Medicare Often Made Overpayments to New England Home Health Agencies for Claims Without Required Outcome and Assessment Information Set Data

摘要

We estimated that the regional home health intermediary for six New England States made approximately $25.1 million in Medicare overpayments because it did not deny claims that home health agencies submitted without the required Outcome and Assessment Information Set data, which is a condition of payment. In 2012, the Office of Inspector General issued a report that disclosed that home health agencies (HHAs) nationwide did not submit required Outcome and Assessment Information Set (OASIS) data for 6 percent of HHA claims in calendar year (CY) 2009, which represented over $1 billion in Medicare payments. Effective January 1, 2010, the Centers for Medicare & Medicaid Services (CMS) began requiring HHAs to submit OASIS data as a Medicare condition of payment. In its response to our report, CMS stated that it cannot enforce this requirement because of limitations in the Medicare claims processing system. CMS stated that it is still working on building a systematic interface of the HHA claims and OASIS submission process. CMS contracts with four regional home health intermediaries (RHHIs) that use the Fiscal Intermediary Shared System (FISS) to process and pay HHA claims. As a followup to our review of CY 2009 claims taking into account the new condition of payment, we reviewed one RHHI that processes and pays HHA claims for six New England States to determine the extent to which it denied CY 2010 claims with missing OASIS data.