Home Health & Hospice Week

"These six measures of questionable billing indicate potential fraud," the HHS Office of Inspector General warns in a new report. Here are the actual thresholds (in BOLD) that put agencies over the top in the OIG's view:

1. High average outlier payment amount per beneficiary -- $403. Total outlier payments each HHA was paid in 2010 relative to the number of beneficiaries for whom the HHA billed Medicare in that year. "We also calculated each HHA's total outlier payments relative to total Medicare payments in 2010," the OIG explains. Number of HHAs exceeding the threshold: 1,684. Median among all HHAs: $13.

2. High average number of visits per beneficiary -- 91. Total number of visits each HHA billed in 2010 relative to the number of beneficiaries for whom the HHA billed Medicare in 2010. Number of HHAs exceeding the threshold: 658. Median among all HHAs: 32.

3. High percentage of beneficiaries for whom other HHAs billed Medicare -- 61 percent. "When multiple HHAs bill for services provided to the same beneficiary in a given period, there is potential for fraud (i.e., beneficiary sharing)," the OIG says. The percentage of each HHA's beneficiaries for whom at least one other HHA billed Medicare in 2010. Number of HHAs exceeding the threshold: 618. Median among all HHAs: 20 percent.

4. High average number of late episodes per beneficiary -- 2. "In a sequence of episodes, late (i.e., third and subsequent) episodes have higher payment rates than early episodes," the OIG points out. Total number of late episodes each HHA billed in 2010 relative to the number of beneficiaries for whom the HHA billed Medicare in 2010. Number of HHAs exceeding the threshold: 426. Median among all HHAs: less than 1.

5. High average number of therapy visits per beneficiary -- 24. "Beneficiaries who require a greater number of therapy services have episodes with higher payment rates," the OIG explains. Total number of therapy visits each HHA billed in 2010 relative to the number of beneficiaries for whom the HHA billed Medicare in 2010. Number of HHAs exceeding the threshold: 257. Median among all HHAs: 9.

6. High average Medicare payment amount per beneficiary -- $11,653. Total payment for home health services that each HHA received in 2010 relative to the number of beneficiaries for whom the HHA billed Medicare in 2010. Number of HHAs exceeding the threshold: 173. Median among all HHAs: $5,112.

Source: Inappropriate and Questionable Billing by Medicare Home Health Agencies (OEI-04-11-00240), August 2012, http://oig.hhs.gov/oei/reports/oei-04-11-00240.pdf.