Medicare. In that year, nearly 10,000 HHAs participated in Medicare.
• CMS determined through its Comprehensive Error Rate Testing program that the 2023 improper payment error rate for home health claims was 7.7 percent, or about $1.2 billion.
• This audit report, part of a nationwide series of home health audits, examined whether Guardian Home Care, LLC, complied with Medicare requirements for billing home health services provided to enrollees from July 1, 2021, through June 30, 2023 (audit period).

What OIG Found

Guardian Home Care complied with Medicare billing requirements for 97 of the 100 home health claims we reviewed. For the remaining three claims, Guardian Home Care incorrectly billed Medicare for claims with unsupported codes or for a skilled service that did not meet a plan of care requirement.

• Two claims did not meet billing and coding requirements, resulting in overpayments totaling $123.
• One claim did not meet a plan of care requirement, resulting in an overpayment of $1,567.

Guardian Home Care received overpayments totaling $1,690 for the claims in the sample.

What OIG Recommends

We recommend that Guardian Home Care: (1) refund the $1,690 in overpayments to the Medicare program and (2) consider conducting one or more internal audits or investigations for claims after our audit period, based on the risks identified by this audit, to identify any similar overpayments that Guardian Home Care might have received and return any identified overpayments to the Medicare program.

Guardian Home Care did not specifically indicate concurrence or nonconcurrence with our first recommendation and described corrective actions it planned to take. Guardian Home Care concurred with our second recommendation.

---