Home Health & Hospice Week

Home health agencies that have billed a lot of outlier episodes or therapy visits or otherwise had "aberrant billing" had better make sure their charts back up their claims.

In a Zone Program Integrity Contractor audit that resulted in one Texas home health agency's payment suspension, ZPIC Health Integrity highlighted these beneficiaries whom its auditors deemed not homebound:

• A beneficiary leaves the house to go shopping, to visit friends and relatives, and to take a taxi to receive medical care. She uses her motorized scooter to visit her brother and other friends in the neighborhood.

The beneficiary also could self-inject her insulin but said it is "easier" for the HHA nurse to do so, so auditors found that she also didn't meet the requirements for skilled care.

• A beneficiary who lives in a second-story apartment with no elevator goes out to eat, to shop, and to receive medical care. Auditors visiting her saw her walking around the apartment with no shortness of breath or "taxing effort." The nurse checked her vitals and meds when she came to visit. Auditors found she also didn't meet the requirements for skilled care.

• A beneficiary with Down Syndrome cannot go out by herself, but can go out as long as family is with her. She cannot draw up insulin or self-inject, auditors admit in the letter.

In this case, "who is to give the shots?" demands Tom Boyd with Rohnert Park, Calif.-based Boyd & Nicholas.