Updated on 03/29/2021

Author: Michael Tidd LVN, HCS-D, COS-C

The Department of Health and Human Services Office of Inspector General (OIG) has announced audit results of a home health agency.  The OIG audited 100 claims submitted and paid by CMS between 2016 and 2017.  The audit focused on ambulation, homebound and medical necessity and found the documentation insufficient to warrant the payment.  Out of these 100 claims the OIG found a total $132,500 in overpayments.  The OIG used this error rate to estimate that it is possible the agency collected $3.3 million in overpayments over the two year audit period.  When asked the reason the agency was targeted for the audit, the OIG responded that a risk analysis of the agencies information.  The analysis demonstrated that they agency had one of the highest case-mix group rankings.


This is an average of $1,325 per claim.  Ask yourself if your agency could take this kind of hit from CMS recouping the overpayments.  Does this mean that your agency is committing Medicare Fraud or at risk of overpayments if you have claims with a high case-mix?  It all depends on your documentation.  Do you know that your documentation clearly shows medical necessity, need for skilled services and homebound status for each of your patient’s assessments and visits?  The OIG did not report finding any insufficiencies in Face to Face documentation provided by the physicians, which is always an area of focus.  Instead the audit demonstrated a weakness in documentation practices.


Notice that the audited agency was not wrong in billing high case-mix claims, but in their lack of sufficient documentation skills to justify the billed case-mix.  In our own complimentary audits, we consistently find agencies show a weakness in agencies ability to sufficiently document and meet the conditions of participation.  One of the hazards of total reliance on agency staff performing audits is largely there is a tendency to overlook weaknesses in documentation.  An outside auditor will instead consistently apply the more critical side of the reviews to ensure an adherence to the Conditions of Participation requirements and increase your ability to pass surveys and audits which ultimately means you keep the money paid to the agency.


Related links: