EXECUTIVE SUMMARY:
This final report points out, for a random sample of 100 claims involving 1,856 home health services provided by the Visiting Nurses Association of Dade County, Inc., during the Fiscal Year (FY) ended December 31, 1993, that 32 claims for 403 services did not meet Medicare reimbursement guidelines. Nine percent of claims were for visits made to individuals who were not homebound, 16 percent were for visits which in the opinion of medical experts were not reasonable or necessary, 4 percent were for visits not made, and 3 percent were for visits which physicians either denied authorizing or authorized improperly. Of the $11.1 million claimed by VNA for the FY, we estimate $1.3 million did not meet the reimbursement guidelines. We are recommending that the Health Care Financing Administration (HCFA) require the fiscal intermediary (FI) to instruct VNA on its responsibilities to properly monitor its subcontractors for compliance with Medicare regulations and HCFA guidelines, monitor the FI and VNA to ensure that corrective actions are effectively implemented, recover all overpayments, and direct the FI to investigate all cases of possible fraud and refer them as necessary to the Office of Inspector General's Office of Investigations. The HCFA concurred with our recommendations.