A recent OIG report suggests that the MACs could be recouping money they believe was incorrectly paid for home health episodes that ended with five to seven visits, slightly above the LUPA thresholds in PPS. And they could be enforcing stricter oversight of periods just above new LUPA thresholds in PDGM.
Twenty out of 25 claims that did not comply with Medicare requirements under the previous PPS methodology also wouldn’t comply with those requirements under the new methodology, the OIG states.
Of the 120 randomly selected claims submitted in 2017, 91 claims complied with requirements and 25 claims did not. Medicare improperly paid agencies for a portion of the payment episode for 14 claims and for the full payment episode for 11 claims, which totaled $41,613, according to the OIG.
Medicare was estimated to overpay agencies nationally $191.8 million for the audit period.
These improper payments occurred because the Medicare administrative contractors (MACs) did not analyze claim data or perform risk assessments to target for additional review those claims with visits slightly above the LUPA threshold of four visits.