Medicare Compliance Review of Home Health VNA for 2011 and 2012

Home Health VNA (the Agency) (located in Lawrence, Massachusetts) did not comply with Medicare billing requirements for 105 of the 497 home health claims we reviewed. As a result, the Agency received net overpayments of $314,000 for calendar years 2011 and 2012. Specifically, the Agency incorrectly billed Medicare because beneficiaries were not homebound, beneficiaries did not require skilled services, documentation from the certifying physicians was missing or insufficient to support the services the Agency provided, or, in one instance, a claim contained an incorrect payment code. These errors occurred primarily because the Agency did not have adequate controls to prevent the incorrect billing of Medicare claims within selected risk areas.

On the basis of our sample results, we estimated that the Agency received overpayments of at least $15.5 million for the audit period. This overpayment amount includes claims with payment dates outside of the 3-year recovery period. Of the total estimated overpayments, at least $6.3 million was within the 3-year recovery period and as much as $9.1 million was outside the 3-year recovery period.

We recommended that the Agency (1) refund to the Medicare contractor $6.3 million in estimated overpayments for claims incorrectly billed that are within the 3-year recovery period; (2) work with the contractor to refund net overpayments outside of the 3-year recovery period, which we estimate to be $9.1 million for our audit period, in accordance with the 60-day repayment rule; (3) identify claims in subsequent years that did not meet Medicare payment requirements and refund any associated overpayments; and (4) take steps to strengthen its procedures. The Agency did not concur with our findings and recommendations.