EXECUTIVE SUMMARY:
This final report provides the results of our review of home health services billed by Visiting Nurse Association (VNA) of Boston under the Medicare program. The objective of our review was to determine whether procedures were established to ensure that home health agency (HHA) services were not billed to Medicare while a beneficiary was an inpatient at a hospital.
Under current Medicare regulations, Medicare does not cover home health services furnished while a patient is an inpatient at a hospital. Moreover, to be covered, home health services must be properly supported. A computer match of the calendar year 1994 inpatient and home health agency paid claims data identified 2,061 home health claims with 45,451 home health visits valued at a cost of approximately $2,535,899 submitted by VNA of Boston in which the home health dates of service overlapped an inpatient stay.
The VNA of Boston generally has adequate controls in place to ensure that services billed are rendered, properly documented, and supported in the medical records. Our review of a random sample of 100 claims representing 2,261 home health visits, identified that only 32 home health visits were billed in error (about 1.4%). We found that 6 home health visits were billed while a beneficiary was an inpatient at a hospital and 26 home health visits did not have supporting documentation in the medical records to show if the services were rendered. As a result of reviewing a random sample of claims, we estimate that the Medicare program visits and costs reported in VNA of Boston's fiscal year 1994 cost report may be overstated by 660 home health visits or a cost of $41,322.
The VNA of Boston is developing policies and procedures addressing "absent visit guidelines." Additionally, we recommend that VNA of Boston continue to strengthen procedures to ensure that services are rendered and supported in the medical records.
In response to the draft report, the VNA of Boston stated in its letter dated June 17, 1996 that "It appears that the information in the Report is correct, and we accept your recommendations".