Submitting OIG:
Report Description:
Under the prospective payment system (PPS), Medicare pays home health agencies (HHAs) for each 60 day episode of care that beneficiary receives, called a payment episode. During our audit period, if an HHA provided four or fewer visits in a payment episode, Medicare paid the HHA a standardized per-visit payment. Claims for these types of payments are called Low Utilization Payment Adjustment (LUPA) claims. Once a fifth visit was provided during the payment episode (i.e., above the LUPA threshold), Medicare paid an amount for the services provided that was, in general, substantially higher than the per-visit payment amount. Because of the large payment increase starting with the fifth visit, HHAs have an incentive to improperly bill claims with visits slightly above the LUPA threshold.
Date Issued:
Wednesday, July 22, 2020
Agency Reviewed / Investigated:
Submitting OIG-Specific Report Number:
A-09-18-03031
Component, if applicable:
Centers for Medicare & Medicaid Services
Location(s):
Agency-Wide
Type of Report:
Audit
Questioned Costs:
$41,613
Funds for Better Use:
$191,773,995
Number of Recommendations:
3
View Document:
Attachment | Size |
---|---|
A-09-18-03031.pdf | 1.55 MB |
Additional Details Link: