Medicare Home Health Fraud: Enough Mistakes Can Add Up

Home health regulatory requirements create a variety of documentation and management challenges that home health agencies must be prepared to address. In particular, emerging regulatory changes surrounding Medicare home health fraud are pressuring agencies to keep an especially close watch over every facet of operations.

According to a CMS Comprehensive Error Rate Testing (CERT) report released last year, billing errors account for a loss of $41.1 billion from Medicare each year. And for the past three years, more than $130 billion was inappropriately paid by Medicare to providers.

As a result of the continued loss of dollars each year, Medicare audits have been on the rise. The Recovery Audit Contractors (RAC) program was implemented in 2009 to identify and recover incorrect payments, with CMS announcing a RAC auditor dedicated exclusively to the home health care industry in 2016. Furthermore, RAC auditors are paid a contingency fee for finding fraud through post-payment reviews. This means that home health and hospice agencies will continue to face even greater scrutiny of even the smallest errors.

While the vast majority of home health agencies are honest providers, disorganized or lax business practices can quickly lead to problems with Medicare fraud investigators, even when home health agencies have no intention of defrauding the government. As agencies struggle to maximize their reimbursements, it can be easy to stumble into Medicare home health fraud by failing to ensure that clinical documentation is accurate and complete.

Here are four tips that your home health agency can use to avoid making errors and mistakes that could potentially put you in the spotlight for Medicare home health fraud:

  1. Take compliance seriously. Just because your agency has never been the subject of a RAC or ZPIC audit does not mean that it never will. As the focus on Medicare home health fraud continues to gain momentum, it becomes increasingly more likely that it will be audited at some point. Prepare now so you are ready when it happens. If you have not done so already, implement a compliance team that will review what you are doing now and what you need to do to minimize your risk of problems should you be audited.
  2. Maintain accurate and complete documentation. According to CMS, “Good documentation ensures your patients receive appropriate care from you and other providers who may rely on your records for patients’ medical histories.” Ensuring your documentation tells the complete patient story will support the claims you submit for payment. It also helps your home health agency address objections raised about the integrity of your claims.
  3. Educate your staff. Most errors occur due to staff not paying close enough attention to what they are doing, or not knowing what information is required for compliance. Take the time to educate your staff on proper documentation habits, correct coding and billing practices, as well as what to do should they have questions on how to proceed. Highly educated staff are much more likely to have fewer errors and reach out to leadership should they run into any problems.
  4. Make sure you have the right technology. All home health EHRs offer some type of clinical documentation capability, but depth and accuracy are key. You must utilize an EHR system that ensures every required assessment question is answered, that a unique plan of care is outlined clearly and meets the needs of the patient, and that every activity is documented against the plan of care. This must then flow seamlessly to coding and billing for proper reimbursement. Without this level of detail and structure, you are very likely to find themselves struggling to provide the supporting documentation required by today’s regulatory environment.

At HEALTHCAREfirst, our EHR capabilities are built to withstand the highest degrees of scrutiny. We aren’t here to make false promises – regulatory compliance is always difficult. We’re here to partner with you to make your path to compliance as simple as possible by delivering everything that you need in one, comprehensive system backed by superior support and service.
firstHOMECARE with CAREpliance™ Care Planning Technology is a comprehensive EHR system built specifically to address home health operations with an emphasis on meeting strict clinical regulatory requirements. Clinicians can conduct assessments, establish the plan of care, and complete visits with ease, all while ensuring compliance with CMS documentation requirements.

To learn more about how firstHOMECARE can help your agency ensure complete, compliant documentation, while reducing errors, call us at 800.841.6905 or schedule a personalized EHR demonstration today!

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