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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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.

In a review of a sample of beneficiary medical files at 37 home health agencies, GAO found that 27 percent of the home health visits were not covered under the program or were questionable. Two major reasons were that beneficiaries were not homebound and the services provided were not reasonable or medically necessary. GAO noted that other studies also disclosed similar results. GAO found that Medicare contractors or intermediaries deny few claims for payment because they receive from home health agencies little information on which to base a judgment. GAO found the homebound requirement of the program to be especially difficult to administer because of a lack of clear criteria as to the ambulatory status of the beneficiaries and the nature and frequency of absences from home. For 28 percent of the cases, GAO was of the opinion that the beneficiary was capable of self care or family or friends were willing and able to provide the services required. GAO found several other factors which were adversely affecting proper utilization of the home health benefits: (1) physicians who authorize program services do not appear to be taking a very active role in the program; (2) Medicare contractors had little specific comparative information about the utilization practices of home health agencies; (3) the medical documentation in agency case files was often not complete; (4) home visits with beneficiaries were needed to verify various program requirements; and (5) contractors have little incentive to make proper coverage determinations.

Recommendations for Executive Action

  1. Status: Closed - Not Implemented

    Comments: 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.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Implemented

    Comments: 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.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to clarify and make more specific the criteria for determining homebound status.

    Agency Affected: Department of Health and Human Services

  3. Status: Closed - Implemented

    Comments: HCFA developed guidelines that included the recommended action. HCFA guidance to HHA for submitting claims were changed to incorporate this recommendation.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  4. Status: Closed - Implemented

    Comments: While HCFA has not revised existing guidelines, it implemented a training program aimed at clarifying criteria on the use of aides.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  5. Status: Closed - Not Implemented

    Comments: HCFA does not believe that action on this recommendation would be cost-effective and it will explore alternatives.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  6. Status: Closed - Not Implemented

    Comments: 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.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  7. Status: Closed - Implemented

    Comments: 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.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  8. Status: Closed - Not Implemented

    Comments: 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.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  9. Status: Closed - Implemented

    Comments: 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.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  10. Status: Closed - Implemented

    Comments: HCFA requires intermediaries to make home visits as part of their on-site coverage audits.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  11. Status: Closed - Implemented

    Comments: HCFA explicitly included the adequacy of intermediary home health claims determinations in assessing intermediaires' performance.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  12. Status: Closed - Implemented

    Comments: 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.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  13. Status: Closed - Implemented

    Comments: HCFA revised its instructions to address the issue of ambulatory status of home health service beneficiaries.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  14. Status: Closed - Implemented

    Comments: HCFA revised its instructions to adequately address the issue of respite care.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  15. Status: Closed - Implemented

    Comments: 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.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

  16. Status: Closed - Implemented

    Comments: HCFA issued guidelines but they do not address situations where family members are unwilling to help the beneficiary.

    Recommendation: 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.

    Agency Affected: Department of Health and Human Services

 

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