A new report by the HHS Office of Inspector General (OIG) released Aug. 2 argues that some $5 million in Medicare home health payments in 2010 were the result of "inappropriate and questionable billing."

The OIG recommends multiple enforcement steps to CMS, including a further lowering of the 10% outlier cap and a moratorium on home health enrollment in Texas and Florida. In its response to the report, CMS seems willing to consider both, but notes that more research is needed to determine the impact of a lower outlier cap on legitimate providers and patients.

The OIG says the $5 million shouldn't have been paid because claims overlapped service dates with hospitals or SNFs or services were billed for services after a beneficiary's death.

Here's a quick breakdown of the OIG's recommendations:

  • Implement specific edits for the problems discovered by OIG.
  • Increase monitoring of home health billing.
  • Enforce and consider lowering the 10% outlier cap.
  • Implement a temporary enrollment moratorium in Florida and Texas.
  • Take action to recoup improper payments identified by the OIG.

CMS concurred with all five recommendations, but questioned the OIG's estimate of false claims based on overlap between providers' service dates. Home health claims usually are rejected when such an overlap occurs, CMS says in its response to the report.

CMS also pledged to forward the report's findings to the zone program integrity contractors (ZPICs) to use in their enforcement work.

For in-depth coverage of this report, turn to next week's issue of HHL.