Medicare Home Health Agency Provider Compliance Audit: Gem City Home Care, LLC

Under the Medicare home health prospective payment system (PPS), the Centers for Medicare & Medicaid Services pays home health agencies (HHAs) a standardized payment for each 60-day episode of care that a beneficiary receives. The PPS payment covers part-time or intermittent skilled nursing care and home health aide visits, therapy (physical, occupational, and speech-language pathology), medical social services, and medical supplies.Our prior audits of home health services identified significant overpayments to HHAs. These overpayments were largely the result of HHAs improperly billing for services to beneficiaries who were not confined to the home (homebound) or were not in need of skilled services. Our objective was to determine whether Gem City Home Care, LLC, (Gem City) complied with Medicare requirements for billing home health services on selected types of claims.Our audit covered $35,689,451 in Medicare payments to Gem City for 10,417 claims. These claims were for home health services provided in fiscal years 2016 and 2017. We selected a stratified random sample of 100 claims with payments totaling $385,724 for review. We evaluated compliance with selected billing requirements and submitted these claims to an independent medical review contractor to determine whether the services met coverage, medical necessity, and coding requirements.