Medicare:

Need To Strengthen Home Health Care Payment Controls and Address Unmet Needs

HRD-87-9: Published: Dec 2, 1986. Publicly Released: Jan 2, 1987.

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Pursuant to a congressional request, GAO provided information on the Medicare home health program, specifically: (1) the status of efforts to strengthen internal controls to prevent payment for services Medicare does not cover; and (2) how many chronically ill elderly persons have home care needs that Medicare and other providers do not meet.

GAO found that: (1) material weaknesses in internal controls over payments for Medicare home health services resulted in improper payments of almost $600 million in fiscal year 1984; (2) the Department of Health and Human Services (HHS) has been slow to implement changes to strengthen management controls in response to 1981 GAO recommendations; (3) HHS needs to better explain what services Medicare covers and how to review payment claims to identify noncovered services; (4) HHS needs to make intermediaries more accountable for their payment decisions and strengthen sanctions against home health agencies that consistently abuse the program; (5) HHS has not evaluated available data to determine what effect stronger controls would have on unmet needs for home care assistance; and (6) in 1982, about 168,000 of the chronically ill elderly lacked needed assistance with such daily living activities as bathing, dressing, and eating, while about 1.1 million lacked assistance with such key day-to-day activities as grocery shopping and transportation. GAO also found that, to meet the home care needs of the elderly population: (1) HHS could expand its Medicare, Medicaid, and private health insurance coverage; (2) the government could provide tax incentives to encourage families and friends to provide care; and (3) the government could provide additional funds under block grants to encourage expansion of community-based services.

Recommendations for Executive Action

  1. Status: Closed - Implemented

    Comments: HHS has developed utilization review screens for home health and is currently using them at several intermediaries. In addition, it has held meetings with regional intermediaries to clarify coverage criteria. A followup report on the home health program is currently being prepared.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, Health Care Financing Administration (HCFA), to implement the recommendations in the 1981 GAO report to develop national prepayment utilization review screens for home health and clarify coverage criteria.

    Agency Affected: Department of Health and Human Services

  2. Status: Closed - Not Implemented

    Comments: HHS stated that the waiver of liability makes it inappropriate to project overpayments for home health agencies. GAO continues to believe that it is imperative that statistically valid techniques be used to project the amount of noncovered care. Continuing problems in calculating denial rates were addressed in a recent report.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to revise the home health postpayment utilization review program guidance to require intermediaries to use statistically valid sampling techniques for identifying and projecting the amount of noncovered care to the universe of claims paid.

    Agency Affected: Department of Health and Human Services

  3. Status: Closed - Implemented

    Comments: HHS has revised the contractor performance evaluation program to more closely assess performance of home health coverage determinations.

    Recommendation: The Secretary of Health and Human Services should direct the Administrator, HCFA, to expand the assessment of intermediary performance under the contractor performance evaluation program to include an assessment of the accuracy of intermediary home health coverage determinations.

    Agency Affected: Department of Health and Human Services

  4. Status: Closed - Implemented

    Comments: HHS cited a number of actions taken, or underway, which address unmet needs. Further analysis will be contained in a forthcoming report on home health.

    Recommendation: The Secretary of Health and Human Services should do further studies to evaluate factors contributing to unmet needs for home care assistance and options for meeting the future home care needs of the elderly.

    Agency Affected: Department of Health and Human Services

  5. Status: Closed - Not Implemented

    Comments: HHS did not agree that reporting under FMFIA was appropriate given the actions taken and planned.

    Recommendation: The Secretary of Health and Human Services should include the internal control weaknesses in the Medicare home health program in the next annual report under the Federal Managers' Financial Integrity Act (FMFIA) and set a timetable for completing actions to correct the deficiencies.

    Agency Affected: Department of Health and Human Services

  6. Status: Closed - Not Implemented

    Comments: HHS did not believe that an internal control weakness exists inlight of planned actions.

    Recommendation: The Secretary of Health and Human Services should identify the limited assessment of the appropriateness of intermediaries' home health payment decisions as a material internal control weakness in the annual report under FMFIA and establish a timetable for prompt corrective action.

    Agency Affected: Department of Health and Human Services

 

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