Source: Office of the Inspector General (“OIG”) Program Guidance for Home Health Agencies

The OIG has identified thirty-one risk areas for home health agencies. These risk areas are listed below and explained in great detail in the footnotes throughout the Compliance Program Guidelines found at 63 Fed. Reg. 152, August 7, 1998.

1. Billing for items or services not actually rendered.
2. Billing for medically unnecessary services.
3. Duplicate billing.
4. False cost reports.
5. Credit balances – failure to refund.
6. Home health agency incentives to actual or potential referral sources (e.g., physicians, hospitals, patients, etc.) that may violate the anti-kickback statute or other similar Federal or State statute or regulation.
7. Joint ventures between parties, one of whom can refer Medicare or Medicaid business to the other.
8. Stark physician self-referral law.
9. Billing for services provided to patients who are not confined to their residence (or “homebound”).
10. Billing for visits to patients who do not require a qualifying service.
11. Over-utilization and under-utilization.
12. Knowing billing for inadequate or substandard care.
13. Insufficient documentation to evidence that services were performed and to support reimbursement.
14. Billing for unallowable costs of home health coordination.
15. Billing for services provided by unqualified or unlicensed clinical personnel.
16. False dating of amendments to nursing notes.
17. Falsified plans of care.
18. Untimely and/or forged physician certifications on plans of care.
19. Forged beneficiary signatures on visit slips/logs that verify services were performed.
20. Improper patient solicitation activities and high-pressure marketing of uncovered or unnecessary services.
21. Inadequate management and oversight of subcontracted services, which results in improper billing.
22. Discriminatory admission and discharge of patients.
23. Billing for unallowable costs associated with the acquisition and sale of home health agencies.
24. Compensation programs that offer incentives for number of visits performed and revenue generated.
25. Improper influence over referrals by hospitals that own home health agencies.
26. Patient abandonment in violation of applicable statutes, regulations, and Federal health care program requirements.
27. Knowing misuse of provider certification numbers, which results in improper billing.
28. Duplication of services provided by assisted living facilities, hospitals, clinics, physicians, and other home health agencies.
29. Knowing or reckless disregard of willing and able caregivers when providing home health services.
30. Failure to adhere to home health agency licensing requirements and Medicare conditions of participation.
31. Knowing failure to return overpayments made by Federal health care programs.

If you have any questions or if you would like more information, please contact:

Connie A. Raffa
212.484.3926
raffa.connie@arentfox.com