Medical Record Collection

We provided the contractor with a list of claims. For each claim, we included the beneficiary’s name, dates of services, and the name and address of the HHA. The contractor sent up to three written requests for medical records to each HHA and made additional telephone calls to each HHA, as needed. The contractor received 489 out of the 495 requested medical records, a 98.8-percent response rate. The contractor was unable to obtain six medical records because the HHAs had closed and the contractor was unable to determine the records’ current locations; we dropped these medical records from our sample. We followed OIG policies to protect personally identifiable information.  

Medical Record Review 

The contractor reviewed the OASIS assessment and other information in the home health medical record to determine whether HHAs correctly coded and documented each 60-day episode. The contractor used Medicare policy on coverage requirements as well as professional judgment to verify that the beneficiary qualified for home health services and determine whether the HHA had accurately coded the OASIS. Contractor staff provided a payment code based on their review of the medical record, which we then used to compare to the one billed by the HHA.

 Based on the medical review, we calculated the proportion of claims that did not meet the Medicare program requirements. We also compared the proportion of inappropriate claims in each of the four strata, looking for differences among them

Medicare Home Health Cost Analysis 

We calculated the total dollar amount of claims that did not meet program requirements. This analysis included only Medicare home health claims that the contractor determined did not meet program requirements. In these situations, contractors reviewed the medical records to identify the appropriate diagnosis and calculated a new HIPPS code based on that information. We then used CMS’s fiscal year 2008 Home Health Prospective Payment System PC Pricer software to calculate the resulting Medicare reimbursement amounts. For each claim, we calculated the reimbursement amount using the recalculated HIPPS code submitted by the contractor. To calculate the total dollar amount of claims that did not meet program requirements, we then compared the recalculated dollar amount to the amount paid to the HHA.

Limitations 

This review assessed the HHA’s medical record for the beneficiary but did not determine whether that record accurately reflected the beneficiary’s medical condition. We did not physically confirm that the beneficiary was homebound or determine whether the care provided was medically necessary. 

Standards 

This study was conducted in accordance with the Quality Standards for Inspection and Evaluation issued by the Council of the Inspectors General on Integrity and Efficiency.