Medicare Home Health Services: A Difficult Program To Control
HRD-81-155
Published: Sep 25, 1981. Publicly Released: Sep 25, 1981.
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Highlights
GAO assessed various Medicare claims to determine the reasonableness and medical necessity of skilled nursing care and therapy, the need for home health aide services, and compliance with the homebound and other requirements of the Medicare program. Aide services provide for the personal care of the beneficiary and represent about one-third of all visits provided under the program. Because family and friends provide similar services, GAO visited 150 beneficiaries in their homes to determine if the use of home health aides was supplanting the support provided by family and friends.
Recommendations
Recommendations for Executive Action
| Agency Affected | Recommendation | Status |
|---|---|---|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator of the Health Care Financing Administration (HCFA) to require home health agencies (HHA) to submit a copy of the beneficiary's medical file where utilization exceeds the national guidelines mandated by the Omnibus Budget Reconciliation Act of 1981. |
HCFA guidelines implementing the applicable provision of the Omnibus Reconciliation Act of 1981 did not establish national utilization guidelines. However, the Department of Health and Human Services required HHA to submit medical information on all claims.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to require intermediaries to obtain from home health agencies a copy of the medical file for a fixed percent of claims that do not exceed the national guidelines. |
When HCFA issued national guidelines, it did not require intermediaries to obtain medical files for a sample of claims that do not exceed the guidelines.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to clarify and make more specific the criteria for determining homebound status. |
HCFA believes the problem results more from interpretation of criteria than the need for clearer criteria. HCFA has undertaken training effort to ensure more consistent interpretations of the criteria.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to require home health agency nurses and aides to specifically document the ambulatory status of beneficiaries, including the nature and frequency of absences from the home. |
HCFA developed guidelines that included the recommended action. HCFA guidance to HHA for submitting claims were changed to incorporate this recommendation.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to clarify the criteria on the use of aides for homemaker type services. |
While HCFA has not revised existing guidelines, it implemented a training program aimed at clarifying criteria on the use of aides.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to require that the estimated cost of the home health services be provided on the authorizing plan of treatment and recertifications. |
HCFA does not believe that action on this recommendation would be cost-effective and it will explore alternatives.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to inform physicians of the overutilization of the home health benefit program requirements and their role in authorizing services. |
HCFA said that it believes HHA should be advised of these matters, not the physician. However, the law requires the physician to prescribe the services and GAO believes that the physician should be made aware of these problems.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to require intermediaries to apprise physicians of the noncovered services provided under plans of care they approve. |
HCFA will only modify physicians of noncovered services identified during medical audits and not for routine denials made by intermediaries. GAO believes that notification of all denials for noncovered services would be more effective in controlling utilization.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to expand and improve on the use of comparative analysis techniques to identify aberrant home health utilization patterns. |
HCFA established a judgmental sampling technique for selecting HHA for review. The criteria used to select agencies do not ensure that aberrant ones will be reviewed.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to emphasize to home health agencies the documentation requirements for clinical records and to strengthen the requirements. |
HCFA requires the intermediaries to notify physicians of noncovered services identified during medical audits, but does not require physician notification when such claims are denied during routine claims processing.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to include home visits to beneficiaries as part of the on-site coverage audits of HHA. |
HCFA requires intermediaries to make home visits as part of their on-site coverage audits.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to revise the intermediary contractor evaluation program to provide for an assessment of the appropriateness of home health coverage determinations. |
HCFA explicitly included the adequacy of intermediary home health claims determinations in assessing intermediaires' performance.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to develop a standard aide needs assessment guide which specifically assesses the availability and capability of family and friends to provide personal care services and require HHA to use it. |
HCFA issued revised instructions that require intermediaries not to pay a HHA when a family member is willing to and does provide care. The revised instructions do not address what should be done when a family member is able to provide care but is unwilling to do so.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to, where home health agencies provide aide services, require them to submit, with their bills, a copy of the aide needs assessment. |
HCFA revised its instructions to address the issue of ambulatory status of home health service beneficiaries.
|
| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to address the issue of respite care, that is, if it is authorized under the program and, if so, under what circumstances. |
HCFA revised its instructions to adequately address the issue of respite care.
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| Department of Health and Human Services | The Secretary of Health and Human Services should direct the Administrator, HCFA, to establish a policy for the use of aides in situations where family members are able, but appear unwilling or reluctant, to help the beneficiary with patient care. |
HCFA issued guidelines but they do not address situations where family members are unwilling to help the beneficiary.
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